NBPP 2024 Part 4: Medicaid/CHIP, Special Enrollment Periods, Income Data & Navigator expansion

The ACA includes a long list of codified instructions about what's required under the law, but many of the specific details are left up to the agency responsible for implementing it since the legal text itself can't possibly cover every conceivable detail involved. The major provisions of the ACA fall under the Department of Health & Human Services (HHS), and within that, the Centers for Medicare & Medicaid (CMS).

Each year, CMS issues a long, wonky document called the Notice of Benefit & Payment Parameters (NBPP) for the Affordable Care Act. This is basically a list of tweaks to some of the specifics of how the ACA is actually implemented.

Yesterday CMS released their proposed 2024 NBPP, which includes some important changes which, if included in the final version, will go into effect starting next fall (for calendar year 2024). The full proposed 2024 NBPP is actually 370 pages long; yesterday I posted the press release & Fact Sheet. Today I'm breaking it down into smaller chunks since there's a lot to talk about here:

CMS proposes that beginning January 1, 2024, that Marketplaces have the option to implement a new special rule for consumers losing Medicaid or Children’s Health Insurance Program (CHIP) coverage that is also considered minimum essential coverage (MEC). This special rule would mean that consumers would have 60 days before, or 90 days after, their loss of Medicaid or CHIP coverage to select a plan for Marketplace coverage.

Marketplaces would have additional flexibilities to decide whether to offer this special rule or not, depending on eligibility and/or enrollment trends for their respective populations. CMS believes that this new proposed special rule would help mitigate coverage gaps when consumers lose Medicaid or CHIP while allowing for a more seamless transition into Marketplace coverage.

This is pretty clearly being done with the upcoming end of the COVID-19 Public Health Emergency in mind. There are up to an estimated 15 million Americans who could potentially be kicked off of Medicaid when the PHE ends:

Medicaid enrollment has risen substantially since the start of the COVID-19 pandemic. Recent data show enrollment jumped by more than 9 million people from February 2020 to January 2021. The higher enrollment is driven by two main causes: the unprecedented pandemic-related job losses concentrated in March to June of 2020 and the continuous coverage requirement of the Families First Coronavirus Response Act, which prohibits state Medicaid agencies from disenrolling beneficiaries during the public health emergency (PHE). Even as the economy improves, however, the continuous coverage provision is likely to contribute to even higher Medicaid enrollment through 2021. We estimate that by the end of 2021, 17 million more non-elderly people will be enrolled in Medicaid than before the pandemic, and we estimate that the number of Medicaid enrollees could decline by about 15 million people in during 2022 after the public health emergency is expected to expire.

Right now the PHE is scheduled to end about a month from now, in mid-January 2023, but it's possible that it will be bumped out by a few more months yet. That would still leave perhaps a 9-month gap between when the PHE ends and this new Medicaid/CHIP special rule went into effect, but I don't know that they can have that implemented any earlier. Many states (I hope) will phase in the transition instead of kicking all those people off the program at once:

CMS has developed a roadmap for the eventual end of the Medicare PHE waivers and flexibilities, and is sharing information on what health care facilities and providers can do to prepare for future events. Similar to the guidance CMS has made available to states, CMS is releasing fact sheets that will help the health care sector transition to operations once the PHE ends, whenever that may occur. CMS continues to seek and receive your input as we release or update regulatory requirements and sub-regulatory guidance. Additionally, we are offering technical assistance to states, as one example, and engaging in public education about the necessary steps to prepare successfully for and operate after the PHE to assist other partners.

The proposed rule also changes the current coverage effective date requirements so that Marketplaces have the option to offer earlier coverage effective start dates for consumers attesting to a future coverage loss. CMS believes that these changes would ensure qualifying individuals are able to seamlessly transition from other forms of coverage to Marketplace coverage as quickly as possible with no coverage gaps.

Currently, if most states, if you enroll in coverage by the 15th of the month, your coverage will start on the 1st of the following month; otherwise it won't start until the 1st of the month after that. For instance, if you enroll between April 16th - May 15th, your new coverage will start on June 1st, but if you enroll between May 16th - June 15th, it won't start until July 1st. This is a real problem for people who know that they're going to lose their current coverage in the middle of an upcoming month, since it means up to a 16-day coverage gap:

For example, if a consumer reports on June 1st that they will lose MEC on July 15th and they make a plan selection on or before July 15th, Exchange coverage will be effective August 1st. The consumer in this case cannot avoid a gap in coverage of more than two weeks...

Because current regulation...does not allow for retroactive or mid-month coverage effective dates, consumers may experience gaps in coverage, especially those consumers who live in States that allow mid-month terminations of Medicaid or CHIP coverage. Further, after the COVID-19 PHE comes to an end, HHS expects to see a higher than usual volume of individuals transitioning from Medicaid and CHIP coverage to the Exchange. This is because States will be required to return to normal eligibility and enrollment operations after the expiration of the continuous enrollment condition that provided a temporary increase in Federal Medicaid matching funds authorized by the Families First Coronavirus Response Act (FFCRA), and we expect that many individuals experienced changes in income or household size since the continuous enrollment condition took effect.

Consumers who become ineligible for Medicaid are at risk of being uninsured for a period of time and postponing use of health care services, which can lead to poorer health outcomes, if they are not able to successfully transition between coverage programs without coverage gaps.

Therefore, to ensure that qualifying individuals whose prior MEC ends mid-month are able to seamlessly transition from non-Exchange MEC to Exchange coverage as quickly as possible with no coverage gaps, we are proposing to revisions to paragraph (b)(2)(iv).

...if a qualified individual, enrollee, or dependent, as applicable, loses coverage..., experiences a change in eligibility for APTC...or experiences a loss of government contribution or subsidy...and if the plan selection is made on or before the day of the triggering event, the Exchange must ensure that the coverage effective date is the 1st day of the month following the date of the triggering event...and, at the option of the Exchange, if the plan selection is made on or before the last day of the month preceding the triggering event, the Exchange must ensure that coverage is effective on the first of the month in which the triggering event occurs.

For example, if a consumer attests between May 16th and June 30th that they will lose MEC on July 15th and selects a plan on or before June 30th, coverage would be effective on August 1st (first of the month after the last day of prior MEC), or at the option of the Exchange, on July 1st (the first of the month in which the triggering event occurs).

Again, a large reason for this is the impending end of the Public Health Emergency, but this also applies to other Medicaid coverage loss scenarios as well (plus some non-Medicaid situations).

The proposed rule will now allow assisters to conduct door-to-door enrollment to increase consumer engagement and advance health equity. Assisters currently conduct door-to-door outreach, education, and schedule follow-up appointments, but are prohibited from providing enrollment assistance upon an initial interaction at the consumers’ residence. Removing this prohibition will make it easier for consumers to get help when enrolling into coverage.

This will be a huge improvement for ACA navigators. As it says, right now they're allowed to do all sorts of outreach/education work with people door to door, but they can't actually sign people up. This almost certainly means they're losing a significant chunk of potential enrollees since many people don't get around to following up and actually enrolling even after they have all the information and assistance they need to do so.

CMS also proposes removing consumer burden by aligning the regulations with the policy and operations of the Marketplaces on the Federal platform for granting special enrollment periods (SEPs) to qualified consumers who are affected by a material plan display error with current plan display error SEP operations. Currently, the regulation requires the qualified individual or enrollee, or their dependent, to adequately demonstrate to the Marketplace that a material error related to plan benefits, service area, or premium influenced their decision to purchase a QHP through the Marketplace. However, we have found that consumers may benefit when other interested parties can demonstrate to the Marketplace that a material plan error influenced the enrollment decision to purchase a QHP through the Marketplace.

If I'm reading this correctly: Right now, if you sign up for an ACA exchange policy and it turns out there was an error or omission about the plan on the ACA website or in the insurance carrier's brochure, you have to complain about it in order to be allowed to switch to a different plan. This change would mean that if someone else discovers the screw-up and proves to the exchange that some enrollees were impacted by it, that would be enough to let the enrollees switch plans as well.

Income Data Matching Issues

CMS proposes to accept the household’s income attestation when HHS requests tax return data from the Internal Revenue Service (IRS) but such data is not available. Such cases often occur when household composition changes across tax years (marriage, divorce, birth of a child) or if individuals were previously below the filing threshold and did not receive advance payments of the premium tax credits. All individuals receiving advance payments of the premium tax credits are required to file taxes and to reconcile those payments with final annual income. These proposed changes would reduce administrative burden, increase access, and have a positive impact on health equity.

This basically means allowing enrollees to use the honor system when it comes to reporting their household income to CMS, although I presume they can still be charged with fraud later on if it can be proven that they willfully misstated their income (as opposed to making an honest mistake estimating it), just like any other tax fraud situation.