Open Enrollment is Here! Now What?

Health Reform Watch

Volume 8, November 7, 2013
On October 1, 2013 Marketplaces in every state opened for business, with coverage beginning January 1, 2014. Federally facilitated Marketplaces – plagued with website difficulties and glitches – have had a rough beginning; however state-run Marketplaces have had a relatively successful launch, with hundreds of thousands already signed up for coverage. As plan specifics become available, state programs are assessing plan options to ensure they meet HIV and viral hepatitis care and treatment needs. The federal government is also continuing to release guidance to highlight new developments and troubleshoot problems. The most recent federal and state updates as well as health department implementation highlights are discussed in detail below.
NASTAD is always interested in hearing about specific state processes to prepare for health reform. Please contact Amy Killelea to share activities or specific documents that have been created. We are in the process of creating a webpage to better share these documents.  

In This Edition

From the NASTAD Blog: The Most Recent Health Reform Posts

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AIDS Drug Assistance Program (ADAP) Alerts

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Federal Implementation Updates

Rule Tweak for Individual Mandate Penalty

  • ACTION STEP: Ensure that clients and outreach and enrollment counselors understand open enrollment dates, coverage effective dates, and individual mandate penalty dates.
In October, the Centers for Medicare and Medicaid Services (CMS) Center for Consumer Information and Insurance Oversight (CCIIO) announced a slight modification to when a person must sign up for coverage to comply with the individual mandate (which requires most people to have insurance coverage starting in 2014). The guidance states that anyone who signs up for coverage during the initial open enrollment period (which runs from October 1, 2013 to March 31, 2014) will be deemed to have satisfied the individual mandate, even though coverage effective dates for someone who signs up during the last days of open enrollment could be as late as May 2014. Importantly, this guidance signaled neither a delay of the individual mandate (it is still in effect for 2014) nor an extension of the initial open enrollment period. These important dates are captured below:

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Draft Application for Individual Mandate Exemptions
  • ACTION STEP: Ensure that clients and outreach and enrollment counselors understand the eligibility rules for exemptions from the individual mandate penalty as well as how to apply for one.
CCIIO has published draft applications to determine eligibility for an exemption to purchase insurance. As a reminder, the following are specified exemptions from the requirement to have “minimum essential coverage” starting in 2014:

As noted in the above chart, to be eligible for certain exemptions, a person must apply directly to the Marketplace, while for others, the exemption is claimed when a person files his or her federal taxes.

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Proposed Rule on Basic Health Plan
  • ACTION STEP: Monitor state plans to implement a Basic Health Plan and assess impact on clients.
In September, the Department of Health and Human Services (HHS) issued a notice of proposed rulemaking implementing the ACA’s Basic Health Plan. The purpose of the Basic Health Plan is to minimize churn between Medicaid and subsidized Qualified Health Plan (QHP) coverage by allowing states to put in place a public program for people with income between 139 and 200% of the federal poverty level (FPL). States pursuing this option are examining ways to design a Basic Health Plan that is closely aligned to Medicaid in order to minimize disruptions in care for people whose income may fluctuate between Medicaid eligibility and QHP coverage. States receive federal payments (95% of the amount individuals would have received in federal subsidies had they enrolled in subsidized QHPs through the Marketplace) to fund the Basic Health Plan. The earliest states may enact a Basic Health Plan is 2015.

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U.S. Pharmacopeia Medicare Model Guidelines Revisions
  • ACTION STEP: Monitor federal release of revised guidelines and any insurance plan changes in compliance with updated guidelines.
As part of the Essential Health Benefits (EHB) provisions, the ACA requires plans sold in the individual and small group markets (including plans sold through the Marketplaces) as well as Medicaid expansion benefits to cover the greater of:
  • One drug in every category and class (as defined by the U.S. Pharmacopeia (USP) classification system); or
  • The same number of drugs in each category and class as the EHB-benchmark plan.
The USP guidelines also govern Medicare prescription drug coverage. The guidelines are periodically updated to reflect new therapies and the guidelines are currently undergoing revision (USP Medicare Model Guidelines v.6.0). The new version will be finalized early in 2014 and incorporates several important changes, including: adding combination HIV therapies to the example drug list (with the exception of Atripla, however, NASTAD and HIV advocates are pushing for inclusion of Atripla in the final version; adding a new “Integrase Inhibitor” antiviral class; adding an “Anti-HCV, NS3 Protease Inhibitor” drug class; and including Boceprevir and Telaprevir on the example drug list.

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Federal Guidance on Same-Sex Marriage
  • ACTION STEP: Make sure that outreach and enrollment counselors as well as married same-sex couples understand the federal definition of “household” and implications for ACA income eligibility.
The Supreme Court’s decision striking down a key provision of the Defense of Marriage Act (DOMA) means that same-sex couples who are legally married will be entitled to the same treatment under federal law as opposite-sex married couples. The decision will have implications for the way that income eligibility is determined for federal programs – including ACA programs. In September, CMS issued guidance (a letter from CCIIO and a letter from the Center for Medicaid and CHIP Services) clarifying that in light of the DOMA decision, people who file their taxes as married filing jointly will have both incomes considered in determining income eligibility for the ACA’s premium tax credits and cost-sharing reductions. However, the federal guidance also clarified that states may opt not to recognize same-sex marriages for purposes of Medicaid and the Children’s Health Insurance Program (CHIP) income eligibility. Additional guidance on how the DOMA ruling impacts other federal programs is expected.

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Federal Guidance on ACA and Immigrants
  • ACTION STEP: Ensure that immigrants understand ACA coverage options and protected application information.
The Immigration and Customs Enforcement Agency (ICE) recently released guidance with regard to use of ACA application information. ICE has clarified that it will not use application information provided to Marketplaces as a basis for pursuing civil immigration enforcement actions against individual applicants or members of their family. The National Immigration Law Center has also published helpful resources on the ACA’s impact on immigrant communities. In particular, this Quick Guide to Immigrant Eligibility for ACA, is extremely useful.

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Federal Guidance on Pharmaceutical Co-pay Assistance Programs and Marketplace Plans
  • ACTION STEP: Ensure that providers and clients know about co-pay assistance program resources and how to access them.
The Secretary of HHS recently provided guidance on whether pharmaceutical co-pay assistance programs will be able to interact with QHPs available through the Marketplace. At issue was interpretation of the federal anti-kickback statute – which prohibits the exchange of anything of value to induce the referral of “federal health care program” business – and whether co-pay assistance programs would be allowed to provide financial assistance to people receiving health insurance through the ACA’s Marketplaces. The recent HHS guidance states that the federal government “does not consider QHPs, other programs related to the Federally-Facilitated Marketplace, and other programs under Title I of the Affordable Care Act to be federal health care programs,” meaning that co-pay assistance programs will be able to interact with these plans moving forward. This is a significant advocacy victory for the HIV community and will help many people living with HIV and viral hepatitis with the high cost sharing attached to their medications.

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State Implementation Updates

Marketplace Rollout
  • ACTION STEP: Monitor state and federal rollout of Marketplace web portals, including announced delays in operability.
On October 1, 2013 Marketplaces opened for business. However, Marketplace web portals (particularly the portal for federally facilitated Marketplaces) have experienced glitches, delays, and other problems. The federal government has committed to making the federal Marketplace portal fully functional by the end of November. In the meantime, the portal has already undergone some adjustments, including directions for applicants to pursue application by phone or in-person. A particular challenge exacerbated by the federal Marketplace portal problems has been the accessibility of QHP information. To help provide access to plan information while the federal portal undergoes adjustments, has been updated to include a search feature of plan options. Once specific plans have been identified, programs have had some success in reaching out directly to QHPs in their state to obtain formulary, provider network, and cost information. NASTAD has recently published a plan assessment tool to assist states in assessing QHP options and deciding which QHPs insurance programs will be able to assist clients to purchase. State-run Marketplaces have been more successful in troubleshooting glitches, and thousands of people (including people living with HIV and viral hepatitis) have already signed up for coverage.

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Health Department Planning

ADAP Assessment of Marketplace Plan Options

As plan information becomes available, ADAP/Part B insurance purchasing programs have developed assessment criteria to determine which plans programs will assist clients to purchase. Significant variation in availability of plan information means that this process is taking more time in some states than in others. Programs that have obtained specific plan information have developed the following comparison and client screening tools which may be useful for other programs:
Importantly, many state programs have communicated with clients, case managers, and community partners, encouraging them to delay QHP enrollment decisions until ADAP/Part B insurance purchasing programs are able to conduct a thorough analysis of plan options and provide program guidance on which plans the program will be able to assist clients to purchase.
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Health Reform Resources
For questions or for suggestions for NASTAD health reform resources that would be helpful to your program, please contact Amy Killelea.

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