Executive Summary

Maine’s potential transition to a state-based marketplace (SBM) presents an opportunity to expand coverage and increase affordability for health care consumers in Maine. This report explores these opportunities and provides policy recommendations to advance these goals. Under the Affordable Care Act (ACA), states can implement their own health insurance marketplaces for the individual and small-group markets, which provide states greater flexibility and independence than using the federally-facilitated marketplace (FFM) on Healthcare.gov. Prior to November 2020, Maine’s participation in the FFM exposed the state to the Trump administration’s shortening of open enrollment periods (OEPs), funding cuts to outreach and enrollment efforts, and the refusal to create a special enrollment period (SEP) for the coronavirus pandemic. In March 2020, Governor Janet Mills signed the Made for Maine Health Coverage Act (H.P. 1425) authorizing the development of an SBM in Maine.1 This report explores the opportunities associated with a potential marketplace transition, informed by over 30 interviews with stakeholder groups across Maine in the fall of 2020. Through this work we learned that the transition to an SBM has the potential to close coverage gaps, enhance outreach to groups that have been historically marginalized in the health care system, and improve population health. This report also applies a framework of targeted universalism throughout its analysis. This goal-oriented mode of equity analysis informs many recommendations focused on making health care accessible and affordable to all Mainers, particularly those historically marginalized by the health care system. Broad Recommendations

In addition to our below recommendations on specific topics, our interviews and research led us to make the following overarching proposals, which should guide the overall transition to an SBM and ensure that consumer engagement and support is at the core of the transition. 1. Increase consumer assistance capacity. 2. Integrate consumer engagement into the process of designing and implementing Maine’s SBM. 3. As a longer-term initiative, re-establish the Maine

Office of Health Equity and empower its staff to coordinate equity efforts across the SBM, the

MaineCare program, and all Department of Health and Human Services (DHHS) Offices.

Using information gathered in our research and interviews, we analyze several policy options pertaining to topics that Maine’s DHHS asked our team to explore. In particular, we were tasked with identifying opportunities for reducing complexity for consumers and improving overall enrollment and affordability. We employ a decision matrix that assesses these policy options for their consumer impact and state feasibility. Based on this analytical framework, we propose the recommendations listed below to guide the implementation and achieve the promise of an SBM.

Enrollment Periods

• Establish an OEP that runs until January 31, so the period lasts a total of 92 days. • Implement SEPs for public health crises, for individuals who become pregnant outside of open enrollment, and for uninsured tax filers beginning the day that their state tax return is filed. • Explore options for an SEP directly after the OEP for Mainers who had valid reasons to miss the OEP deadline.

Displaying Clear Choice Plans

• Use an intake questionnaire and display plans based on responses. • Build a comparison tool that: (1) automatically highlights differences between selected plans, and (2) includes a “Compare to Other Standard Plans” function. • Include a pop-up glossary feature when customers hover over a technical term, and enable screen reading audio capability for accessibility. • Distinguish Clear Choice plans with naming, visual cues, sorting, and/or filtering.

Auto-Renewal

• Design more consumer-friendly auto-renewal notices. • Set the default for consumers eligible for cost-sharing reductions to high-value silver plans. • Auto-renew consumers with discontinued plans into Clear Choice plans. • Explore using auto-renewal defaults to incentivize carriers to lower costs. • Consider allowing consumers to choose their auto-renewal priorities.

MaineCare Integration

• Use existing state data to target and personalize outreach to facilitate enrollment. • Resolve consumer-facing bottlenecks in MaineCare and SBM enrollment. • Embed the Office for Family Independence (OFI) in the policy planning and SBM implementation process, given their responsibility for determining MaineCare eligibility.

Planning for the Future

• In the procurement, implementation, and maintenance of the SBM eligibility and enrollment system, prioritize platform capacity to adjust the inputs for the rules engine to adapt to federal policy innovations and changes.