Enrollment Periods

The flexibility of an SBM offers opportunities to expand OEPs and SEPs, which can promote greater access to health care for populations in Maine that have historically faced barriers to accessing insurance and care.

This section first outlines the current status of OEPs and SEPs for the FFM and state marketplaces. This is followed by five policy recommendations, based on our research and interviews with Maine stakeholders. These recommendations are aimed at maximizing insurance coverage while accounting for some of the potential limitations presented by adverse selection.

We recommend the following:

1. Establish an OEP that runs until January 31, so the period lasts a total of 92 days. 2. 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. 3. Explore options for an SEP directly after the OEP for Mainers who had valid reasons to miss the

OEP deadline.

Background

Open enrollment periods are intended to give consumers a window to enroll in health coverage and prevent consumers from waiting until they are sick to enroll. The FFM currently operates an annual 45-day OEP beginning on November 1 and ending December 15. In addition, the ACA offers eligible individuals the ability to enroll in coverage outside of the standard open enrollment timeframe through various SEPs.72 These SEPs are offered by both the FFM and SBMs and are triggered by qualifying life events. The primary types of triggers are loss of qualifying health coverage, change in household size or residence, change in eligibility for marketplace coverage or subsidies for coverage, or enrollment or plan error.i

The details of eligibility and verification for an SEP depend on the event type. In 2017, the federal government added restrictions for some of these events, making it more difficult for consumers on the federal platform to enroll in health coverage outside of the OEP.73 For example, the new rules required pre-enrollment verification for all SEPs, which could act as a hurdle to consumers and reduce overall marketplace enrollment. These new restrictions do not apply to SBMs. In addition to shielding consumers from restrictive enrollment policies at the federal level, SBMs provide states their own unique decision-making flexibilities. SBMs have added a number of new SEPs such as: • Public health emergency (COVID-19); • Pregnancy; • Change in disability status; • Natural disaster or act of terror; • Loss of military insurance; • Loss of hardship exemption; and • Issues with insurance carriers, enrollment processes, payment, etc. Maine may benefit from instituting any or all of the above SEP types. Implementing new SEPs could offer an opportunity to increase coverage, especially for individuals experiencing life challenges that would be exacerbated by significant health care bills. For example, during the coronavirus pandemic, most SBMs implemented an SEP to allow marketplace enrollment, while the FFM relied on its usual SEPs.74 This policy provided an opportunity for many Americans to face the pandemic better prepared for the health and economic consequences of contracting COVID-19. Meanwhile, some believe SEPs provide a disincentive to sign up during open enrollment as individuals may wait to enroll only when they need coverage if they know they will qualify for an SEP. One analysis of an insurer’s data in 2015-2016 provides some evidence that SEP enrollees have higher inpatient and emergency department costs.75 However, the stakeholders we interviewed did not express significant concerns about SEP impacts on premiums. While we heard some concerns from carriers about risk pooling, we also heard that SEP enrollment has not been as expensive for insurers as originally feared, at least since SEPs became more strictly verified.ii Therefore, it does not appear that risk pooling concerns in general should preclude an expansion of SEPs in Maine. When implementing any new SEPs, careful consideration should be given to whether verification is truly needed, as it adds complexity to the consumer experience which may reduce the policy’s effectiveness. The Biden administration may potentially expand en-

i There are also a number of other more complex SEPs, such as when a Medicaid application filed during OEP is denied after the deadline. Source: “Enroll in or change 2020 plans — only with a Special Enrollment Period.” Healthcare.gov. https://www.healthcare.gov/coverage-outside-open-enrollment/special-enrollment-period/ ii This statement is based on background interviews with Maine stakeholders. For a recent analysis of changes to SEP risk-adjustment since 2017, see: Dorn, Stan, Bowen Garrett, and Marni Epstein. “New risk-adjustment policies reduce but do not eliminate special enrollment period underpayment.” Health Affairs 37.2 (2018): 308-315. ENROLLMENT PERIODS | 23

rollment opportunities in order to bolster insurance coverage in the aftermath of the coronavirus pandemic. This may be a chance for Maine to glean additional perspectives using data from any SEP or OEP expansions in the FFM.76 In addition to the recommendations we discuss below, the State should seek to leverage federal outcomes in the upcoming year to enhance analysis of enrollment trends. Recommendation 1: Establish an OEP that runs until January 31, so the period lasts a total of 92 days.

The Trump administration has reduced the length of the FFM’s OEP from 92 days (November 1 to January 31) to 45 days (November 1 to December 15). This policy constrains the time consumers have to enroll during a season in which many Americans are already experiencing a scarcity of time, money, or other resources.77 This lack of mental bandwidth can make it harder for individuals to complete complex tasks like health insurance enrollment.78 One opportunity for states transitioning to an SBM is the ability to decide the length of their OEP, which for the most part means extending the period. Table 1 displays the OEP closing dates used by SBMs and Table 2 displays deadlines for January 1 coverage. No OEP begins before or after November 1.

Consumer Impact

A longer OEP would have a positive effect on coverage and would allow more time for enrollment assisters to provide outreach and enrollment support to marginalized communities. Particularly for community organizations serving Mainers whose primary language is not English and/or those who cannot or will not enroll directly, an extended OEP is critical to providing sustained enrollment support to consumers. It would also allow more time for consumers to sort through any complexities they face in the process.

State Feasibility

In our interviews, stakeholders demonstrated broad interest in extending the OEP under an SBM. In fact, one stakeholder expressed that if the State was not willing to extend the OEP and add SEPs, building an SBM would not be worth the effort. Enrollment assisters see an extended OEP as an opportunity to partially make up for the barriers to enrollment in Maine,

Table 1. Open Enrollment Period Length by State-Based Marketplace79

OEP Closing Date SBM(s)

December 15 Connecticutiii, Idahoiv, Maryland, and Vermont December 22 Minnesota January 15 Colorado, Nevada, Pennsylvania, and Washington January 23 Massachusetts and Rhode Island January 31 California, New Jersey, New York, and Washington, DC

Table 2. Deadline for January 1 Coverage by State-Based Marketplace

Deadline* for January 1 coverage SBM(s)

December 15 Coloradov, Connecticut, Idaho, Maryland, New York, Vermont, Washington, and Washington, DC December 22 Minnesota, Pennsylvania December 23 Massachusetts December 30 California December 31 Nevada, New Jersey, and Rhode Island

*Coverage purchased after this date is effective February 1; however, coverage purchased between January 15 and January 31 in New York and Washington, DC is effective March 1.

iii Connecticut has extended the 2021 OEP to January 15, 2021 due to the coronavirus pandemic. If residents enroll during the extension, their coverage starts February 1, 2021. iv Idaho has extended the 2021 OEP to December 31, 2020, the last date to apply for January 1, 2021 coverage. v This year, Colorado temporarily extended the enrollment deadline for January 1 coverage to December 18, 2020. 24 | ENROLLMENT PERIODS

including technological limitations and system outages, language barriers, low call center capacity, and delayed notices by mail. We heard from these groups that Mainers rely on enrollment assisters because they lack internet access at home, in addition to wanting one-on-one support with the enrollment process. Assisters also cited lack of trust in the health care system and confusing eligibility requirements for certain communities, like immigrants and refugees, as barriers to enrollment in a short OEP. These assisters see the current six-week period as a “mad dash” and “absolute insanity,” and would benefit from more time to adequately serve Mainers. Although carriers highlighted that many Mainers enroll close to the deadline80 regardless of the date, they were broadly accepting of an extended OEP, as long as the length would not facilitate increased adverse selection. In response to this concern, one consumer advocacy group pointed out that shorter OEPs discourage younger consumers, for whom the costs (complexity, time, money, etc.) of enrollment outweigh the benefits, potentially cutting out a population that is traditionally valuable to carriers.81

Finally, one stakeholder expressed interest in starting the OEP earlier, rather than pushing the deadline later, due to the time constraints for processing enrollments after December 15, and one stakeholder supported extending the OEP for as long as possible. Extending the OEP would have a limited budget impact, with the largest expenses likely to be increased marketing and employing call center staff for a longer period of time. Implementation would be relatively straightforward. If the OEP were to be extended later, the State would need to work with insurers to build adequate processes to begin coverage no later than February 1 for consumers who enroll between December 16 and January 31. The State could join most other SBMs in requiring consumers to enroll by December 15 for January 1 coverage. Recommendation 2: Implement an SEP for public health crises.

In response to the coronavirus pandemic, 12 of 13 SBMs opened a broad SEP, while the federal marketplace did not.82 These emergency SEPs ranged from six weeks to six months. While the FFM SEP for lost coverage allowed many of the newly unemployed to enroll, those who did not have health coverage when they lost their job do not qualify.83 We recommend using such an SEP to improve health insurance coverage in future public health crises.

Consumer Impact

The most significant consumer impact of such an SEP is that insured rates could increase during the public health crisis. There is evidence that several SBM states with a COVID-19 SEP had much greater marketplace enrollment in the first months of the pandemic response than FFM states.84 Consumers who enroll using the SEP could gain the financial security to utilize more preventive health care or access a provider when sick. This might improve their health outcomes and also could have positive spillovers to the crisis response by limiting contagion.

State Feasibility

A number of the stakeholders we interviewed expressed support for an SEP in response to COVID-19 and similar public health crises. As this was implemented in almost all SBM states, it is likely feasible from a political and implementation standpoint. While there may be some variable costs, budget impacts should be limited given that the marketplace will already be providing other SEPs. In our stakeholder interviews, one carrier expressed concerns about possible risk pooling issues for such an SEP. However, the COVID-19 instance provides a counterexample to this concern. Carrier spending on reimbursements has dropped significantly during the pandemic.85 It appears that carriers, at least in this crisis, would have substantial cushion to absorb risk pooling costs. Meanwhile, increasing the coverage rate might be useful to provide some help to hospital budgets given they have been deeply strained during the pandemic.86

Recommendation 3: Establish an SEP for individuals who become pregnant.

Uninsured individuals who become pregnant should be eligible for an SEP following verification of pregnancy by a provider. This would lead to greater access to prenatal care, which impacts maternal and infant health. Limiting the length of this SEP may reduce the risk of pregnant individuals waiting until they have significant health care costs before enrolling.vi

vi For example, consumers who are pregnant in a state with no time restrictions on a pregnancy SEP enrollment window may wait until they experience complications before enrolling.

Under current FFM rules, pregnancy is not a qualifying life event that triggers eligibility for an SEP. Uninsured individuals who become pregnant outside of the OEP may become eligible for MaineCare due to higher income eligibility levels for people who are pregnant than for other adults, but only qualify for enrollment in a marketplace plan through other circumstances. An SEP for uninsured individuals who become pregnant is one potential solution that some states have implemented to raise coverage levels for pregnant individuals entering a period associated with high health care costs. This policy option has received substantial support from various groups, including the American Congress of Obstetricians and Gynecologists as well as Planned Parenthood.87

Table 3 lists the states that currently allow an SEP for pregnancy. Total length of the SEP varies; in New York and Vermont, pregnant individuals are permitted to enroll at any time during their pregnancy. All states require some level of verification from a provider, which can be a barrier for uninsured individuals.vii

Table 3. SBMs and Availability of Pregnancy Special Enrollment Period88

State SEP Lengthviii Verification

Connecticut89 30 Days Provider Washington, DC90 60 Days Provider

Maryland91 90 Days Provider

New York92 Unlimited Provider

Vermont93 Unlimited Provider

Consumer Impact

Pregnancy can present health considerations that require affordable access to health care services. For pregnant individuals with no insurance, “maternity care and delivery can cost $10,000 to $20,000 without complications.”94 An SEP for pregnancy ensures that expectant individuals are able to afford prenatal care, which is linked with better health outcomes including lower rates of low birth weight and maternal mortality.95 Encouraging greater utilization of important preventive services can also forestall costlier health issues in the future.

Existing racial disparities could be mitigated with a pregnancy SEP. Data for 2017 indicates that 36.3% of Black pregnant individuals lacked insurance prior to pregnancy, compared to 12.4% of white pregnant individuals.96 Furthermore, Black, Hispanic, and American Indian individuals who are pregnant are all more likely than white pregnant individuals to receive late or no prenatal care in Maine.97 An SEP may be able to address these gaps by encouraging and facilitating coverage for those ineligible for MaineCare.

State Feasibility

Stakeholders we interviewed recognized the importance of establishing a pregnancy SEP, but some carriers also expressed concern about extensive SEPs allowing consumers to selectively choose when they enroll in the marketplace. Enabling a pregnancy SEP may also lead to an influx of consumers with higher health care costs. Yet data suggests that the actual burden on carriers to extend coverage to pregnant individuals should be modest.98 In 2017, an estimated 13.3% of expectant Mainers were uninsured prior to pregnancy.99 Combining this figure with data from Maine’s Division of Public Health Systems provides us with an estimated 1,635 pregnant individuals who were without insurance coverage prior to pregnancy in 2017.ix However, a significant number of these individuals would likely be eligible for MaineCare, given the program’s higher income limits for pregnant individuals. Considering that 39.2% of all births in Maine were covered by MaineCare in 2017 (before the State expanded MaineCare), we would expect only a fraction of those 1,635 individuals who were uninsured prior to pregnancy to require marketplace coverage.100 Placing a time limit on this SEP could lessen concerns about pregnant consumers timing their purchase of insurance to avoid paying into the shared cost pool. If Maine chooses to set a time limit for this SEP, it can follow the examples of other states with limits ranging from 30 days to 90 days. Ensuring that individuals receive prenatal preventive care is likely to translate to lower future costs by avoiding costly complications and NICU admissions.101 Furthermore, providing insurance coverage to pregnant individuals who are ineligible for MaineCare can reduce cost pressures on the State’s Free Care program. Improvements in health outcomes for individuals

vii If necessary, expanding the scope of practice for certain health care workers would enable greater access for uninsured individuals to be able to verify their pregnancy as a requirement for triggering an SEP. This expanded pool can potentially include nurse practitioners, nurse midwives, and physician assistants. viii Starting from the day of provider verification. ix Most recent data available at time of report. Source: “Maternal & Birth Outcomes.” Maine Division of Public Health Systems. Retrieved December 11, 2020. https:// www.maine.gov/dhhs/mecdc/public-health-systems/data-research/vital-records/births.shtml 26 | ENROLLMENT PERIODS

and infants as well as future cost savings likely outweigh any risks of adverse selection. Recommendation 4: Establish an SEP for uninsured tax filers, beginning the day that their state tax return is filed.

The process for this SEP could be modeled on Maryland’s Easy Enrollment system. Uninsured individuals who file taxes would first be screened for MaineCare eligibility; those ineligible for MaineCare would have a set number of days from the filing of their income taxes to enroll in a marketplace plan. In 2015, the FFM enacted a one-time SEP during the tax season as individuals adjusted to the individual mandate and its associated penalty.102 Following the elimination of the federal individual mandate, a number of states implemented their own tax penalties for uninsurance, and similarly provided an SEP for individuals who were unaware of the penalty. This year, California and DC both provided tax filers with a tax season SEP in order to leverage the tax penalty to encourage insurance enrollment.103,104

Maryland, despite lacking an individual mandate for coverage, has established an SEP to enroll tax filers as part of the State’s Easy Enrollment system. Tax filers can check a box on their tax returns indicating that they currently lack insurance and are interested in purchasing coverage (see Figure 2). The state marketplace subsequently coordinates with the State Comptroller to verify a tax filer’s eligibility for Medicaid or premium subsidies.105 All individuals, regardless of eligibility for subsidies, then have a 35-day SEP to enroll. A bill has been introduced in New Jersey to create a similar enrollment system.106

Consumer Impact

In our interviews, some stakeholders mentioned an Easy Enrollment program in Maine as an innovative way to increase coverage. Income taxes are a captive point of interaction between the State and its residents, allowing Maine an opportunity to communicate information on insurance that individuals might otherwise ignore or miss. The State can also obtain income information from taxpayers that can be used to initiate enrollment, including calculating eligibility for MaineCare or APTCs. Maine could leverage a tax filing SEP to drive insurance enrollment by making it convenient for taxpayers to opt-in to applying for insurance ontheir income taxes.x Enabling this SEP could also appeal to individuals who were sidelined during the OEP due to limited finances. With tax refunds in hand, some consumers may be more comfortable buying insurance after the OEP has ended.107

Figure 2. MD Tax Filing Checkoff108

A tax filing SEP opens up the insurance marketplace to a number of consumers who may have less health care utilization. Individuals required to file taxes are likely employed, which research suggests is associat ed with better overall health.109 Historically, income tax filers have also tended to be younger than the general population: in 2018, adults ages 18 to 35 made up 41% of income tax filers under 65, compared to 30% of the overall population of adults under 65.110 These factors all indicate that individuals who enroll as a result of a tax filing SEP may skew younger and healthier, resulting in positive impacts on the risk pool, which could translate to lower costs for consumers.

State Feasibility

This policy would require significant coordination across state government and potentially additional legislation. The SBM, Maine Revenue Services, and OFI would need to coordinate their systems and data-sharing to ensure that tax filers who elect to enroll are given accurate information on their eligibility for MaineCare or subsidies. There would be added complexity and costs for Maine Revenue Services to process and verify the date of tax filing for purposes of triggering an eligibility period.xi

Recommendation 5: Explore options for SEP directly after OEP for Mainers who had valid reasons to miss the OEP deadline.

As discussed above, many consumers will begin marketplace enrollment near the end of the OEP regardless of its length. Ethnographic research on Rhode Island’s SBM found that bureaucratic barriers to enrollment, such as system errors, are a significant factor extending the length of the ACA enrollment process.111 These unexpected barriers may cause a consumer attempting to sign up late in the period to miss the deadline. We recommend exploring the most common reasons for missed deadlines and whether they should be addressed by an SEP extension.xii Stakeholders expressed that some delays outside of consumers’ control include technical delays in eligibility or payment processing, lack of available assister appointments until after the deadline, and long waits for necessary translation or call center services. The technology platform vendor may also be able to proactively identify common enrollment delays in other SBM platforms.

Consumer Impact

This SEP would increase coverage by giving eligible consumers an extra chance to enroll. Given that it would function like a limited extension of the enrollment deadline, the SEP should have a similar risk pool profile to the OEP. Developing such an SEP in consultation with advocates could allow it to be responsive especially to the higher barriers faced by marginalized communities. For example, the policy could extend the deadline via SEP for consumers who did not receive needed translation services prior to the OEP deadline.

Designing a simple verification process for consumers may be difficult, given that the eligibility of the SEP is based on their user experience, not characteristics of the consumer. Still, a verification hurdle might be justified to prevent consumers from counting on the extension deadline as the “real” OEP deadline, defeating the purpose to provide a second chance to meet enrollment deadlines. These concerns will need to be carefully balanced in the design of this type of SEP.

State Feasibility

Limited SEPs for missing the enrollment deadline already exist at the federal level.112 These triggering events include technical errors on the enrollment site or inaction by professional enrollment support.xiii Furthermore, SBMs have used their platform flexibility to expand the list of reasons which qualify a consumer for SEP extension of the OEP.xiv These examples demonstrate that implementing this recommendation is feasible. Such an SEP could also be especially useful in the first year of an SBM to ease the transition and make sure that coverage rates are maximized despite any platform-related issues.

xi As Maryland enters the second year of Easy Enrollment implementation, Maine should coordinate with Maryland to share data and outcomes to better inform implementation of a similar system. xii We envision such SEPs being triggered either by missing the deadline or being notified of an error in the enrollment process at some point after the deadline. This would qualify the enrollee for an SEP of similar length to other SEPs, at least 30 days. xiii “Professional enrollment support” refers to insurance companies, navigators, brokers, or certified application counselors. xiv Examples include SEPs triggered when the OEP deadline is missed due to conditional Medicaid denial after OEP, non-system error, and acts of terror. Source: Rakotoniaina, Adney. “How States Are Increasing Coverage through Special Enrollment Periods.” The National Academy for State Health Policy. September 29, 2020. https:// www.nashp.org/how-states-are-increasing-coverage-through-special-enrollment-periods/ 28 | ENROLLMENT PERIODS