Insurance Exchanges

How would a Supreme Court ruling for the plaintiff in King v. Burwell affect consumers, insurers, providers, and states? A new series on The Commonwealth Fund Blog looks at the potential real-world impact of the case being argued next week. The series will examine the consequences of a decision that would end subsidies for residents of the 34 states that have federally run health insurance marketplaces. The first post looks at how individual consumers would fare in health insurance markets that would likely function even more poorly than those that existed before the Affordable Care Act was enacted.

Analysis of Marketplace enrollment has focused primarily on the initial 2014 open enrollment period. But as the second open enrollment period ends—and as open enrollment periods shorten in future years—special enrollment periods (SEPs) will warrant increasing attention. This paper analyzes the legal framework, limited enrollment data, and first year special enrollment experiences in five State-Based Marketplaces (SBMs) and finds that Marketplace systems and consumer outreach and enrollment efforts did not yet match the significant potential for SEP enrollment. The paper identifies several themes that may help policymakers improve SEP enrollment systems in 2015 and beyond.

This final rule sets forth payment parameters and provisions related to the risk adjustment, reinsurance, and risk corridors programs; cost sharing parameters and cost-sharing reductions; and user fees for Federally-facilitated Exchanges. It also finalizes additional standards for the individual market annual open enrollment period for the 2016 benefit year, essential health benefits, qualified health plans, network adequacy, quality improvement strategies, the Small Business Health Options Program, guaranteed availability, guaranteed renewability, minimum essential coverage, the rate review program, the medical loss ratio program, and other related topics.

Private insurance plans typically require some form of cost sharing (also called out-of-pocket costs) when enrollees receive a health care service covered by their plan.  These expenses, which are in addition to the amount an enrollee spends on his or her monthly premium, come in a variety of forms, including copayments, coinsurance, and deductibles. Insurers use cost sharing to keep down monthly premiums, but cost sharing can also lead to unexpected costs for some enrollees and can be difficult to decipher when shopping for plans or reviewing medical bills. This brief shows the cost sharing in plans sold to individuals through Healthcare.gov, with a focus on the variation in the ways plans may set cost sharing for services, such as physician visits, prescription drugs, and hospital stays.

The Affordable Care Act's drafters envisioned a continuing, significant role for brokers in the reformed nongroup insurance markets, but circumstances limited their active participation in the first year of marketplace enrollment. This analysis delineates the early barriers to brokers' full engagement, highlights the main concerns with their having a more prominent role and offers options for making them more effective in enrolling the uninsured. The information presented in this brief is based upon interviews conducted with stakeholders (e.g., providers, insurers, consumer advocates, navigators, assisters, brokers) in 21 states and the District of Columbia during the first half of 2014.