Marketplace Annual Redeterminations for Health Coverage
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Marketplace Annual Redeterminations for Health Coverage CMS Proposed Rule. Reducing Coverage Gaps. Historically, coverage loss at renewal is all too common in public health coverage programs like Medicaid and CHIP

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Reducing coverage gaps
Reducing Coverage Gaps

  • Historically, coverage loss at renewal is all too common in public health coverage programs like Medicaid and CHIP

  • Some 8 million consumers will experience the Marketplace renewal process this fall for the first time, and millions more will need to recertify their Medicaid eligibility

  • 2014 coverage ends December 31, 2014 for all plans

  • Conducting outreach now is critical to ensure the efficiency of the 2014-2015 open enrollment period

Current marketplace redeterminations protocols
Current Marketplace Redeterminations Protocols*

  • Insurer will send information prior to November 15thabout updated premiums and benefits

    • If consumer is happy with current plan—and income or household size HAVE NOT changed—s/he doesn’t need to do anything.

      • The Marketplace will auto-enroll the consumer in the same plan for 2015

    • If income or household size HAVE changed, the consumer will need to report it to the Marketplace to get the correct PTC amount

      • If information is not updated, the PTC from 2014 will be used

*Source: Blog 6-30-14

Current marketplace redeterminations protocols1
Current Marketplace Redeterminations Protocols*

  • If a consumer wants to change plans, s/he can:

    • Choose any other Marketplace plan within the same insurer and service area if s/he wants to stay with same company

    • Choose a new health plan from a different insurance company through the Marketplace

    • Buy a new private plan outside the Marketplace. (Will not be eligible for PTC or CSR)

  • In some cases, 2014 plans won’t be offered in 2015. These individuals will be automatically enrolled in a similar plan unless s/he chooses another plan and enrolls.

    • Will be eligible for SEP because of plan ending

*Source: Blog 6-30-14

Auto enrollment

  • Aaron Albright, a spokesman at CMS said, “At least 95 percent* of consumers in the Marketplace will not have to do anything to renew their plans and their financial assistance. They won’t have to do anything to re-enroll.”

  • However, it may be to a consumer’s advantage to have the Marketplace reassess their eligibility and recalculate subsidies due to possible premium increases for 2015—many may be eligible for larger subsidies.

*Source: NY Times 6-26-14

Auto enrollment1

  • Consumers should be strongly encouraged to use the open enrollment period as an opportunity to update their information and reevaluate their health coverage needs for the coming year

  • Consumers (during open enrollment) always have the ability to return to the system for:

    • Shopping

    • Changing plans

    • Reporting life changes

Auto enrollment2

  • It is important to remember that even if a consumer is auto-enrolled (by choice or unaware of the redetermination process), he or she can still go back into their Marketplace account during open enrollment to

    • Cancel or change their plan

    • Update eligibility information

  • Any plan selections or eligibility updates made will follow existing effective dates

Hhs proposed rule
HHS Proposed Rule

  • On June 26, 2014, HHS published a proposed rule in the Federal Register entitled Patient Protection and Affordable Care Act; Annual Eligibility Redeterminations for Exchange Participation and Insurance Affordability Programs; Health Insurance Issuer Standards Under the Affordable Care Act, Including Standards Related to Exchanges

    • Proposes modifications to 45 CFR §155.335 specifying three amendments to annual eligibility redeterminations and renewal and re-enrollment notice requirements for QHPs

  • Comments on the rule are accepted until 5 p.m. on July 28, 2014.

Hhs proposed rule amendment one
HHS Proposed Rule–Amendment One

  • Individuals who request an eligibility determination for APTC or CSR must report all changes in income within 30 days at redetermination time

  • BUT individuals who have not requested eligibility determinations for PTC cannot be required to report changes that would have affected eligibility had they requested assistance

  • Does not propose to allow the Marketplace to establish a reasonable threshold for changes in income—any changes should be reported

Hhs proposed rule amendment two
HHS Proposed Rule—Amendment Two

  • The Marketplace can refuse to accept reporting of changes by mail in circumstances affecting eligibility

    • Due to the dynamic and intricate process of eligibility redetermination, HHS has concluded it is better to conduct the entire process by phone (online and in-person is also permitted)

  • If this proposal is finalized, the Marketplace will cease to accept change reporting by mail.

    • Medicaid agencies must still allow an individual to respond to an annual redetermination or report changes via mail

Hhs proposed rule amendment three
HHS Proposed Rule—Amendment Three

  • If individuals are enrolled in a QHP for one year, they are automatically reenrolled unless they terminate coverage or switch plans.

  • Addresses what will happen if an enrollee’s plan is no longer available in the following order of priority:

    • The enrollee’s coverage will be renewed in a plan at the same metal level as the enrollee’s current QHP

    • If the enrollee’s current QHP is not available and the product no longer includes a plan at the same metal level as the current QHP, the coverage will be renewed in a plan that is one metal level higher or lower than the enrollee’s current QHP

    • The above conditions apply, and the product no longer includes a plan at a metal level higher or lower than the current QHP, then the enrollee’s coverage will be renewed in any other plan under the product in which the enrollee's current QHP is offered and the enrollee is eligible to enroll

Ffm standard notices
FFM Standard Notices

  • First, the Marketplace will request updated tax return information from the Secretary of the Treasury for all enrollees receiving advance payments of the premium tax credit (APTC) or cost-sharing reductions (CSR), and who have authorized the Marketplace to request updated tax return information for purposes of annual redetermination

  • The Marketplace will provide three notices based on the information received, although the notices may be combined for efficiency

Ffm standard notices1
FFM Standard Notices

  • The Marketplace will send a notice to all qualified individuals, including those who didn’t enroll, who submitted an application to the Marketplace during the 2014 plan year.

  • The notice will contain:

    • Open enrollment dates for 2015 plan year

    • A description of the annual redetermination and renewal process

    • Reminder of the requirement to report changes

    • Key dates for ensuring coverage effective January 1, 2015

    • Group-specific information on next steps (standard, income-based or special notices)

Issuer notices
Issuer Notices

Notices from insurers must contain:

  • PTC information sufficient to inform enrollees of expected monthly premium payments under the renewed coverage;

  • An explanation of the requirement that enrollees report changes that might affect eligibility to the Marketplace, the timeframe and channels through which changes can be reported, and the implications of not reporting changes;

  • For enrollees with PTCs, a description of the APTC reconciliation process; and

  • For enrollees who receive CSRs if the enrollee is being renewed in a QHP at a non-silver metal level, an explanation that, unless the enrollee selects a new silver-level plan, CSRs will not be provided for the upcoming year

Issuer notices1
Issuer Notices

  • For non-grandfathered individual policies, notices must be sent before the 1st day of Open Enrollment

  • For grandfathered individual policies, notices must be sent at least 60 calendar days before renewal

  • Discontinuance notices must be sent 90 days prior to discontinuation

Income based outreach notices
Income-based Outreach Notices

  • IRS provides updated information from tax data that reflects:

    • A household income in excess of 350% of the FPL

    • A increase or decrease in household income of greater than 50%, when compared to the household income from the most recent Marketplace eligibility determination for 2014

Income based outreach notices1
Income-based Outreach Notices

  • For an enrollee who authorized the Marketplace to request updated tax return information for use in the annual redetermination process:

    • For those receiving APTC, a description of the reconciliation process

    • Notice will include a projected eligibility determination for insurance affordability programs for the following year based on the tax information and all other eligibility information on file with the Marketplace regarding income and family size

      • It will also include projected plan premiums for the individual’s QHP and information on the benchmark plan

Income based outreach notices2
Income-based Outreach Notices

  • For an enrollee who did not authorize the Marketplace to request updated tax return information for use in the annual redetermination process (reportedly about 100,000 individuals):

    • For those receiving APTC and CSR, an explanation that unless the individual contacts the Marketplace to obtain an updated eligibility determination by December 15th for coverage effective January 1, 2015, APTC and CSR will end on December 31, 2014

    • The Marketplace will renew the enrollee’s coverage in a QHP for 2015 without APTC and CSR if coverage is otherwise renewable

Special notices individuals found in excess of 500 fpl
Special Notices: Individuals Found in Excess of 500% FPL

  • Individuals who are enrolled in a Marketplace QHP with APTC or CSR who authorized the Marketplace to request updated tax information will receive the standard notice, and they will be told that if they do not contact the Marketplace to update their information they will be terminated from PTC and CSR and be reenrolled in their QHP without assistance if the plan is renewable

    • Individuals must report eligibility changes by December 15, 2014 to receive an updated eligibility determination

Evaluating outcomes of the new rule
Evaluating Outcomes of the New Rule


  • Many consumers may not be aware of the redetermination process (do not open their postal mail or email)

  • Indiana’s market is increasing which may offer better plans for consumers thinking about reenrolling in their current QHP

  • Worries about the formula that determines which plan is most similar if a consumer’s original plan is unavailable


  • Greater attention can be given to people who remain uninsured

  • Simplified process for the consumer

  • Ensures that consumers can easily retain their coverage

  • Indiana’s market is increasing which means a greater selection

Indiana s expanding insurance market
Indiana’s Expanding* Insurance Market

  • The following Insurers have applied to HHS to offer health plans in Indiana:

    • AllSavers Insurance

    • Southeastern Indiana Health Organization

    • Indiana University Health Plans, Inc.

    • Time Insurance Company

    • CareSource Indiana

    • MDWise

    • Coordinated Care (Celtic) (HMO)

    • Advantage Health Solutions

    • Physicians Health Plan of Northern Indiana

    • Anthem Blue Cross (WellPoint Inc.)

*These are not officially approved

Educating consumers about the renewal process
Educating Consumers about the Renewal Process

  • Establish a systematic way for staff to remind consumers about their coverage renewal date and/or the Open Enrollment period

  • Add an alert to medical records that staff can see when patients come in for appointments

  • Use social media to promote messages that inform about reporting life changes and renewal processes

  • Use appointment cards, posters and mailings to communicate with patients at time of renewal

  • Develop materials geared toward your clients that highlight the key aspects of the renewal process


  • Read the entire proposed rule

  • Enroll America’s guide: Helping Consumers Keep Affordable Health Coverage

  • Five Recommendations to Make Renewal a Success (Enroll America)

  • Supporting Consumers After Enrollment (Part 1)

  • Instructions for Draft Standard Notices of Product Discontinuation and Renewal (CMS)

    • Insurance Standards Bulletin Series—Information (CMS)

Questions or comments
Questions or Comments?

Jessica Ellis, Outreach & Enrollment Specialist

(317) 630-0845

Emily Daw, Outreach & Enrollment Assistant

(317) 630-0845