By Emma Walsh-Alker, Georgetown University Center on Health Insurance Reforms
The annual open enrollment period for marketplace coverage is right around the corner. There are many new policies impacting the marketplace in 2023, including an extension of enhanced financial assistance through the Inflation Reduction Act; a federal fix to the “family glitch” that will create more affordable coverage opportunities for families; and tools to make shopping for a marketplace plan more consumer-friendly. Below is a summary of these and other recent policy changes that consumers may encounter this year.
Extension of Enhanced Premium Tax Credit Subsidies: The American Rescue Plan Act (ARPA) of 2021 established enhanced premium tax credits (PTCs) for eligible consumers who enrolled in a marketplace plan in 2021 and 2022. This expansion of affordable coverage helped boost marketplace enrollment to a record high, as an estimated 2.8 million additional consumers received PTC subsidies in 2022. In August 2022, Congress passed the Inflation Reduction Act (IRA), which extended the enhanced PTCs through 2025. Under the enhanced premium credits, families with incomes between 100 and 150 percent of the federal poverty level have their premium contribution reduced to $0. Families with incomes over 400 percent of the federal poverty level have their premium contribution capped at 8.5 percent of their household income.
Fixing the Family Glitch: This year, the Biden administration has proposed a new policy to fix the longstanding “family glitch.” Previously, if an employer offered affordable health coverage (defined in 2023 as coverage with an annual premium that costs less than 9.12 percent of your total household income) to an employee but not to the employee’s family, the entire family would be ineligible for subsidized coverage on the marketplace. Once the new rule is finalized (which is expected before the start of open enrollment), as many as one million people may be eligible for more affordable marketplace coverage.
Extended Special Enrollment Opportunity for Low-Income Groups & Reduced Paperwork Requirements: Individuals and families with household income under 150 percent of the federal poverty level are eligible for a monthly special enrollment period (SEP) if their premiums would be $0 after applying tax credits. This opportunity will continue through 2025, as the low-income SEP is tied to the enhanced premium tax credit subsidies under the IRA. The SEP is available to eligible marketplace enrollees in most states. However, state-based marketplaces (SBMs) can choose whether or not to implement this low-income SEP, so check with your state marketplace to confirm that is offered in your state.
In addition to the extension of the low-income SEP, consumers will face less paperwork when applying for a SEP this year. Since eligible individuals and families can be deterred from applying for a SEP when required to submit excessive documentation, the new policy will give SBMs more flexibility to verify eligibility and lessen administrative burdens on consumers.
Extension of Failure to Reconcile Tax Credits: Under regular rules, individuals who fail to file taxes and reconcile the PTCs they received in the previous year with the amount they should have received may lose their PTCs when they are automatically reenrolled in a marketplace plan. This is not the case for plan year 2023. Federal guidance granting flexibility to taxpayers in response to COVID-19 prevents individuals from losing their advanced PTCs for 2023 coverage for failure to reconcile their past year’s PTCs.
Historic Investment in Consumer Assistance: Recognizing the importance of navigators in providing outreach, education, and enrollment services for consumers, the Biden administration has awarded nearly $100 million of funding to navigator organizations for this year’s open enrollment period. Navigator grantees will be particularly focused on helping traditionally underserved communities access affordable marketplace coverage. A portion of federal funding is also earmarked for assisting eligible Medicaid beneficiaries transition to marketplace coverage.
Price Comparison Tools: Beginning January 1, 2023, federal law will require health plans to develop and maintain an online price comparison tool for plan enrollees. This new tool will allow enrollees to compare the amount of cost-sharing they are responsible for across providers in their plan network. In 2023, price comparison tools must include data for the 500 most common medical services. Plans will also be required to offer price comparison guidance over the phone.
Standardized Benefit Design Options: Beginning in plan year 2023, insurers offering plans on HealthCare.gov are required to offer standardized plan options. This means that for every product, metal level, and geographic market in which insurers offer a “non-standardized” plan, they must also provide a standardized option that shares common features (like deductibles and cost-sharing) with products at the same metal level offered by other insurers. The goal of this new policy is to simplify the plan selection process for consumers shopping for health coverage on the marketplace.
Past-due Premiums: A previous policy allowed insurers to deny coverage to individuals who owe a past-due premium for prior coverage. That policy has been reversed for plan year 2023. If a consumer applying for coverage on the marketplace owes outstanding premiums, an insurer cannot require the enrollee to pay the debt as a condition of enrolling in a new plan.
Requirements for Web-Brokers: Web-brokers that are authorized to assist consumers with QHP enrollment must meet certain new requirements to help consumers make informed enrollment decisions. For example, websites must non-deferentially display comparative information for all QHPs offered including but not limited to premium and cost-sharing information, summary of benefits and coverage, provider directories, and quality ratings. If a web-broker does not support enrollment in all the QHP options available to consumers, the website must disclose this through a standardized disclaimer from HHS and direct consumers to the appropriate exchange website where they can access a complete list of their enrollment options.
Free Coverage of At-Home COVID-19 Tests for the Duration of the Public Health Emergency: As of January 2022, federal guidance requires insurers to cover and waive cost-sharing for at-home COVID-19 tests that are sold over-the-counter. Insurers must fully reimburse the cost of authorized at-home tests regardless of whether the test was deemed medically necessary by a health care provider. However, insurers are allowed to limit enrollees to receiving 8 free tests per member per month.
Stay tuned for more information about marketplace enrollment in our Navigator Resource Guide, set to relaunch at the end of October. The updated guide will feature frequently asked questions (FAQs), resources for diverse communities (including FAQs available in Spanish), state-specific enrollment information, the opportunity for navigators and consumers to “Ask an Expert” complex enrollment questions, and more.
[This blog was originally published by the Georgetown University Center on Health Insurance Reforms, an independent research center based at the McCourt School of Public Policy.]