Preparing for 2019 Open Enrollment: Softheon Enhanced Direct Enrollment (EDE) delivers a better consumer experience and enables new consumer self-service policy management capabilities

As health plans consider implementing and launching an EDE solution for ACA 2019 Open Enrollment, it’s become clear that EDE is much more than an improvement to the Marketplace (or on-exchange) enrollment process and post- enrollment policy management for consumers – it’s the beginning of a real-time, API driven service to promote an improved healthcare consumer insurance benefit shopping experience with online self-service updates.

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NMHIX: New Mexico State Health Insurance Exchange 2018 and beyond

New Mexico (beWellNM) is one of only five states that operates a state-based marketplace on the federal platform, more commonly known as SBM-FP. While this platform has proven to be successful for the last 5 years, the state has recently started looking to revitalize its exchange.

On December 13, 2012, New Mexico submitted a technical implementation letter to CMS to become a state-based health insurance exchange and was approved by CMS on January 3, 2013 to begin to follow and comply with state-based regulations. In an effort to grow into the healthcare era, NMHIX Centennial Care, New Mexico requested an extension on its current 1115 waiver, which is set to expire by December 31, 2018. The waiver, which will renew the state’s Medicaid managed care program, was sent to CMS on December 6, 2017. CMS has acknowledged the letter and confirmed that New Mexico’s extension application has met the requirements.

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Virginia Senate passes Medicaid Expansion

400,000 Virginians will soon benefit, following Wednesday’s decision by state legislature, to expand its Medicaid program.  

Virginia joins 32 states and the District of Columbia in expanding its public health insurance program under the Affordable Care Act. The new health care law, which is slated to take effect on January 1, would introduce changes to Virginia’s Medicaid program, which, according to reports, is one of the most “restrictive” in the nation.  

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New Jersey becomes second state to institute an individual mandate for health coverage

Shortly after announcing that the state will manage its own health insurance exchange for the 2019 Open Enrollment, New Jersey Governor Phil Murphy signed into law a bill enacting an individual mandate.

The bill, signed yesterday, requires all New Jersey residents to have health insurance coverage or pay a penalty. Democratic lawmakers drafted the bill in response to Congress’ decision to appeal the federal mandate established in the Affordable Care Act.

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Texas leads multi-state Affordable Care Act lawsuit

In February 2018, the attorney general of Texas, joined by attorneys general and governors from nineteen other Republican states, filed a lawsuit asking a Texas judge to invalidate the entire ACA.  

Their theory is that during a Supreme Court argument held in 2012, Congress lacked constitutional authority to enact the ACA’s individual responsibility requirement as a mandate, but upheld it as a tax. In 2017, Congress zeroed out the tax, thus, plaintiffs argue, the individual responsibility requirement now lacks any constitutional basis and is void. But, the argument continues, the individual responsibility requirement is key to all the rest of the ACA, so the entire ACA must be invalidated. In April, the plaintiff states (joined by two individual plaintiffs) asked the court to block the enforcement of the ACA and all associated regulations through a preliminary injunction. 

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CMS cautions non-expansion states about Medicaid work requirements

CMS Administrator Seema Verma is worried about a “subsidy cliff” in states that have not expanded Medicaid but are seeking to implement Medicaid work requirements.

The cliff impacts those who earn too much to qualify for Medicaid, but not enough to receive government subsidies. Verma is worried that if states without expanded Medicaid programs require recipients to get jobs, the added income will push them into this grey zone, leaving them without coverage.

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Addressing Social Determinants of Health (SDoH) through Medicaid

Affecting a broad range of health and quality-of-life outcomes, socioeconomic, and environmental factors constitute what is known as Social Determinants of Health (SDoH). These factors can be used to create social and physical environments that promote good health.

To achieve better outcomes, states and managed care organizations (MCO) must first understand what determines and impacts their members’ health. These stakeholders must be able to “assess risk, identify trends, stratify member risk, and proactively intervene.” To this notion, there is a clear demand for predictive accuracy of risk associated with healthcare and related costs.

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The single risk pool at risk

The Affordable Care Act’s coverage expansions in the individual and small group markets were based on a key idea—as of 2014, all who had coverage in the individual market would be part of single, state- and insurer-wide, risk pools, with separate small group single risk pools.  Indeed, the risk adjustment program would spread risk among all insurers in the individual and small group markets creating, in a sense, a single statewide risk pool in each market. The individual responsibility requirement would drive individuals into the market, while premium tax credits for moderate income individuals would pull them in.  The healthy would help cover the costs of the sick, and all would find affordable premiums.

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Connecticut: Another State to make mid-year rate reductions

On January 22nd H.R 195 was signed into law, suspending the collection of health insurance provider fees in the 2019 calendar year. The bill was originally introduced on January 3, 2017 to resolve differences throughout the year from House actions and Senate actions. From this new law, States were mandated to pass on requirements for each health insurance Issuers within their state to submit updates to rates.  

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