Findings from the Field: Enrollment and Consumer Assistance in Four States in Year Three of the ACA

Introduction

As of Spring 2016, states had completed the third open enrollment period (OE3) for the Health Insurance Marketplaces established by the ACA and most of the 32 states, including DC, that had adopted the Medicaid expansion to low-income adults were well into their third year of implementation. With three years of expanded coverage in place, many states have streamlined their eligibility and enrollment processes with the goal of increasing enrollment and retention of Medicaid and Marketplace enrollees. They continue to invest in outreach and consumer assistance, even as these efforts and programs evolve in response to changes in funding and priorities.

In Spring 2016, the Kaiser Family Foundation’s Commission on Medicaid and the Uninsured (KCMU) conducted case studies to gain an on-the-ground view of ACA implementation in four states, Colorado, Connecticut, Kentucky, and Washington, after completion of OE3. Working with PerryUndem Research/Communication, the Foundation conducted 28 in-person and phone interviews with a range of stakeholders in each state, including Medicaid and Marketplace officials, consumer advocates, assisters, and hospital and community health center (CHC) representatives. In addition, focus groups were conducted with Medicaid and Marketplace enrollees in each state. This work builds on previous analyses that examined states’ preparation for implementation prior to the initial ACA open enrollment period in October 2013 and subsequent reports examining state experiences after completion of the first and second open enrollment periods. Together, this work provides an in-depth understanding of ACA implementation from multiple perspectives, tracking and documenting experiences that may help shape efforts moving forward.

The four states included in these case studies implemented the Medicaid expansion and established a state-based Marketplace (SBM) in 2014.  As of OE3, all four states had very successful experiences implementing the coverage expansions. As such, these states’ experiences may provide key lessons about factors contributing to successful enrollment and greater insight into access and utilization of care as a growing number of people gain coverage. This brief reviews these states’ experiences with enrollment and renewal in Medicaid and Marketplace coverage, as well as outreach and consumer assistance during OE3. A separate brief reviews the experiences of Medicaid enrollees with access to care and explores state efforts to transform the Medicaid and broader health care delivery system.

Key Findings

Enrollment and Renewal

Perspectives on the Third Open Enrollment Period

Stakeholders in all four study states viewed OE3 as successful. They reported that systems functioned smoothly with fewer glitches than in previous years. Overall, enrollment continued to grow and Marketplaces were largely stable with the exception of some high profile plan exits. Moreover, stakeholders felt consumer awareness and understanding of coverage options and how to navigate enrollment and renewal processes improved compared to prior years. However, stakeholders also pointed to remaining challenges, including difficulties enrolling immigrant and mixed immigration status families as well as families with mixed coverage, in which some individuals qualify for Medicaid and others qualify for Marketplace coverage. Stakeholders also noted reductions in funding for outreach and enrollment assistance resources. In Kentucky, the gubernatorial election included significant debate around the future of coverage through its Marketplace, kynect, as well as the Medicaid expansion, with the newly elected Governor running on a platform to dismantle kynect. This led to confusion among consumers about the availability of kynect, which stakeholders felt dampened enrollment.

All four study states have had large declines in their uninsured rates since implementation of the ACA, which continued through OE3 (Table 1). Stakeholders agree that successful enrollment into the ACA coverage options contributed to these large declines, which have led to record low uninsured rates in each of the study states. Even with the significant success in reducing the number of uninsured, stakeholders in the states believe it is possible to achieve continued coverage gains by increasing enrollment of the remaining uninsured who are eligible for coverage. They noted that many of the remaining uninsured are eligible for Medicaid and that through continued efforts they should be able to find and enroll these individuals.

Eligibility Systems

During OE3, all four states had an integrated eligibility system that made eligibility determinations for both Medicaid and Marketplace coverage. In the four study states, the Marketplace eligibility system served as the online enrollment pathway for both Marketplace and Medicaid coverage during OE3 (Figure 1). In Colorado, the state also maintains a separate online Medicaid application, called PEAK, which allows individuals to apply for Medicaid and other programs, such as food and cash assistance, simultaneously. After OE3, Kentucky began dismantling its kynect eligibility system.

States continued to enhance system functionality between OE2 and OE3. For example, during OE2, Washington utilized a premium aggregation approach in which consumers paid premiums to qualified health plans (QHPs) directly through the Marketplace system, Washington Healthplanfinder; however, problems with the system led to many consumers experiencing delays in completing the enrollment process. Washington eliminated premium aggregation from its system in OE3, which Marketplace officials reported significantly reduced problems for consumers. For OE3, Colorado implemented an expedited enrollment path that uses a set of initial dynamic income questions to direct people to the right program. It also added new decision support tools for consumers, including formulary and network tools, which officials indicated were particularly useful for helping individuals with chronic conditions select a QHP. In addition, Colorado added a broker referral tool to help individuals identify local brokers and implemented an online chat function. However, the chat function was not as successful as the state anticipated, and it will likely eliminate it next year. In Connecticut, AccessHealthCT launched a decision support tool during OE3; stakeholders noted that about 30% of consumers spent nearly 15 minutes using the tool to help them select a QHP.

Stakeholders in all four study states reported that eligibility systems worked well during OE3 with fewer glitches than in previous years. In Connecticut, stakeholders pointed to faster system operations and fewer shutdown periods. They also indicated that many previous system issues that had produced duplicate applications had been resolved. In Colorado, state officials reported that the share of individuals receiving real-time eligibility determinations has improved from year to year, and that during OE3, approximately 80% of applicants received a determination upon completion of an application. Stakeholders in Kentucky and Washington noted that, in addition to improved system functionality during OE3, increased consumer familiarity with the systems contributed to improved experiences. Most participants in the Medicaid and Marketplace focus groups also reported that the systems were functioning better compared to previous years, though some said they continued to experience problems enrolling or renewing online.

Initially it was confusing….it was much smoother now.  I think they worked out all the kinks, so it’s much easier to navigate and to reenroll.
-Kevin, Colorado Marketplace enrollee

While systems are functioning well overall, some challenges remain for certain individuals and situations. Stakeholders reported that some groups, including immigrants and mixed immigration status families as well as children turning 19, continue to experience problems with eligibility determinations. In Colorado, stakeholders also pointed to issues coordinating between the Connect for Health CO Marketplace system and the PEAK Medicaid eligibility system as well as with county Medicaid offices. For example, they noted that updates or information entered through the PEAK system did not always successfully transfer to Connect for Health CO, which sometimes led to enrollment delays or coverage losses. In Connecticut, stakeholders indicated that there had been some delays between an individual receiving an eligibility determination through AccessHealthCT and having their information entered into the Medicaid enrollment system, since this is still a manual process. The state has worked to reduce this delay and is working with providers to ensure enrollees can access care while this data entry is pending. In Washington, while the elimination of premium aggregation resolved many problems, some consumers reported that they did not receive their subsidies and were charged the full price for their premium. The Marketplace recognized that some insurers are having trouble transferring subsidy data to the Marketplace system, resulting in an about 5,000 people being overcharged, and is resolving these problems on a case-by-case basis.

Three of the study states are building on their existing systems to make continued improvements going forward, while Kentucky is dismantling its system. Connect for Health CO is planning additional system enhancements, including a total out-of-pocket calculator. Washington Healthplanfinder is considering adding a similar tool, but officials referenced some concerns about the ability to provide accurate information. In Connecticut, a new Medicaid enrollment system is set to launch in October, which will be better integrated with the AccessHealthCT eligibility determination system and allow for a more fully automated enrollment process. Despite these planned improvements, stakeholders indicated that resource limitations remain a challenge to system upgrades. In Connecticut, a lower than expected Marketplace budget limited funding available for system maintenance and improvements. Similarly, in Colorado, officials from Connect for Health CO indicated that funding for system fixes dropped from $8.7 million to $2.0 million planned for OE4. In contrast to the other three study states, Kentucky is dismantling its single integrated Medicaid and Marketplace system, kynect. The state will transition to Healthcare.gov for Marketplace eligibility determinations in OE4, and launched a new state-level system, called Benefind, to processes eligibility determinations for Medicaid and other assistance programs (see Box 1).

Medicaid Enrollment and Renewal

Enrollment in Medicaid remained strong in the four states, with growth stabilizing during the OE3. Across the four study states, Medicaid enrollment has been successful, outpacing enrollment in the Marketplaces. All four states have experienced significant enrollment growth since initial implementation of the ACA (Table 2). Stakeholders noted that although enrollment growth continued during OE3, it leveled off compared to the prior two years since they had already enrolled so many of the eligible population. Stakeholders noted that those who have not yet enrolled are harder to reach and often need more assistance with the application and enrollment process. Two states have made or are planning to make changes to their Medicaid programs that will likely affect enrollment. Connecticut reduced parent eligibility from 205% to 155% of the federal poverty level in 2015. Many of these parents were able to maintain coverage through Transitional Medicaid Assistance (TMA); however, this TMA coverage ended on August 1, 2016. The state plans to help the nearly 18,000 parents affected by this change to transition to Marketplace coverage, but anticipates that some individuals may lose coverage when their TMA coverage ends. In Kentucky, Governor Bevin has submitted a request to the Centers for Medicare and Medicaid Services to alter the Medicaid expansion by charging premiums, among other changes that, if approved, could affect enrollment in future years.

All four of the study states have implemented automated renewal processes in Medicaid that are generally working well. Stakeholders indicated that automated processes have improved the timeliness and processing of renewals. Overall, the share of renewals completed through automated processes ranged from 60% in Kentucky to 70-80% in Washington and Connecticut. In addition, officials in all four states estimated that about 90% of enrollees are successfully renewed. While renewals generally are working well, stakeholders referenced some remaining challenges. For example, officials in Washington noted that the majority of Medicaid renewals occur during the Marketplace open enrollment period, creating an additional burden for Medicaid, Marketplace, and call center staff, as well as the website during a period of high-volume enrollments. Stakeholders in Colorado noted that renewal letters are confusing for enrollees and system issues are leading to some individuals losing coverage even though they thought they had successfully renewed. The state is working to make the renewal notice more client friendly. In Connecticut, stakeholders reported the renewal process is generally working smoothly; however, when enrollees report changes to their information on file, staff must manually enter the changes into the legacy Medicaid system, which can lead to delays in completing the process. The launch of the new Medicaid system later this year should further streamline the renewal process.

You even have the option of clicking to verify that your income hasn’t changed and if it hasn’t changed, you just submit and it’s automatically applied.
–Michael, Kentucky Medicaid enrollee

I feel like it was automatic because… I didn’t do anything. And they have all your information so I just know I got a new card.
–Eva, Connecticut Medicaid enrollee

Marketplace Enrollment and Renewal

The study states had varying experiences in plan participation and premium increases in their Marketplaces going into OE3 (Table 3). Competition in the Marketplaces was strong, with robust plan participation; however, CO-OP plans in Kentucky and Colorado both exited the markets prior to OE3. The exit of the CO-OP in Kentucky had particularly significant effects because it was the lowest-cost plan and had about 50,000 people enrolled. Marketplaces in both states conducted outreach to individuals enrolled in the CO-OP plans to help them enroll in a new plan. In contrast, the Marketplaces in Connecticut and Washington were relatively stable, with no major plan exits. Stakeholders in Washington noted some small carriers left the market, but these exits did not cause major disruptions for consumers. Average premium increases for QHPs in the four states also varied. In each state, the percent change in the premium for the silver benchmark plan in the largest city ranged from an increase of 32% in Denver to a decrease of 11% in Seattle. In Colorado, there remains significant geographic variation in price points, with very high prices in resort areas.

Marketplace enrollment increased in three of the study states during OE3. In Colorado, Connecticut, and Washington, Marketplace enrollment grew (Table 4). In Connecticut, stakeholders noted that 20,000 new enrollees signed up for Marketplace coverage, which was a nearly 20% increase over OE2. Officials in Washington reported that, after not meeting Marketplace enrollment targets in OE2, enrollment rebounded in OE3 and it met enrollment goals. Stakeholders in Colorado also reported strong Marketplace enrollment in OE3. They noted that 48% were new enrollees in OE3, which was the highest share of new enrollees among all states. In contrast, Marketplace enrollment in Kentucky was nearly unchanged compared to OE2 and only 9% higher than enrollment as of December 2015. Stakeholders cited a number of possible reasons for the leveling off of enrollment, including confusion over whether coverage through kynect remained available following the Governor’s election, as well as some problems with the renewal process.

[The renewal process] was very easy. We kept the same Silver level and everything and I don’t even remember going online.  I think it was one of these things like just sign this if you want to keep everything the same or whatever.
–Lucinda, Connecticut Marketplace enrollee 

My plan…wasn’t renewed, so I had to change and they had…very similar options, but honestly that was the most confusing thing. I’m like ‘this is basically exactly what I had,’…but they called it something else.
–Elisa, Colorado Marketplace enrollee

Marketplace renewal generally went smoothly in the study states, but changes in QHP availability created confusion for consumers. Stakeholders reported that consumers had greater familiarity with the renewal process, which contributed to a more positive consumer experience. While some focus group participants reported the renewal process was seamless and straightforward, others expressed frustration that their plans were no longer available, forcing them to find a new plan. The need to change plans occurred in both states where insurers exited the market and in states where insurer participation did not change. In Kentucky, there were some challenges with passive renewals. When individuals initially enrolled in kynect, they had the option to choose only one year of auto-enrollment. Many individuals who selected this option and who auto-renewed last year were not aware that they needed to take action to complete enrollment during OE3, which may have led to some people losing coverage.

Despite gains in Marketplace enrollment, affordability of coverage remained an enrollment barrier. In some cases, individuals lack information about the availability of subsidies, but in other cases, the premiums and cost-sharing are still unaffordable for individuals even when the subsidies are applied. Marketplace focus group participants in Kentucky, Washington, and Connecticut said their premiums were manageable but expensive, and the cost put more pressure on their household finances. Some participants reported missing payments and others worried about being able to keep up with their payments. Participants in Colorado generally reported their premiums were affordable. However, stakeholders in Colorado noted that premiums in some geographic areas, such as the resort towns, remain very high.

It’s manageable.  For three people I can’t really complain.
– Amy, Connecticut Marketplace enrollee 

I’ve definitely made lifestyles choices in the last year, like I don’t have a car anymore…I’ve made adjustments so I can afford insurance.
– Roniq, Washington Marketplace enrollee

Marketplace officials in Colorado, Connecticut, and Washington expressed concern about the affordability of coverage and indicated they were exploring strategies to provide consumers with more information on costs, including building on the decision support tools they had developed. In Kentucky, stakeholders noted that plans were more affordable for people who qualified for cost-sharing reductions and worried about the long-term affordability of plans for those who do not qualify for subsidies.

I feel like what I’m paying for isn’t that affordable considering I still have to pay a lot if I do go to the doctor or anything like that happens.
-Jessica, Kentucky Marketplace enrollee

Deductibles and other out-of-pocket costs also pose challenges for many Marketplace enrollees. While most Marketplace focus group participants appreciated having coverage, those with high deductible plans worried about what would happen if they experienced a major medical need. Respondents who qualified for cost-sharing reductions did not appear to be facing affordability challenges, but those with income just over the threshold for this assistance reported significant challenges. Stakeholders in Connecticut noted that about 12% of individuals who would qualify for cost-sharing reductions by enrolling in Silver plans have instead enrolled in Bronze plans, leading them to face greater out-of-pocket costs for care. Similarly, stakeholders in Colorado and Washington were concerned that many consumers were enrolling in Bronze plans to minimize premium costs, but would have difficulty affording their deductible and out-of-pocket costs.

Coverage Transitions

While no major problems were identified with people moving from Marketplace to Medicaid coverage, stakeholders noted that some people losing Medicaid may not be transitioning to Marketplace coverage. In Colorado, stakeholders indicated that there is a lack of awareness among individuals about the availability of Marketplace coverage and subsidies that may be contributing to gaps in coverage after individuals lose Medicaid eligibility. To try to address this issue, Connect for Health Colorado officials are targeting outreach on those who receive a Medicaid denial notice, are eligible for subsidies in the Marketplace, but fail to enroll. Stakeholders in the study states also indicated that there may be gaps in coverage for people moving from Medicaid to Marketplace because of the requirement to select a QHP within a certain period of time. Officials in Washington noted that systems changes implemented following OE3 have created a more seamless process that allows consumers losing Medicaid coverage to select a QHP after the 23^rd of the month to avoid a gap in coverage.

Outreach, Marketing, and Consumer Assistance

Consumer Awareness

Across the study states, stakeholders agreed that consumer awareness of ACA coverage options has improved compared to prior years, but that gaps in knowledge about availability of financial assistance in the Marketplaces persist. Stakeholders indicated that, overall, individuals have much better understanding of coverage options as well as enrollment and renewal requirements and processes than they did in OE1 and OE2. However, there remain some gaps in knowledge about the availability of Marketplace coverage and subsidies, particularly among the lower-income population covered by Medicaid. Stakeholders in Connecticut and Washington noted that consumers need education on the availability of cost-sharing reductions and the differences between Silver and Bronze plans. Stakeholders in all states also pointed to continued needs to improve health insurance literacy among individuals enrolling in coverage by providing education about what their insurance covers and how to use it. Particularly for Marketplace consumers, assisters in Washington emphasized the importance of helping clients understand what deductibles are and how they work. In Kentucky, in addition to helping clients select a Marketplace plan or a Medicaid managed care plan, assisters reported encouraging individuals to use primary care providers in lieu of relying on the hospital emergency department when they seek care.

Outreach and Marketing

Consistent with previous years, the study states employed a wide range of local level outreach and enrollment strategies. Stakeholders in all four study states emphasized the importance of ongoing outreach to maintain and grow enrollment in coverage. In OE3, they utilized activities that built on successful strategies in year one and two and relied on community partnerships through libraries, churches, and schools. Stakeholders in Washington noted that assisters were often available at community locations and community events, such as health fairs, to provide outreach and education. In Connecticut, officials from AccessHealthCT met with community leaders across the state to engage their support in conducting outreach to eligible consumers. Assisters and Marketplaces also deployed targeted efforts to reach specific populations, including immigrants, people of color, and the LGBT community. In Washington, assisters worked with county court systems to provide outreach and enrollment assistance to inmates being released from jail. The state Department of Corrections is now looking to adopt a similar approach statewide. Kentucky also has similar efforts underway, which began in year two and continued in OE3.

I was walking through the mall and I saw the little booth and…it didn’t look too busy so I stopped in and I said how long does this take, and they said about 30 minutes…It was real smooth when I went with them.
-Adam, Kentucky Marketplace enrollee

In Kentucky, enrollment storefronts placed in the community continued to be highly successful in OE3. Following successful efforts in previous years, Kentucky offered two enrollment storefronts during OE3, which had high visibility. Focus group participants in Kentucky were aware of the storefronts and several reported using them to get help applying for coverage. Assisters, known as kynectors, and other stakeholders noted that the enrollment storefronts provide the opportunity to have key enrollment staff co-located in one place to assist with complex cases. Stakeholders in Washington indicated the Marketplace is considering establishing storefronts in five counties for OE4 as a way to improve convenience for consumers and increase visibility of coverage options. Colorado only had one storefront available during OE3. While the storefront was successful, stakeholders did not view it as such a significant driver of enrollment compared to Kentucky.

Funding decreases led to some reductions in mass media campaigns. For example, Colorado and Washington shifted away from television advertising toward digital marketing. Stakeholders in Colorado noted there were more limited media buys for cable television during OE3. Washington did not run any television ads, and radio ads were limited to mostly Spanish-language radio. Stakeholders in Kentucky reported that a longstanding marketing contract ended in December and the state did not put any additional marketing efforts in place. They suggested that the absence of a marketing campaign added to public confusion regarding the Governor’s decision to dismantle kynect and uncertainty about whether coverage remained available. In contrast, AccessHealthCT continued its mass media campaign to continue building the brand and to drive enrollment in QHPs. Stakeholders indicated that a renegotiation of the marketing contracts for OE3 provided the same marketing push for less money.

Consumer Assistance

As in previous years, navigators, certified application assisters (CACs), CHCs, and agents and brokers all provided application and enrollment assistance to consumers. Most of the individuals and programs providing assistance in OE3 had provided assistance in prior years. Stakeholders in Colorado and Washington reported that this previous experience coupled with improved systems enabled assisters to devote more time to outreach and helping people understand how to use their coverage and the scope of their benefits. Assisters also assumed a larger role in addressing post-enrollment problems and tax-related issues. Brokers continue to play a significant role in the study states. In Colorado and Kentucky, brokers account for 50% of assisted enrollments. Focus group participants in Colorado who relied on brokers were generally satisfied with the assistance they received. However, some stakeholders remain concerned about whether brokers receive adequate training on coverage options. AccessHealthCT also relies heavily on brokers to provide enrollment assistance, but there are concerns that reductions in commissions paid for Marketplace plans will limit broker willingness to continue this role in the future.

Increased emphasis on finding and enrolling consumers into QHPs led to restructuring of assister networks. In Colorado, Connecticut, and Washington, assisters faced tensions between the goal of maximizing coverage regardless of coverage type and the Marketplaces’ emphasis on boosting QHP enrollment. To increase QHP enrollment, Washington Healthplanfinder restructured the Lead Organization (navigator) contracts, making full funding contingent on meeting separate Medicaid and QHP enrollment targets. While Healthplanfinder met overall QHP enrollment goals, this change led to some turnover among assister programs, including three Lead Organizations that did not renew their contracts, and restructuring of assister networks. In Colorado, stakeholders noted a lack of coordination between Health Coverage Guides responsible for helping consumers enroll in QHPs and assisters who help consumers enroll in Medicaid. Funding cuts have also contributed to restructuring of assister networks in Colorado and Connecticut. Unlike the other states, Connecticut eliminated its year-round in-person assister program following OE1 and transitioned some assisters to CACs. Its navigator program now consists of temporary workers hired during the open enrollment period who provide enrollment assistance in libraries and other locations. A new emphasis on expanding Marketplace enrollment, plus the need to assist the nearly 18,000 parents losing transitional Medicaid coverage, has renewed discussions in the state over whether or how to restructure the program.

In Kentucky, there is uncertainty about the future role and funding for kynectors. Kynectors continued providing outreach and enrollment assistance during OE3. However, when the Benefind Medicaid portal launched in February, kynectors were initially unable to assist clients who received termination notices or who needed to renew their coverage. Only state Medicaid eligibility workers could resolve these problems through the new system. Since then, the state has provided kynectors access to Benefind, and they can now assist their clients with the entire application or renewal process. Stakeholders noted that the kynector contracts have been extended through October 31^st; however, contracts and funding for OE4 remain uncertain.

While stakeholders noted improvements in call center wait times and ability to respond to consumer needs, problems with capacity and staff capability remain. As systems have improved in the study states, the number of calls to call centers have dropped. In addition, states have adjusted call center capacity to meet anticipated demand. As a result, stakeholders noted that call center wait times during OE3 were shorter compared to prior years. However, stakeholders reported that there were still long waits during peak times, and there remain concerns about the quality of assistance provided through the centers. For example, in Washington, some focus group participants reported that the staff did not provide adequate answers to their questions. Similarly, stakeholders in Connecticut felt the call center training was not adequate, leaving the staff unable to handle complicated cases. AccessHealthCT negotiated a contract with a new vendor to run the call center that will reduce costs by 40-60%. Officials at Connect for Health CO expressed concern over long wait times and indicated that the state is examining how to improve call center capacity through contracting arrangements. In Kentucky, with the confusion around kynect and Benefind, the call center experienced increased call volume, and stakeholders reported that there were long wait times and limited capacity to deal with the calls. As issues related to the transition to Benefind are addressed, the call volume is expected to decline.

Conclusion

As of the end of the third open enrollment period, states were continuing to make progress with implementing the ACA coverage expansions. In the four study states, eligibility systems were working well, and Medicaid and Marketplace enrollment continued to grow. Consumer awareness of available coverage options has improved as has their knowledge of how to navigate enrollment and renewal processes and where to go to get help. Outreach and consumer assistance in year three built on successful strategies from prior years and remained an important component of state efforts to find and enroll eligible individuals.

Looking ahead, with coverage gains established, three of the study states will continue to make improvements to their eligibility and enrollment systems. However, new leadership in Kentucky is moving to dismantle the integrated eligibility and enrollment platform, kynect, shift to separate portals for Medicaid and QHP enrollment, and possibly change the terms of the state’s Medicaid expansion.  It remains to be seen how these changes will affect health coverage rates overall. Affordability of Marketplace coverage remains a concern and state officials are exploring strategies to address costs and help consumers make informed health plan choices. Investments in outreach and consumer assistance efforts remain important, especially to find and enroll harder to reach populations. An increased focus on enrolling consumers into QHP coverage coupled with funding constraints may lead to further restructuring of navigator and other assister programs and may have implications for continued strong enrollment in Medicaid.