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Commentary Op-Ed

Comments on Marketplace enrollment policies in the 2024 payment rule

Editor's Note:

This comment letter is part of the USC-Brookings Schaeffer Initiative for Health Policy, which is a partnership between Economic Studies at Brookings and the University of Southern California Schaeffer Center for Health Policy & Economics. The Initiative aims to inform the national health care debate with rigorous, evidence-based analysis leading to practical recommendations using the collaborative strengths of USC and Brookings. This comment was submitted to the Department of Health and Human Services on January 30, 2023.

Matthew Fiedler and Adrianna McIntyre provided comments to the Department of Health and Human Services (HHS) on the 2024 Notice of Benefit and Payment Parameters. Their letter makes three main comments about potential changes to the Marketplace enrollment process:

  • Transitioning enrollees who miss premium payments to zero-premium plans, rather than disenrolling them, would help hundreds of thousands of people retain coverage annually, benefiting enrollees and advancing the administration’s policy goals. The proposed rule seeks comment on transitioning enrollees who miss required premium payments into zero-premium plans, when possible, rather than disenrolling them. Evidence suggests that this policy would help hundreds of thousands of people retain coverage annually, benefiting the affected enrollees and advancing the administration’s coverage expansion goals. The impact would be largest if the policy applied to enrollees who never made a binder payment, not just enrollees who later stopped paying premiums, as evidence suggests that initiating premium payments is a common stumbling block for enrollees. Furthermore, there are viable options for coordinating this policy with the three-month grace period available to enrollees who receive the advance premium tax credit.
  • Several changes to Marketplace enrollment processes that are included in the proposed rule would increase coverage or shift enrollees into plans that better meet their needs. HHS’ proposed changes related to data matching inconsistencies and the “failure to reconcile” rules would increase coverage by reducing the administrative burdens enrollees bear to enroll and stay enrolled. Similarly, automatically transitioning certain enrollees eligible for cost-sharing reductions from bronze plans to silver plans would shift affected enrollees into plans that better meet their needs.
  • Recent expansions of the premium tax credit create various other opportunities to expand coverage by changing Marketplace rules. Recent premium tax credit expansions have greatly increased the number of Marketplace enrollees who are subject to small, positive premiums. Evidence suggests that even small premiums can meaningfully reduce coverage due to the administrative burden involved in remitting them; this could be avoided by allowing or, ideally, requiring insurers to treat enrollees with small premium balances as having paid in full. Recent premium tax credit expansions have also greatly increased the number of people eligible for zero-premium plans; as a result, automatically enrolling people who start the Marketplace enrollment process, but stop before selecting a plan, into zero-premium plans could now generate much larger increases in enrollment. Each of these policies could increase coverage by at least tens of thousands of people.

Read their full letter here.

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The authors thank Julia Paris for excellent research assistance and Caitlin Rowley for excellent editorial and web posting assistance.


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