2015 Exchange changes

The Center for Medicare and Medicaid Services (CMS) released their final rules for next year’s open enrollment last week. There are a couple of big rules that will have significant impact.

Default Enrollment Options

A QHP that was certified in 2014 and that is recertified in 2015 can maintain the same plan and HIOS identification numbers that it used in 2014. Additionally, current enrollees in recertified plans will remain enrolled into the new benefit year, as long as those enrollees do not terminate their coverage.

The assumption will be that a person who is enrolled in good standing in a plan that is offered in both 2014 and 2015 will be re-enrolled in that plan for the 2015 plan year. This, I think, is a good rule. I have talked a couple of times about choice overload and this should reduce choice overload a bit where the default is opt-out of renewing instead of opt-in to renew. The big problem will be for individuals who are in bad plans this year who want to change, the default will discourage a few people from changing to better plans. The experience with Medicare Part D shows that the improvement of choice is a multi-year process.

Network Adequacy

For benefit year 2015, we will utilize a general ECP enforcement guideline whereby if an application demonstrates that at least 30 percent of available ECPs in each plan’s service area participate in the provider network, we will consider the issuer to have satisfied the regulatory standard. In addition, and as required for the prior year, we expect that the issuer offer contracts in good faith

Essential Community Providers (ECP) are core community services (AIDS, hemophilia, birth control, federally qualified health clinics, community health clinics etc). In 2014, a plan only had to contract with 20% of the ECPs in a region. Now it is 30% or a damn good explanation. The narrowest networks will become a little bit wider. This may not change the decision to include high end specialty hospitals like Seattle Children into a network but it should improve access in non-urban center counties for the narrowest networks. Modestly narrow networks probably won’t be changed by this rule.

Open Enrollment
Open Enrollment will be November 15, 2014 to February 15, 2015. Enrollment in a policy on or before Dec. 15 will have coverage effective date of Jan. 1, enrollment between 12/16 and 1/15 will have coverage effective on 2/1/15 and enrollment between 1/16 and 2/15 will have effective coverage on 3/1/15. Final plan design approval will occur by October 15, 2014, so there will be a month long advertising blitz as plans are approved.

There are plenty  of other details that interest me (and should interest anyone invested in coffee futures), but these are boring technical implementation details.

51 replies
  1. 1
    Belafon says:

    I see, according to NewsMax, that Obamacare has an Emanuel. How come Obamacare gets an Emanuel and I don’t?

  2. 2
    Omnes Omnibus says:

    @Belafon: If it’s Rahm, do you really want one?

  3. 3
    Belafon says:

    @Omnes Omnibus: If I wanted to be mature about it, probably not. If I want to act like NewsMax’s audience, though, I should throw a tantrum until I get one no matter how much it hurts me.

  4. 4
    Omnes Omnibus says:

    @Belafon: My head now hurts.

  5. 5
    RaflW says:

    So the one thing I don’t understand is the open enrollment window. What happens if you lose your job on, say, June 30?

    I’m assuming you can still COBRA, but those are often more expensive than what an individual would likely choose, esp if s/he has just lost a job.

    Are you just SOL till the end of the year? Or are you subject to traditional underwriting for the balance of the year?

  6. 6
    El Caganer says:

    Richard, I know this is off-topic, but I’d appreciate it if you would comment on this story. Is this a big deal or much ado about nothing? It says much about today’s news media that my first assumption is that it’s crap.


  7. 7
    Richard Mayhew says:

    @RaflW: good question, and that will be a post next week.

    Short answer, if there is a major life event ( job loss, marriage, birth in the family, death in the family, divorce, moving between states etc) individuals have a short window around the date of the major change where they can go on the Exchange and get a policy without penalty.

    If I moved from Washington D.C. to Seattle in August, my D.C policy is almost useless, so I can get a Washington State policy on their Exchange.

  8. 8
    RaflW says:

    @Belafon: I also see from Newsmax that the Bible is now offering medical advice in the guise of food cures. So there is that.

  9. 9
    askew says:

    Don’t all plans that cover spouses have to cover same-sex spouses even if the state hasn’t legalized SSM in 2015 as well?

  10. 10
    Omnes Omnibus says:

    @RaflW: Open enrollment is just a period when anyone can change for any reason. After the open enrollment period, you would need a triggering event (like losing a job, getting married, getting divorced, etc.) to access the exchanges. It works the same way in employment-based insurance.

    ETA: What RM said.

  11. 11
    Richard Mayhew says:

    @El Caganer: Not a big system breaking deal, but it has real world implications for people who are in a very narrow income window where they qualify for substantial subsidy under 2013 Federal Poverty guidelines (just over 100% 2013 FPL) but are under 100% FPL using 2014 guidelines. This really hurts people in non-Medicaid expansion states as people in Medicaid expansion dates and in the very narrow income window would be in Medicaid either way.

  12. 12
    askew says:

    @Richard Mayhew:

    So, it’s another mistake on healthcare.gov that it is giving incorrect subsidy information or just the way the bill/rules were written?

  13. 13
    El Caganer says:

    @Richard Mayhew: Thanks!

  14. 14
    Tommy says:

    Richard I have a question for you. Feel like I should know this but I don’t. Worked in DC for an ad agency that had a health provider as a client. As you might guess all their ad spending was around open enrollment. I bought my plan through the IL exchange. Will I have the same chance to change this time next year?

  15. 15
    Tommy says:

    Oh let me add to my question Richard. I bought a silver plan that didn’t have vision. Murphy’s law at work, I now need glasses for the first time. I was kind of stunned at the cost. Just paid it out of pocket, but I’d like to change my plan next year.

  16. 16
    MomSense says:

    Richard, thanks for this information. Are you familiar with Maine Community Health Options? It is a health insurance co-op that was made possible by the ACA. So far I’m really impressed with them. Customer service is great and everything has been smooth. The only sort of glitch we had was that they couldn’t make cards fast enough to keep up with the demand but all we had to do was log in to our customer portal and print off temporary cards. So far, really good service.

    I have a success story to report. My office mate has been uninsured for about 4 years since she lost her job. We don’t have health insurance through our employer. Three years ago she married a nice guy in every way except his politics (he is of the tea variety and thinks Obama caused the 2008 stock market crash). He is self employed and uninsured. They are both smokers. Well you can imagine that he did not want ObamaCare nor did he trust it. Because of the looming deadline and her desire and need for health care, she finally got on healthcare.gov and entered her information. Today she came in with lots of questions about the various plans so we looked at everything and she is going for a cost sharing silver with MCHO. She is thrilled because it is affordable. Apparently his head exploded when she was telling him about the options last night because he thought that they were going to be really expensive with crap coverage and now they are getting very good news.

  17. 17

    Do you know what the hell is going on in Massachusetts?

  18. 18
    Richard Mayhew says:

    @Tommy: yes, you can change your plan between Nov. 15 and Feb 15 next year and get one with Vision coverage as an add-on.

  19. 19
    Richard Mayhew says:

    @askew: Someone put the wrong reference table/reference value to the subsidy window shopping pointer. Common enough data fuck-up but not a systemic fuck-up. It is fixable, or should be fixable in a morning.

  20. 20
    MomSense says:

    Oh, btw today is the 4th anniversary of the House passing the PPACA.

  21. 21
    Tommy says:

    @MomSense: So happy to hear. I work for myself. The plan I got through the Exchange is far superior to what I had. I am paying $78 less a month. And that is $78 less with no subsidy.

  22. 22
    MomSense says:


    They are getting a huge subsidy. I think they will end up paying about $200 a month. It would be cheaper but they are smokers.

  23. 23
    Tommy says:

    @Richard Mayhew: That is huge. I figured that was the case but wanted to ask. As somebody that lived in DC and had a lot of friends that worked for the Federal government, the enrollment period was key. As you got older you could upgrade your plan. If you got married or had children, you could expand your plan. You had choice.

    I know the Republicans hate this cause it is going to work. It is working.

  24. 24
    Tommy says:

    @MomSense: I doubt getting this will change the opinion of her husband but I guess there is hope. To be very frank that they have health care is more important to me then changing their thinking.

  25. 25
    MomSense says:


    It might not change his mind but it will change his life! He hasn’t been to a doctor in a long time.

    I do think this will plant seeds for a lot of people. They have been subject to such fear mongering about the ACA that it might make them question how the reality could be so different from the dire warnings.

    I don’t know if you saw the news blip about Scott Brown meeting with a NH Republican legislator and hearing them say that a pre ACA health crisis cost them their house and destroyed them financially. The wife actually said thank god for ObamaCare. Scott started the conversation by calling it a monstrosity and was obviously not expecting the reaction he got.

  26. 26
    Tommy says:

    @MomSense: I’d say it is the hippie liberal in me but I will take changing his life/health over changing his mind. I am 44. My parents are not what you’d call liberals. They were over as I signed up for my plan and honestly, they saw me cry. Dad was a government worker. They have never had to think about health care, cause well they had government health care. I had to explain to them the fear I had about my health coverage.

  27. 27
    shelly says:

    Scott started the conversation by calling it a monstrosity and was obviously not expecting the reaction he got.

    And this guy (Brown) was a practicing attorney. Doesn’t he know that you never ask a question where you don’t already know the answer ?

  28. 28
    Amir Khalid says:

    @Omnes Omnibus:
    Isn’t Zeke the Obamacare Emanuel?

  29. 29
    Dee Loralei says:

    I finally signed up on the exchange on Sat. Haven’t heard anything from Humana, and I tried to pay online, but it wouldn’t let me. I did hear from Cigna and got my dental paid for, I think. I figure if I don’t get an email from Humana by Monday, I’m going to start making phone calls. Also, I didn’t qualify for a subsidy. And paying for healthcare is going to take 90% of my monthly income. But, I’m 51 and haven’t had insurance for 10 years, so I’m in desperate need of it. And I live at home, so my basic needs are taken care of, but as it is now, without the subsidy, I’ll have something like $100 a month to pay my self-employed income tax, etc. Also, I though we’d be able to pay with a debit card, but that wasn’t the case with Cigna.

    All-in-all, I’m still overjoyed ObamaCare is the law of the land, and that I’ll finally have insurance again. But Fuck the TN Legislature and Governor for not expanding Medicaid ! I feel like I’m getting royally screwed by the system, and have no idea how I’m going to pay for anything like my income taxes, etc. And forget trying to save a penny. Or paying anything towards my future retirement.

    I don’t mean to whine. I’m seriously thankful for the insurance, But I’m still in a financial bind. And my future looks bleak, but healthy. YAY!

    I guess my question would be, why haven’t I heard anything from Humana yet? And why didn’t I qualify for a Federal subsidy?

  30. 30
    Richard Mayhew says:

    @Dee Loralei: that is a bizarre situation — 2 sets of questions that might be going on here.

    1) Is your income extremely variable? If you had a really good 2012 but a crappy 2014, you can file an income redetermination with the Exchange so that they calculate your income off of 2014 instead of your 2012 tax return and get a subsidy.

    2) Are you in a Medicaid expansion state? $1,000/month should qualify you for expansion Medicaid.

    3) Are you an immigrant? Healthcare.gov has had problems processing immigrants.

    If you are not in a Medicaid expansion state and you earn under 100% 2013 Federal Poverty line, you are in the Fuck You Chief Justice Roberts hole as Exchange subsidies as written into the law were only for people with more than 100% FPL income as the assumption was all states would expand Medicaid and get anyone who made less than 100% FPL into Medicaid.

  31. 31
    Richard Mayhew says:

    @Richard Mayhew: Okay, I see that you’re in a non-Expansion state, most likely you are making just under 100% FPL, and thus don’t qualify for subsidy on the Exchange.

    See if you can restate your income so that you are $1 over 100% FPL for 2013.

  32. 32
    Richard Mayhew says:

    @Dee Loralei: Are you on a Humana Platinum plan? That is really good coverage, and the numbers make sense if I assume you’re a smoker in Nashville via Healthsherpa — any other plans with a little bit skimpier coverage would be cheaper.

  33. 33
    Dee Loralei says:

    @Richard Mayhew: Was unemployed in 2013. No income. I took over the book keeping for my father’s company after my mother died. And he’s paying me $500 a month for that. There may be more work at a later date this year, but that’s all the income I can count on for sure. So that’s exactly what I put on the exchange. And no, I’m not in a Medicaid expansion state, I’m in TN. And yes, I was born in the US. So, I was wondering why I was denied even a federal subsidy, or is that also conditioned on Medicaid expansion?

    @Richard Mayhew: Memphis. Yes smoker. Humana Gold. But I figured I needed the Gold to control the out of pocket expenses, etc. Since I have very little money to cover any out of pocket expenses. I thought it would be better to get the absolutely best coverage I could afford than it was to get one where I had a high deductible, because that would put me back in to the never going to the Doctor unless I absolutely had too, just as I did when I had no insurance at all.

    I do appreciate you answering my questions and all of your wonderfully informative posts on this subject. You’ve been a blessing to this blog. And I mean that sincerely.

    Ok. I see your follow-up. So, I need to figure out what the Federal poverty level is for one adult and make $1 more than that? And then I might get a subsidy?

  34. 34
    Elizabelle says:


    Vice President Biden predicted Friday that Republican governors who have declined the federal Medicaid expansion will eventually be forced to reverse course and take the expansion because of political pressure.

    Speaking to the National Association of Community Health Centers in Washington, Biden criticized the GOP governors who have declined the extra funding but said he expects them to come around.

    “I’m convinced, as a practitioner of the so-called art of politics, that they … will not be able to sustain the heat,” Biden said.

  35. 35
    Richard Mayhew says:

    @Dee Loralei: Yeah, the way the subsidy system was set up was that if you made less than 100% of FPL (which you currently make significantly less than 100% FPL) the law assumes you would be covered under Medicaid Expansion as it was assumed that every state would have taken a massive pot of free money to cover their working poor. Subsidies kick in at 100% FPL and taper out at 400% FPL.

    Fuck you Chief Justice John Roberts et al for making Medicaid expansion optional without losing legacy Medicaid money. You’re now stuck in the limbo of making too much money or not being the right type of deserving poor to get Tennessee Legacy Medicaid and not enough to get subsidized on the Exchange.

    Kaiser Family Foundation has an interesting brief for you to read:

    While there are steep fines for knowingly lying on a government application for financial assistance, if someone merely miscalculates their income above the poverty level in 2014, and is later found to have made less than the poverty level, they won’t have to pay any money back, according to the Treasury Department.

    “There’s little risk because under the rules you don’t have to pay anything back,” said Richard Trembowicz, vice president for Celtic Insurance Co., a subsidiary of Centene Corp. which is offering plans on several exchanges, including Mississippi.

  36. 36
    Richard Mayhew says:

    @Richard Mayhew: If you go this route, at 100% FPL + $1, you’ll be eligible for Silver reduced cost share plans. Get one of those. Gold currently pays out roughly 80% of the expected acturial value of your health expenses. Silver reduced cost share/cost share assistance pays out 97% of acturial value for someone making 100.0001% FPL.

    Silver will be significantly cheaper than Gold, and in this scenario, it offers significantly better coverage.

  37. 37
    MomSense says:


    I agree that getting people the care they need is more important. I cried, too! I have a pre-existing condition and couldn’t purchase insurance–not that I could afford it anyway before the ACA. There is a constant base line of stress when you don’t have insurance–and that can’t be good for your health. It is definitely a relief.

  38. 38
    Dee Loralei says:

    Ok, that’s great news! Especially, the no penalty for miscalculating bit! Let me recalculate everything. BLS.gov has the poverty levels right?

  39. 39
    Richard Mayhew says:

    @Dee Loralei: use the 2013 Federal Poverty Levels at the link below:


  40. 40
    Kylroy says:

    Fairly off – topic: while reading an article at Cracked about how awful being a pro wrestler is, I saw a comment about how the frequency of injuries means you have no hope of getting health insurance and I immediately thought “Not anymore!”

    Which got me thinking – if the PotUS will appear on FunnyOrDie to get the coveted young people attention to the exchanges, is there any pro wrestler anywhere who would pipe up about ” I have health coverage for the first time in my life and it’s awesome”? It’s a demographic that’s resistant – to – hostile to the exchanges, hearing how it has tangibly benefited a celebrity they follow.

  41. 41
    Ruckus says:

    I lost my health insurance back in 05 when I quit my job to start a business. (A Job Creator!) Didn’t take Cobra because the cost was about $900 per month. Had pretty good insurance on that job. Tried in 06 to purchase individual insurance on the open market but my pre-existing conditions gave me few choices, all of them bad. Prices ranged from $1000-1200 per month, all with very limited coverage and huge co-pay/deductibles. A few months ago I checked on the exchange here in CA and my cost for a silver plan would be around $200-250/month, with much better coverage/co-pay/deductibles.
    Now here comes the kicker. A friend who travels a lot just got home from Italy and found out his insurance goes up to $296 per month. A FB RW/TP acquaintance posted that it’s all Obamacares fault. My friend makes more than enough so that he would get no subsidy, so that is his cost. And he didn’t say what it went up from or what coverage he gets. But notice that no one asked any questions, Obamacare just gets blamed and not even by my friend.

    Coming around to the view that conservatives are not only selfish, hypocritical, crazy little turds but are also fucking stupid.

  42. 42
    bemused says:


    This is what I don’t get. People who are so bullheaded angry they will refuse to listen to their self-preservation instincts and simply check out if ACA could help them on the off chance, just in case. Talk about cutting off their noses. Stupid is as stupid does.

    You should tell your co-worker the story of the NH Republican Rep who had Scott Brown in his home, now a trailer after losing their house, and told Brown Obamacare was a godsend for he and his wife.

  43. 43
    another lurker says:

    I get family coverage through my employer. Based on my W-2 the cost is about $2,000 per month, which is a lot higher than the numbers I’ve seen talked about here. It seems like it would make sense for my employer to discontinue providing health coverage and allowing us to purchase from the exchange. Are the fines prohibitive?

  44. 44
    MomSense says:


    First, I am so glad you have health insurance now!! That is fantastic. We were paying 1,600/month and finally just couldn’t continue. Insurance premiums were going up every year before the ACA and lots of things weren’t covered. Were people not paying attention before? At least it would be nice if the major media outlets would remind people of this to put premium increases into context. I guess it is much easier and politically expedient to blame ObamaCare for everything.

  45. 45
    MomSense says:


    She is signing up! Like it or not, he will get coverage too!

  46. 46
    another lurker says:

    @another lurker: I checked health sherpa and it looks like my existing plan is available for $500 less per month. My employer could give me a raise and let me buy my own insurance and we would both come out ahead.

  47. 47
    Elizabelle says:

    Another thing: don’t have the details, but I was told that in Virginia (a non-exchange and non Medicaid-expansion state, thanks former Gov. Transvaginal Bob) —

    someone whose health insurance quote comes in too high can appeal. There’s info somewhere on healthcare.gov, allegedly.

    Anyone else hear about this? (If not, I’ll look for the info and post it later …)

  48. 48
    Ruckus says:

    I ended up realizing that I could get into the VA so I didn’t have to purchase anything, which I didn’t financially qualify for before. Of course I had to pay 4 yrs of my life and the possibility of my life, but I’m still here so it all worked out in the end.

    You are right though, if you are stupid enough, you can just blame the person who not only tried to make your life better, but actually succeeded.

  49. 49
    bemused says:

    @MomSense: I

    Chuckle worthy. I’d like to hear the discussions going on between those two. He must be sputtering. How, oh how, is he going to tell his republican pals what he has done?

  50. 50
    MomSense says:


    I know!! We were kidding that she should go home and tell him that they are all signed up now, they just have to go to the hospital to get micro-chipped, purely for medical records and billing purposes of course.

  51. 51
    bemused says:


    Hilarious. I hope he doesn’t have high blood pressure because this is going to be a very frustrating, stressful thing for him to come to terms with. But hey, he’s got healthcare now.

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