Report to the Massachusetts Legislature

Report to the Massachusetts Legislature:

Activities and Accomplishments of the Massachusetts Health Insurance Marketplace Fiscal Year 2019

Massachusetts Health Connector January 2020

Table of Contents

Table of Contents ...................................................................................................................................2 Preface ...................................................................................................................................................4 1.0: Introduction.....................................................................................................................................5 2.0: Non-group Membership ..................................................................................................................7 3.0: Small Group Membership ............................................................................................................ 14 4.0: Dental Membership ..................................................................................................................... 20 5.0: Administration and Operations .................................................................................................... 21 6.0: Outreach, Assistance, and Education .......................................................................................... 25 7.0: Policy and Regulatory Responsibilities ........................................................................................ 32 8.0: Concluding Comments ................................................................................................................. 37 Appendix.............................................................................................................................................. 38 Endnotes ............................................................................................................................................. 39

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List of Tables and Figures

Figure 1 : Massachusetts Health Coverage Enrollment by Insurance Type, 2017-2019 Figure 2: Massachusetts Non-Group Membership On- and Off- Exchange as of March 2019 Figure 3: ConnectorCare Plan Types by Income Figure 4: ConnectorCare Enrollment by Plan Type Figure 5: ConnectorCare Enrollment by Carrier Figure 6: On-Exchange Unsubsidized vs. Off-Exchange Non-Group Enrollment (2015-2019) Figure 7: Average APTC-Only Family Level Premiums by Subscriber Age Band Figure 8: Average Unsubsidized Family Level Premiums by Subscriber Age Band Figure 9: Non-ConnectorCare Enrollment by Metallic Tier Figure 10: Average 2019 Rates for On- and Off-Exchange Products by Metal Tier Figure 11: Non-ConnectorCare Enrollment by Carrier Figure 12: 2019 Non-ConnectorCare Non-group Enrollment On- and Off-Exchange by Carrier Figure 13: Purpose of Health Connector for Business Figure 14: Small Group Enrollment by Exchange Use, March 2019 Figure 15: Small Group Enrollment by Metallic Tier Figure 16: Small Group Enrollment On-Exchange by Carrier Figure 17: 2019 Small Group Enrollment On- and Off-Exchange by Carrier Figure 18: Average Premiums for Small Groups On- and Off- Exchange Figure 19: Health Connector for Business Choice Models Figure 20: Health Connector for Business New Groups and Members by Plan Offering Figure 21: Health Connector for Business New Groups by Employer Size Figure 22: Redesigned Wellness Program Figure 23: ConnectWell Activities Figure 24: Non-group Dental Enrollment by Benefit Type Figure 25: Non-group Dental Enrollment by Carrier Figure 26: Health Connector Member Experience Figure 27: Health Connector Day of Coverage Cambridgeside Galleria Mall Flash Mob Figure 28: ConnectorCare Eligible but Unenrolled Study Simplified Enrollment Letter Figure 29: Health Connector-Department of Revenue Letter to the Uninsured

Table 1: Table 2: Table 3: Table 4: Table 5: Table 6: Table 7: Table 8: Table 9: Table 10: Table 11: Table 12:

Milestones in Massachusetts Market Reform FY19 ConnectorCare Budget FY19 Premium Waiver Requests FY19 Appeal Requests FY19 Navigator Organizations Community engagement activities, paid media, earned media, OE18 vs. OE19 2019 SOA Strategy Affordability Schedule in Context CY2019 Affordability Schedule for Individuals CY2019 Affordability Schedule for Couples CY2019 Affordability Schedule for Families Penalty Schedule for Failure to Comply with the Individual Mandate, 2013-2019

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Preface

Massachusetts has a long history of health care reform efforts aimed at expanding health insurance coverage to its residents. The Massachusetts Health Connector is proud to be a key part of the legacy created when the Commonwealth's landmark health reform law, Chapter 58 of the Acts of 2006, was passed and included a state-based Exchange: a place where individuals, families, and small businesses can find, compare, and get help to afford health insurance coverage. As a result of that legacy, Massachusetts has the highest rate of insurance in the county, with over 97 percent of residents insured.

The work of the Health Connector and the sustained success of health reform in Massachusetts has benefited from the support and assistance of the Legislature and many state agencies. The Health Connector would like to thank the Office of the Governor, the General Court, the Executive Office of Health and Human Services, MassHealth, the Executive Office for Administration and Finance, the Division of Insurance, the Group Insurance Commission, the Department of Revenue, the Executive Office of Technology Services and Security, the Center for Health Information and Analysis, the Department of Public Health, the Division of Unemployment Assistance, the Massachusetts Board of Higher Education, the Health Policy Commission, the Office of the Attorney General, and the Massachusetts Office of Business Development for our collaborative efforts towards Massachusetts health reform.

The Health Connector is governed by a Board of Directors consisting of 11 members. The staff of the Health Connector wishes to extend its deepest gratitude to all past and current Directors for their commitment to health reform. Directors who served in Fiscal Year 2019 (FY19) include:

? Secretary of the Executive Office of Health and Human Services Marylou Sudders, Chair of the Board;

? Secretary of the Executive Office for Administration and Finance Michael Heffernan ? Gary Anderson, Commissioner of the Division of Insurance ? Roberta Herman, M.D., Executive Director of the Group Insurance Commission; ? Michael Chernew, Ph.D., Leonard D. Schaeffer Professor of Health Care Policy at Harvard

Medical School; ? FayeRuth Fisher, Political Director of 1199 SEIU MA ? Mark S. Gaunya, GBA, LIA, Co-owner and Chief Information Officer, Borislow Insurance; ? Louis F. Malzone, Executive Director of the Massachusetts Coalition of Taft-Hartley Funds; ? Dimitry Petion, President and CEO of Mulberry Systems, Inc.; ? Nancy Turnbull, Senior Lecturer on Health Policy and Associate Dean at Harvard School of

Public Health; and ? Rina Vertes, President of Marjos Business Consulting.

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Executive Summary

During Fiscal Year 2019, which spanned portions of the 2018 and 2019 plan years, the Health Connector saw record enrollment levels in both its individual and small-group products. Despite a challenging and dynamic federal policy landscape, the Health Connector has continued to find ways to support state residents in enrolling in health and dental coverage. The Health Connector ended FY19 with 287,000 non-group medical plan enrollees and 6,600 small-group medical enrollees. These enrollments represent a 13 percent increase in non-group and a 17 percent increase in smallgroup membership compared to the end of Fiscal Year 2018.

Enrollment growth is the result of the strong "culture of coverage" in Massachusetts as well as strategic approaches the Health Connector takes to its work:

? The ConnectorCare program provides subsidies to qualified low- and moderate-income Massachusetts residents, ensuring that health insurance is not prohibitively expensive. Premiums increase gradually with income with plans as low as $0 a month for those with incomes up to 150 percent of the Federal Poverty Level (FPL) and $126 a month for those at 300 percent FPL.

? In part a result of the ConnectorCare program's design, unsubsidized premiums available to individuals and small groups, who consistently report struggling with affordability, in Massachusetts through the Health Connector are competitive and consistently among the lowest in the nation.

? The Health Connector's small-group platform, Health Connector for Business, supports the businesses who need it most, offering flexible benefit options as well as premium rebates for small employers participating in a wellness program.

? Using a decade of knowledge about the uninsured, the Health Connector cultivates a strong, tailored outreach strategy that includes free, in-person help for applicants and members.

? The Health Connector employs a proactive approach to keeping insurance markets healthy, including continued administration of the state-level requirement that individuals carry health insurance.

The Health Connector's commitment to continually improving the member experience was underscored by the launch of the Customer Experience Procurement Project (CXPP) in FY19, which solicited vendors to provide enrollment, billing, and customer service functions to Health Connector applicants and members. In FY19, the Health Connector balanced facilitating needed improvements to the customer experience with maintaining stability for members in the current state. New vendors will come online in Fiscal Year 2020, bringing enhancements members have consistently asked for.

The Health Connector will continue to build on its legacy of providing residents of Massachusetts with access to high-quality health insurance, responding to consumer needs and an ever-evolving policy and market landscape. The Health Connector looks forward to working with other stakeholders to help Massachusetts remain a national leader in health reform.

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1.0: Introduction

1.1: History of the Health Connector

In Massachusetts, Chapter 58 of the Acts of 2006, our state's health reform law, and the Health Connector were built on the understanding that access to affordable and comprehensive coverage is a fundamental need of all Commonwealth residents. For over a decade, the Health Connector has maintained an essential role in the Massachusetts merged non-group and small group market, including through the state's transition to the federal Patient Protection and Affordable Care Act (ACA), which became law in 2010 and was largely implemented in 2014.

Through that transition, including adjusting state policies and regulations to conform to the ACA and the new availability of federal premium tax credits and cost-sharing reductions to subsidize individuals purchasing coverage from health insurance Exchanges like the Health Connector, Massachusetts continued its commitment to keeping insurance affordable for low-income individuals and created the ConnectorCare program to supplement federal subsidies. ConnectorCare provides additional support to members to reduce both premiums and out-of-pocket costs at the point of service, like co-pays. The program serves Health Connector members with income under 300 percent of the Federal Poverty Level, which is around $36,420 a year for an individual, or $75,300 for a family of four. ConnectorCare has been critical to preserving coverage gains made in Massachusetts prior to the ACA and driving competition that helps keep premiums stable and low in the merged market.

In the next chapter of the Health Connector's history, the Exchange will work to examine the merged market, employ outreach strategies to reach 100 percent coverage across the Commonwealth, and continue to improve the member experience for non-group enrollees while creating opportunities to meet the needs of the small-group market in Massachusetts. Though the external policy landscape of the Exchange has changed since its inception, the mission and results remain consistent, as hundreds of thousands of people rely on the Health Connector for affordable health insurance. Key milestones in Massachusetts's commercial market are highlighted in Table 1.

Table 1: Milestones in Massachusetts Market Reform

1992 ? 1996 Massachusetts introduced consumer protections to the non-group and small-group market, including guaranteed issue and a state version of adjusted community rating rules.

2006 ? 2008 Massachusetts enacted Chapter 58 of the Laws of 2006 (Chapter 58), comprehensive reforms that aimed to achieve near-universal health coverage. Key components of Chapter 58 included:

? The creation of the Health Connector, an independent agency that serves as an "exchange" marketplace to assist individuals and small employers in accessing health insurance, as well as subsidies to promote affordable coverage for residents with incomes up to 300 percent FPL through the Commonwealth Care program.

? State shared responsibility requirements for individuals and employers. ? The merger of the non-group and small group markets into a single risk pool. 2010 ? 2014

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Massachusetts prepared to implement the ACA, opting to retain its state-based marketplace and merged market structure. Additionally, the Commonwealth enacted comprehensive cost-containment legislation. 2014 ? 2019 Massachusetts retained its state-based marketplace, the Health Connector, and transitioned Commonwealth Care enrollees to ConnectorCare, a new program within the Exchange for residents with income up to 300 percent FPL that includes federal Advance Premium Tax Credits (APTCs) and Cost Sharing Reductions (CSRs) and maintains a "state wrap" to meet a state affordability schedule that sets lower enrollee contributions than the federal affordability schedule. Residents between 300-400 percent FPL are also eligible for premium tax credits. As of July 2019, the Health Connector had nearly 287,000 enrollees, including over 216,000 ConnectorCare enrollees under 300 percent FPL and approximately 17,000 APTC-only enrollees with incomes between 300-400 percent FPL.

2.0: Non-group Membership

At the end of FY19, the Health Connector provided coverage to nearly 287,000 individuals, an increase of 13 percent when compared to enrollment at the end of FY18. These Massachusetts residents received high-quality coverage through Qualified Health Plans (QHPs) certified by the Health Connector. Plans are organized into four metallic tiers that represent the richness of the benefits provided: Platinum, Gold, Silver, and Bronze. Platinum plans provide low out-of-pocket costs for services, but have higher premiums, while Bronze plans have higher out-of-pocket costs for services, but lower monthly premiums. Additionally, the Health Connector offers "Catastrophic" plans with higher cost-sharing for individuals under age 30 or who have a financial hardship that makes purchasing more robust coverage unaffordable.

Individuals (non-group members only) under 400 percent of the Federal Poverty Level (FPL) may qualify for federal tax credits to reduce their premiums, and individuals under 250 percent may qualify for cost-sharing reductions (CSRs) to reduce their out-of-pocket costs. The ACA allows for the premium tax credits to be taken during the tax year or claimed when filing after the tax year closes. When used during the tax year, they are known as advance premium tax credits (APTCs). In addition to federal subsidies, Massachusetts provides enrollees with incomes under 300 percent FPL with supplemental state subsidies via the ConnectorCare program.

All non-group coverage in the Commonwealth has grown over the last two years, while employersponsored insurance (ESI) and MassHealth enrollment have decreased, according to CHIA statistics (see Figure 1).The Health Connector covers 82 percent of the state's non-group market, with 18 percent of Massachusetts's individual purchasers obtaining coverage outside of the Exchange by purchasing coverage from a carrier directly (see Figure 2). Approximately 50,000 members were enrolled in Exchange coverage without subsidies, representing 15 percent of non-group on-exchange enrollment and 45 percent of unsubsidized members in the overall unsubsidized market segment.

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Figure 1: Massachusetts Health Coverage Enrollment by Insurance Type, 2017-2019

7,000,000 6,000,000 178,821 5,000,000

67,069 1,069,253

111,723 207,095

87,631 1,102,761

127,040

% Change

SCO, OneCare, Pace 30.7%

4,000,000 3,000,000

1,306,139

1,183,141

Non-group outside ConnectorCare

ConnectorCare

13.7% 15.8%

2,000,000 1,000,000

3,475,884

3,412,373

Medicare MassHealth

3.1% -9.4%

15/03/2017

Total enrollment 6,208,889

ESI

15/03/2019 Total enrollment

6,120,041

-1.8%

Source: CHIA Enrollment Trends August 2019 Databook. Data from March 2019. . Note: This analysis does not include the unclassified sub-category of private commercial insurance which grew by 11,000 between March 2017 and March 2019.

Figure 2: Massachusetts Non-Group Membership On- and Off- Exchange as of March 2019

Off-Exchange 18% (60,779)

Health Connector 82% (273,356)

ConnectorCare 62% (207,095)

Unsubsidized QHP 15% (49,786)

QHP w/ APTC 5% (16,475)

Source: CHIA Enrollment Trends August 2019 Databook. Data from March 2019. .

2.1: ConnectorCare Membership

The ConnectorCare program provides comprehensive, affordable health insurance to Massachusetts residents with incomes below 300 percent FPL. Because federal premium tax credits and costsharing subsidies are supplemented with state funds in this program, ConnectorCare coverage is more generous than the federal standard. There are five ConnectorCare Plan Types that depend on an individual's income (see Figure 3). Enrollees make small premium payments on a sliding scale, in

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