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The Scoop: health insurance news – December 16, 2020

A round-up of state and national headlines regarding individual health insurance and health reform

The Centers for Disease Control (CDC) has cleared the way for the COVID-19 vaccine to be covered by nearly all health insurance plans in the United States. Image: Rido / stock.adobe.com

Open enrollment continues in 11 states and DC

In most of the country, open enrollment for 2021 individual/family health plans ended yesterday. (HealthCare.gov gave people until 1:59 a.m., Pacific time, and due to high call volume, they gathered contact information for some callers and will be reaching out to those people over the next few days to help them complete their enrollments.) The Trump administration rejected numerous calls to extend open enrollment in light of the ongoing global pandemic. Although the Biden administration might reopen the enrollment window next month, enrollment is currently closed for people in most states who hadn’t at least begun the enrollment process or left their contact information with the marketplace by the end of open enrollment (unless they have a qualifying event).

But in twelve states and DC, open enrollment is still ongoing. This includes Connecticut, where the extension was announced on December 16, and Idaho, where an extension was announced on December 18; the rest of those states had announced their extensions several weeks ago.

In some of these states, people who are currently enrolling (after December 15) will have coverage effective in February or March, instead of January. But several are offering extended enrollment deadlines for a January effective date. Pennsylvania, California, Colorado and Idaho all announced such extensions this week. Here are the applicable enrollment deadlines:

California’s state-run exchange, Covered California, has permanently extended open enrollment through the end of January. But CoveredCalifornia is working to try to give more Americans access to an extended open enrollment window for 2021 coverage, asking CMS this week to extend open enrollment via HealthCare.gov until the end of December or even through January. Oregon and Wisconsin have recently made similar requests, but CMS has given no indication that they plan to offer an extended enrollment window.

As of December 5, when there were still at least 10 days remaining in open enrollment nationwide, 3.8 million people had enrolled in plans through HealthCare.gov in 36 states. And by December 9, nearly 1.2 million people had enrolled in plans through several of the state-run exchanges, although not all of them have published enrollment data yet. There is always a significant spike in enrollment activity in the final few days of open enrollment, and auto-renewals will be processed by HealthCare.gov now that open enrollment has ended.

COVID-19 vaccine added to covered preventive care benefits for non-grandfathered health plans

On Friday evening, the FDA granted an emergency use approval for the Pfizer-BioNTech COVID-19 vaccine. Within hours, the CDC’s Advisory Committee on Immunization Practices (ACIP) held an emergency meeting and voted to add the COVID-19 vaccine to the list of vaccines that are recommended for routine preventive care. CDC Director Robert Redfield soon signed off on the recommendation, clearing the way for the vaccine to be covered by nearly all health insurance plans in the United States.

Under the CARES Act, enacted last spring, non-grandfathered health insurance plans have to add coverage for COVID-19 vaccines (with zero-cost-sharing) within 15 business days of the ACIP recommendation. This is much faster than the normal timeline for adding new preventive care services to health insurance plans, and it will help to ensure that when the vaccine becomes available for various populations, their health insurance will cover the cost.

South Carolina lawmakers pre-file Medicaid expansion legislation

There are a dozen states that still have not accepted federal funding to expand Medicaid. One of them is South Carolina, where several Medicaid expansion bills have been pre-filed for the upcoming legislative session. House Bill 3226 and Senate Bill 210 call for the state to expand Medicaid as of January 1, 2022, under the terms of the Affordable Care Act. Senate Bill 83 and House Bill 3269 call for the state to hold an advisory referendum during the 2022 general election, which would ask South Carolina residents to weigh in on whether the state should expand Medicaid as of 2024.

But advisory referendums are not binding. And unlike other states where Medicaid expansion has been implemented via ballot measures in recent elections, South Carolina does not have a mechanism that would allow voters to approve Medicaid expansion via a ballot initiative. (Of the remaining states that have not expanded Medicaid, only Mississippi and Florida have a ballot initiative process.)

Both chambers of South Carolina’s legislature have strong Republican majorities, and have spent the last decade rejecting Medicaid expansion. But as the number of non-expansion states dwindles to a small minority of the country, there’s increasing pressure on lawmakers to address the coverage gap, protect rural hospitals, and ensure access to medical care – especially in light of the ongoing global pandemic.

Legislation introduced in New Jersey to create an ‘easy enrollment’ system

Legislation to create an “easy enrollment” system was introduced last week in New Jersey’s Senate. The legislation is modeled on a similar program that Maryland debuted this year, and that Colorado will start to use in early 2022.

The idea is to use state tax returns to identify uninsured individuals and then determine, based on the tax returns, whether those individuals would qualify for Medicaid or financial assistance through the New Jersey exchange. If enacted, New Jersey’s bill calls for the state to implement the program starting with either the 2021 tax year (ie, the returns that people file in early 2022) or, if that’s not feasible, the 2022 tax year.

Surprise balance billing legislation gains bipartisan, bicameral support, but future still uncertain

Last Friday, leading Democrats and Republicans in committees in both the House and Senate reached an agreement on a legislative proposal, dubbed the “No Surprises Act,” that would end surprise balance billing in most situations. Loren Adler, Associate Director of the USC-Brookings Schaeffer Initiative for Health Policy, explains the details in this Twitter thread. ThinkAdvisor’s Allison Bell has a good summary of the proposal and its legislative prospects, as does Dylan Scott at Vox and Christopher Holt at American Action Forum.

There is widespread political and public support for taking consumers out of the middle of surprise balance billing situations, and this is an issue that regulators and lawmakers have grappled with for years. But there continues to be disagreement between health insurers and medical providers in terms of how the details should be handled. The No Surprises Act relies on arbitration to settle price disputes between providers and insurers, and America’s Health Insurance Plans has expressed concerns about that approach. The American Hospital Association has also expressed concerns about various aspects of the payment negotiation process.

Supreme Court issues a unanimous ruling that allows states to regulate pharmacy benefit managers

Last week, the Supreme Court ruled unanimously that Arkansas did not overstep its regulatory authority when it passed a law in 2015 that requires pharmacy benefit managers (PBMs) to pay independent pharmacies at least the wholesale cost of drugs, and that allows pharmacies to refuse to sell drugs at a loss. A consortium of PBMs had sued the state, claiming that they are regulated under ERISA instead, and that the state did not have regulatory authority. (Self-insured health plans are regulated by ERISA, and states do not have regulatory authority over them).

The Supreme Court’s ruling paves the way for other states to regulate PBMs in an effort to protect consumers’ access to independent pharmacies. (The court’s ruling was 8-0; the case was argued before Justice Coney Barrett was confirmed to the bench.)


Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

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