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How to avoid the surprise of health plan ‘mapping’

If your health insurance plan is discontinued, your carrier or the exchange can 'map' you to a new plan

I’ve written a lot (including a book chapter) about why you might want to avoid letting your health insurance plan auto-renew – including the possibility that your premium costs could be significantly different in the new year. But if you choose to auto-renew your current plan, you could be in for another alarming surprise: an entirely new plan that was selected by your health insurance carrier on your behalf in a process called “mapping.”

And starting with the 2017 plan year, the exchange can also select a new plan for you, if your carrier is leaving the exchange altogether (details on the changes that took effect for 2017 — and later years — are in the Notice of Benefit and Payment Parameters for 2017).

When your plan is phased out

Prior to 2014, individual health insurance in almost every state was medically underwritten. When carriers made changes to a plan, they would typically “sunset” the old plan: existing enrollees could remain on it, but only the new version was available to new applicants. In this scenario, premiums for the sunset plan tended to increase significantly over time, as the risk pool would no longer be adding newly underwritten members.

Pre-2014, if carriers made changes to a plan and applied them to existing enrollees, state regulations could require the carrier to allow existing enrollees to transition to any of the carrier’s other plans, with no medical underwriting. Carriers tended to avoid that scenario in an effort to prevent adverse selection.

But that’s no longer an issue. Every policy is available to every applicant during open enrollment. Medical underwriting is no longer used, and people are no longer stuck with the plan they have because of their medical history. So it no longer makes sense for carriers to sunset products; instead, they make changes as necessary, applying them to existing policyholders as well as new applicants. And in turn, every policyholder has the option of switching to any other plan during open enrollment, regardless of pre-existing conditions.

Although new plan designs were rolled out on a regular basis prior to 2014, carriers are working in a significantly different landscape now. Nationwide, many individual market carriers have struggled with financial losses since 2014. The adjustments they’re making in order to remain viable and competitive mean that plan changes are more common than they were prior to 2014.

When plan designs are phased out and replaced, carriers “map” insureds to different plans that are the “most similar” to what they currently have. It’s a better option than having policyholders lose their coverage altogether if they don’t return to their exchange to actively research and select a new plan.

Unfortunately, even if you’re mapped to the “most similar” plan, it could mean that the premium, provider network, and design of your mapped policy could all be different from what’s in your existing plan.

Mapping and the exchanges

In September 2014, HHS clarified that auto-renewal would be the default provision to avoid gaps in coverage for exchange enrollees who don’t return to actively select a new plan for the coming year during open enrollment. (State-run exchanges are free to set their own guidelines, but for 2018 coverage, all of the state-run exchanges have auto-renewal as the default, as long as the insurer is continuing to offer coverage in the exchange; for cases where the insurer is leaving the exchange, there’s a bit more variation among state-run exchanges in terms of how to handle it — see below for more details). In most cases, the expectation is that the same plan will be available in the coming year, and enrollees who don’t return to the exchange to select a plan during open enrollment are simply auto-renewed in their current plan.

So auto-renewal for 2018 is available for most current enrollees. But that does not mean they’ll all be renewed onto the same plan they had in 2017, or that the provider network will still be the same. If a current plan will no longer be available, the carrier can “map” insureds to a new plan that they deem to be “most similar” to the current plan. And if the carrier is exiting the exchange, the enrollee can be automatically re-enrolled in the plan that the exchange deems the closest match, assuming that the enrollees don’t return to the exchange to pick their own new plans.

Mapping to the ‘most similar’ plan

For cases where an existing plan won’t be available in the coming year, HHS implemented a hierarchy in 2015 for determining what plan would be considered “most similar” to an enrollee’s current plan. HHS noted that the insurance carriers (as opposed to state regulators or the exchanges) are uniquely qualified to determine which plan is most similar to a plan that will no longer be available.

When a plan must be replaced, the carrier submits a “crosswalk” designation to the exchange, indicating which plan should be substituted during the auto-renewal process. The exchange uses that data to map current enrollees onto plans for the coming year, assuming the enrollees don’t return to the exchange to actively select their own plan.

Starting with 2016 coverage, it became increasingly popular for carriers to eliminate PPO plans in favor of HMOs, which allow carriers more control over costs. Illinois, Texas, and Arizona are examples of states where some enrollees were auto-renewed onto different plans with narrower networks in 2016 because their carriers stopped offering PPO networks and/or benefit designs (in all cases, insureds also have the option to return to the exchange and pick their own plan; auto-renewal only happens if you don’t pick a plan yourself).

Can you be mapped to a new carrier?

For 2017, and again for 2018,  we’re seeing a not-insignificant number of carriers leaving the exchanges altogether. Obviously, all of the impacted enrollees have the option to return to the exchange during open enrollment to pick a new plan. But not everyone in that situation will do so. How does auto-renewal work in that situation?

For 2015 and 2016 coverage, HHS guidelines prevented the exchange from mapping enrollees to a plan offered by a different carrier. So if your health insurance carrier was exiting the exchange or pulling out of the individual market altogether – as was the case with 12 CO-OPs at the end of 2015 – the exchange generally couldn’t automatically re-enroll you in a similar plan from a different carrier. (New York State of Health made an exception for CO-OP members who lost coverage at the end of November 2015.)

But for 2017, new rules were implemented, and they’re still in use for 2018. In the Benefit and Payment Parameters for 2017, HHS noted that

“whenever feasible, the Exchange should, and the FFE will attempt to, re-enroll enrollees in silver metal-level QHPs no longer available through the Exchange into the silver metal-level QHP offered by another issuer through the Exchanges of the same product network type with the lowest premium.

If the QHPs that have become unavailable are in metal levels other than silver, then whenever feasible, the Exchange should and the FFE will seek to re-enroll the affected enrollees in the QHP available on the Exchange of the same metal level of the same product network type with the lowest premium.

Exchanges should, and the FFEs will endeavor to, implement such a re-enrollment process for enrollees of QHPs whose issuers are discontinuing their coverage, for as many groups as is feasible given the short timelines and complex operations that could be required in these scenarios.”

Essentially, the exchange will — if possible — assign people to a new plan from a different carrier in the exchange, if the enrollee’s current carrier will no longer be offering plans in the exchange after the end of the year. Note that they use the words “the FFE will attempt to…” and “the FFE will endeavor to…”

State-based exchanges can use the federally exchange’s protocol for mapping enrollees to new plans when an insurer leaves the marketplace, but they are not required to do so. For example, Idaho’s exchange confirmed that they are mapping BridgeSpan members to new plans for 2018, and Washington’s exchange is mapping Community Health Plan & Regence members to new plans. But Maryland’s exchange is not mapping Cigna members to new plans (Cigna enrollees in Maryland’s exchange will be uninsured as of January 1, 2018 if they don’t pick a new plan by December 31, but they will have a special enrollment period that continues for 60 days after the end of December during which they can pick a new plan)

Can you be mapped to an off-exchange plan?

The 2017 Benefit and Payment Parameters also address the scenario where a carrier exits the exchange but continues to offer off-exchange coverage for the coming year. HHS explains:

“we are finalizing a rule that would provide for auto-reenrollment through the Exchange, as opposed to permitting auto-reenrollment outside the Exchange. Under this rule, an enrollee could automatically be re-enrolled into a QHP from a different issuer through the Exchange.”

So if your health insurer is leaving the exchange but remaining in the off-exchange market, the exchange will be able to auto-re-enroll you in a plan from a different carrier (assuming you don’t return to the exchange to pick a new plan), but your carrier will not be able to auto-renew your coverage to an off-exchange version of your plan.

HHS notes that carriers can communicate with their insureds, letting them know that the off-exchange plans are available. But they cannot simply switch insureds to the off-exchange plans automatically.

Could you be mapped to a higher premium?

It’s possible that the mapped plan could have a higher premium, despite the fact that it will be the plan deemed “most similar” to what you’ve got now. Rates are increasing substantially for 2018 (particularly silver plan rates), including both on- and off-exchange plans. So whether your plan changes or not, chances are the premium will be higher than it was in 2017.

But for eligible enrollees, Obamacare premium subsidies will offset some of the increase, regardless of whether the insured is mapped to a new plan. Subsidies will still be available for most exchange enrollees who had them in 2017 and opt to let their plans auto-renew. There are some exceptions however, detailed in the renewal section of my open enrollment guide.

Because the cost of cost-sharing reductions has been added to silver plan rates in most states, premium subsidies are generally much larger for 2018 than they were in prior years. This is resulting in free bronze plans in some areas, and gold plans that are less expensive than silver plans in some areas. Because of the sharp variation in premiums by metal level for 2018, it’s strongly recommended that people return to the exchange to select their own plan during open enrollment (or during a special enrollment period triggered by impending loss of coverage) regardless of whether their current plan will continue to be available.

Can you avoid mapping?

If you want to have a hand in determining your new plan, you have to return to the exchange and actively select a plan for 2018. In most states, the deadline to do that – and have the coverage effective in January – is December 15 (there are quite a few exceptions to this deadline, but December 15 is a good general rule of thumb, as none of the states have a deadline prior to that)

Pay attention to the notices you’ve received recently from your health insurer and your exchange – they’ll tell you in advance if your current plan is being discontinued or modified.

And don’t rely on auto-renewal. Instead, log back into your exchange account and actively select a plan for 2018. That will give you a chance to compare all of the available plans, which may be very different from what was available when you shopped last year or the year before. It will also give you a chance to update your personal information with the exchange, including any recent changes in income (resulting in fewer surprises when you reconcile your subsidy on your tax return).

And in the event that your existing plan will no longer be available after the end of the year, selecting your own plan for 2018 gives you much more control over the situation than simply letting your health insurer or the exchange assign you to the plan they consider most similar to what you had this year.

What happens after December 15?

If you find out that your plan has changed and you’d rather pick a different option, you may still be able to make a change to your coverage after December 15 or even after the first of the year, depending on where you live and whether your insurer is leaving the market in your area at the end of 2017.

If your plan is being terminated and you pick a new plan during your special enrollment period (triggered by loss of coverage) by December 31, 2018, the new plan will take effect January 1, 2018. But if your plan is terminated and your use your special enrollment period after December 31, 2018, the earliest possible effective date you’ll have for your new plan will be February 1. In that case, the plan onto which you were mapped will be in force from January 1 until your new plan selection takes effect (or, if you’re in a state-run exchange that doesn’t map you to a new plan, you’ll be uninsured until your own plan selection takes effect).