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

  • By
  • healthinsurance.org contributor
  • August 19, 2016

I’ve written a lot (including a full 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 could also select a new plan for you, if your carrier is leaving the exchange altogether (details on the changes for 2017 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, carriers have struggled with financial losses in 2014, 2015, and 2016. 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 2017 coverage, all of the state-run exchanges will have auto-renewal as the default, except Kentucky, assuming their transition to Healthcare.gov is completed in time for the November 1, 2016 start to open enrollment). In most cases, the expectation is that the same plan would be available in the coming year, and the enrollee would simply be auto-renewed into that plan.

So auto-renewal for 2017 will be available for most current enrollees. But that does not mean they’ll all be renewed onto the same plan they have in 2016, 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, rather than seeing PPOs replaced with HMOs, 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.)

But for 2017, there are new rules. 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…”

They also note that this process will involve working with the states, and some states are pushing back against the idea of the exchange automatically re-enrolling people in plans from a different carrier. Nebraska and Wisconsin have said that the proposal amounts to “the placement of business by unlicensed entities” (ie, the federal government), and have said they will not cooperate with Healthcare.gov’s efforts to automatically re-enroll people in new plans if their carriers are leaving the exchange and they don’t log back in to pick a new plan (UnitedHealthcare is exiting the exchange in both states).

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 you health insurer is leaving the exchange but remaining in the off-exchange market (as will be the case in most of the areas where Aetna is exiting the exchange at the end of 2016), the exchange will be able to auto-re-enroll you in a plan from a new 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 very 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 expected to be sharply higher in 2017, including both on- and off-exchange plans. So whether your plan changes or not, chances are the premium will be higher than it was this year.

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 have them in 2016 and opt to let their plans auto-renew. There are some exceptions however, detailed in the renewal section of my open enrollment guide.

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 2017. In most states, the deadline to do that – and have the coverage effective in January – will be December 15.

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 2017. 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 2017 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 can still do so anytime until January 31, 2017.

If you pick a new plan between December 16 and January 15, the coverage will be effective February 1 (although in Massachusetts, Rhode Island, and Washington all allow plan selections to be made as late as December 23 for a January 1 effective date, so in those states, the window for getting a February 1 effective date is December 24 to January 23). The plan onto which you were mapped will be in force from January 1 until your new plan selection takes effect.

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