American Indian and Alaska Native (AI/AN) Marketplace Enrollment. and Cost Sharing Payments, as of November

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1 American Indian and Alaska Native (AI/AN) Marketplace Enrllment and Cst Sharing Payments, as f Nvember January 23, 2018 This brief prvides data t Tribes n the number f AI/ANs enrlled in health insurance cverage thrugh a Marketplace in 2017, enrllment trends amng AI/ANs ver the past tw years, and the average amunt f cst sharing payments made n behalf f AI/AN enrllees wh receive Indian specific cstsharing prtectins. Backgrund Health Insurance Marketplaces, established by the Affrdable Care Act (ACA), allw cnsumers t cmpare available health plans, determine eligibility fr federal financial assistance (such as premium tax credits), and enrll in cmprehensive health insurance cverage. T assist AI/ANs in accessing health care services when enrlled in Marketplace cverage, the ACA established Indian specific cst sharing prtectins, under which AI/ANs wh meet the ACA definitin f Indian pay n deductibles, cinsurance, r cpayments when receiving essential health benefits. 2,3 AI/ANs meeting the ACA s definitin f Indian can enrll in either a zer r limited cst sharing plan, depending n their incme level. The Centers fr Medicare and Medicaid Services (CMS) has prvided reprts fr 2015, 2016, and nw 2017 n enrllment f AI/ANs thrugh the Federally Facilitated Marketplace (FFM). Fr the first time, CMS has prvided data (fr 2017) n enrllment f AI/ANs thrugh State Based Marketplaces (SBMs). 4 AI/AN Marketplace Enrllment Attachment A belw prvides data n AI/AN Marketplace enrllment in the 39 states with an FFM. 5 The table shws, by state, the number f AI/ANs meeting the ACA s definitin f Indian enrlled thrugh the Marketplace in states with an FFM, as well as the number f thers eligible fr services thrugh the Indian 1 This brief is fr infrmatinal purpses nly and is nt intended as legal advice. Fr questins n this brief, please cntact Dneg McDnugh, TSGAC Technical Advisr, at DnegMcD@Outlk.cm. 2 The definitin f Indian under the ACA is a member f an Indian Tribe r sharehlder in an Alaska Native reginal r village crpratin. In additin, data are prvided in this brief n enrllment f IHS-eligible individuals wh are nnenrlled members f a Tribe. 3 The ACA als prhibits health insurers frm reducing payments t Indian health care prviders (IHCPs) by the amunt f any cst-sharing that AI/ANs wuld have wed withut these prtectins. 4 Fr the data n enrllment thrugh SBMs, nly data n AI/ANs meeting the ACA s definitin f Indian were prvided, and nt data n ther (nn-enrlled) IHS-eligible individuals. 5 The data in Attachments A, B, and D include figures fr states with an FFM, State-Based Marketplace n the Federal Platfrm, r State-Partnership Marketplace (all states using the HealthCare.gv platfrm). Page 1 f 10

2 Health Service (IHS) 6 wh enrlled in a plan, in 2016 and The table als shws the change in enrllment f AI/ANs in Marketplace cverage in states with an FFM, by state, frm 2016 t As f Nvember 2017, a ttal f 59,405 AI/ANs (including AI/ANs meeting the ACA s definitin f Indian (32,778) and ther IHS eligible individuals (26,841)) were enrlled in Marketplace cverage in states with an FFM. Natinwide, verall enrllment f AI/ANs in Marketplace cverage in states with an FFM increased by 3,834, r 6.8%, frm 2016 t The change in verall enrllment f AI/ANs thrugh the FFM masks significant differences in the year tyear enrllment between the tw grups f AI/AN cmprising the ttal. Fr AI/ANs meeting the ACA s definitin f Indian (wh are eligible fr cmprehensive cstsharing prtectins under Marketplace cverage), enrllment thrugh the FFM grew by 20.7% frm 2016 t Fr ther IHS eligible individuals, enrllment thrugh the FFM declined by 6.2% frm 2016 t Figure 1 f Attachment B belw includes a graph n AI/AN Marketplace enrllment in states with an FFM fr 2015, 2016, and 2017, with enrllment levels (and year t year percentage changes) shwn fr the tw categries f AI/ANs. In Table 2 f Attachment C belw, data are prvided n AI/AN Marketplace enrllment in the 12 states with an SBM. The table shws, by state, the number f AI/ANs wh enrlled in a zer r limited cst sharing plan thrugh the Marketplace in states with an SBM in In 2017, 6,107 AI/ANs enrlled thrugh a SBM and secured ne f the tw types f Indian specific cst sharing reductins (CSRs). 7 In Figure 2 f Attachment C, available data fr 2017 are prvided fr each enrllment categry. In 2017, AI/ANs enrlled in Marketplace cverage (thrugh an FFM r SBM) wh meet the ACA s definitin f Indian ttaled 38,885. When enrlled Tribal members (in FFM and SBM states) are cmbined with ther IHS eligible individuals (in FFM states), AI/AN enrllment ttaled 65,726 in Cst Sharing Payments Made n Behalf f AI/AN Marketplace Enrllees Attachment D, Table 3 belw prvides data n average cst sharing payments made t health plans by the federal gvernment n behalf f AI/ANs wh enrlled in a zer r limited cst sharing plan thrugh the Marketplace in states with an FFM. Natinwide, these payments averaged $1,988 per health insurance 6 These AI/ANs d nt meet the ACA definitin f Indian and thus d nt qualify fr the Indian-specific cst-sharing prtectins. 7 Data n enrllment f ther IHS eligible individuals in SBM states was nt prvided by CMS. January 23, 2018 Page 2 f 10

3 plicy per year, r $166 per enrllee per mnth, in Data n average cst sharing payments fr 2017 is nt yet available. Additinal Infrmatin n AI/AN Enrllment Thrugh the FFM and SBM In Attachment E, the full CMS reprt is prvided n AI/AN enrllment thrugh the FFM in The table is labeled Table 4: American Indian and Alaska Native Applicants and Enrllees (Active) in the Federally Facilitated Marketplace. The table prvides infrmatin n enrllment thrugh the FFM by the fllwing factrs: By age grup; By metal level; By gender; By special enrllment perid (SEP) cde; By cst sharing reductin type; and By state. A number f plicy and peratinal issues cme int questin frm a review f these data. Fr example: A sizable number f AI/ANs tk the time t begin an applicatin t enrll in the FFM but ultimately did nt enrll. 48,838 individuals identified as meeting the ACA s definitin f Indian were determined t be eligible fr qualified health plan (QHP) enrllment thrugh the FFM. Of this ttal, nly 32,778 (67%) actually selected and enrlled in a health plan. With regard t ther IHS eligible individuals, the difference in the number being determined eligible fr QHP enrllment thrugh the FFM and the number actually enrlling in a plan were even starker. 74,940 IHS eligible individuals were determined eligible fr QHP enrllment thrugh the FFM, but nly 26,841 (r 36%) actually enrlled. These percentages might (r might nt) mirrr experiences with the general ppulatin, but they als might indicate an interest and pprtunity t increase AI/AN enrllment in Marketplace cverage. With regard t CSR type, fr enrllees wh meet the ACA s definitin f Indian and, as such, are eligible fr the cmprehensive Indian specific CSRs as lng as ther cnditins are met, nt all received the cmprehensive Indian specific CSRs. Of the 32,778 AI/ANs meeting the ACA s definitin f Indian enrlled in Marketplace cverage thrugh the FFM, nly 28,213 (86%) received the cmprehensive Indian specific CSRs. Nearly 9% (2,819) f these enrllees received the much less cmprehensive CSRs that are available t the general ppulatin. Mre than 5% f these enrllees (1,746) received n CSRs. January 23, 2018 Page 3 f 10

4 Mre effective utreach t AI/AN Marketplace enrllees might be required t prevent, fr instance, enrllment f eligible and nn eligible family members in the same health plan, as this will blck eligibility fr the Indian specific cst sharing prtectins. The data prvided n plan metal level f AI/AN Marketplace enrllees might indicate an additinal pprtunity fr imprving educatin f AI/AN enrllees. 77% f Tribal member enrllees enrlled in brnze level Marketplace cverage, 20% in silver level cverage, and 2% in platinum r gld level cverage. Given the availability f the cmprehensive Indian specific cst sharing prtectins fr these individuals, the extra premium csts fr the 23% f enrllees with Marketplace cverage abve the brnze metal level might nt be necessary r beneficial. The abvebrnze metal level cverage culd be beneficial, thugh, in instances where an AI/AN is eligible fr the limited CSR but des nt have access t referrals fr cst sharing frm an Indian health care prgram. 8 8 Fr AI/ANs enrlled in Marketplace cverage wh qualify fr the limited CSR, t secure the cst-sharing prtectins when seeing nn-indian health care prviders, a referral fr cst-sharing is needed frm an Indian health care prgram. January 23, 2018 Page 4 f 10

5 Attachment A Table 1: Enrlled Tribal Members 1 and IHS Eligibles with Cverage thrugh the Federally Facilitated Marketplace (FFM), 2016 and , 3 State Enrlled Tribal Members 4 Other IHS Eligibles % Change % Change 2017 vs % Change Alabama % 1,053 1, % % Alaska % % % Arizna % % % Arkansas % % % Delaware % % 2 1.7% Flrida 963 1, % 2,923 2, % % Gergia % 1,469 1, % 4 0.2% Hawaii % % % Illinis % % % Indiana % % % Iwa % % 3 1.5% Kansas % % % Kentucky Luisiana % % % Maine % % % Michigan 1,013 1, % % % Mississippi % % % Missuri % 1, % % Mntana 797 1, % % % Nebraska % % % Nevada % % % New Hampshire % % % New Jersey % % 6 0.8% New Mexic % % % Nrth Carlina % 2,853 2, % % Nrth Dakta % % % Ohi % % % Oklahma 8,986 13, % % 3, % Oregn % % % Pennsylvania % 1, % % Suth Carlina % % % Suth Dakta % % % Tennessee % % % Texas 2,824 2, % 4,011 3, % % Utah % % % Virginia % 1,499 1, % % West Virginia % % 2 1.7% Wiscnsin 1,053 1, % % % Wyming % % 4 1.2% All States 27,158 32, % 28,627 26, % 3, % 1 An enrlled Tribal member is an individual wh meets the definitin f Indian under the Affrdable Care Act as a member f an Indian Tribe r sharehlder in an Alaska Native reginal r village crpratin. 2 Figures are fr May 2016 and Nvember Ttals include values in suppressed cells. 3 The FFM includes State Based Marketplaces n the Federal Platfrm and State Partnership Marketplaces. 4 Enrlled Tribal members are eligible fr cmprehensive Indian specific cst sharing prtectins; "ther IHS eligibles" are nt. 5 Kentucky mved frm a State Based Marketplace t a State Based Marketplace n the Federal Platfrm in late All January 23, 2018 Page 5 f 10

6 Attachment B Figure 1: Enrlled Tribal Members and IHS Eligibles with Cverage thrugh the Federally Facilitated Marketplace, ,778 (+20.7%) 26,841 ( 6.2%) ,158 (+17.1%) 28,627 (+17%) ,189 24, ,000 20,000 30,000 40,000 50,000 60,000 70,000 Enrlled Tribal Members IHS Eligibles January 23, 2018 Page 6 f 10

7 Attachment C Table 2: Enrlled Tribal Members 1 with Zer r Limited Cst Sharing Reductins (CSRs) in State Based Marketplaces, (Suppress Cells <=11) State Tribal Members with Tribal Members with Zer CSRs Limited CSRs Ttals Califrnia 2, ,682 Clrad Cnnecticut District f Clumbia ** Idah Maryland Massachusetts Minnesta New Yrk Rhde Island Vermnt 14 ** 14 Washingtn Ttals 4,663 1,444 6,107 1 An enrlled Tribal member is an individual wh meets the definitin f Indian under the Affrdable Care Act as a member f an Indian Tribe r sharehlder in an Alaska Native reginal r village crpratin. 2 Figures are fr September January 23, 2018 Page 7 f 10

8 Attachment D Table 3: American Indians/Alaska Natives Receiving Zer and Limited Cst Sharing Reductins (CSRs) fr Enrlled Tribal Members 1 in the Federally Facilitated Marketplace (as f December 2016) (Suppress Cells <=50) State Enrlled with AI/AN Zer r Limited CSR Average Advanced CSR Payment (per mnth) Average Advanced CSR Payment (annualized) Alabama 358 $178 $2,139 Alaska 762 $426 $5,118 Arizna 1,073 $132 $1,583 Arkansas 499 $150 $1,802 Delaware ** $196 $2,355 Flrida 992 $178 $2,138 Gergia 326 $159 $1,910 Hawaii ** $125 $1,498 Illinis 334 $152 $1,819 Indiana 163 $182 $2,185 Iwa 77 $183 $2,192 Kansas 840 $139 $1,672 Luisiana 266 $203 $2,431 Maine 199 $170 $2,046 Michigan 1,009 $175 $2,101 Mississippi 62 $147 $1,767 Missuri 770 $177 $2,129 Mntana 1,013 $192 $2,310 Nebraska 393 $181 $2,167 Nevada 370 $199 $2,391 New Hampshire ** $129 $1,553 New Jersey 52 $158 $1,891 New Mexic 903 $129 $1,551 Nrth Carlina 665 $217 $2,603 Nrth Dakta 984 $146 $1,747 Ohi 122 $161 $1,927 Oklahma 9,319 $146 $1,747 Oregn 683 $163 $1,951 Pennsylvania 168 $132 $1,579 Suth Carlina 216 $184 $2,207 Suth Dakta 755 $186 $2,228 Tennessee 309 $156 $1,875 Texas 3,125 $150 $1,799 Utah 845 $120 $1,443 Virginia 297 $145 $1,740 West Virginia ** $193 $2,310 Wiscnsin 1,134 $217 $2,607 Wyming 191 $248 $2,981 Ttal (including suppressed)/average: 29,360 $166 $1,988 Adjusted Enrlled (including Enrlled but nt receiving 02/03 CSRs) in FFM cverage: 31,901 Other IHS beneficiaries (nn Enrlled) in FFM cverage: 28,553 Ttal Enrlled and IHS beneficiaries in FFM cverage (December 2016): 60,454 1 "Enrlled" Tribal member is an individual wh meets the definitin f Indian under the Affrdable Care Act as a member f an Indian tribe r sharehlder in an Alaska Native reginal r village crpratin. January 23, 2018 Page 8 f 10

9 Attachment E Table 4: American Indian and Alaska Native Applicants and Enrllees (Active) Active Plan Selectins Only Page 1 f 2 Cverage Year 2017; Data as Best AI/AN Ca Tribal Member AI/AN Indicatr Race AI/AN Member At Least 1 AIAN Enrllment Detected but Nt Sub Categry N AIAN Enrllments n All s Submitted t the Marketplace All AIAN Members Enrlled n N AIAN Enrllments n At Least 1 AIAN Enrllment Detected but Nt All All AIAN Members Enrlled n N AIAN Enrllments n At Least 1 AIAN Enrllment Detected but Nt All All AIAN Members Enrlled n Ttal s 5,279 1,260 33,074 43,128 2,642 39,190 6, ,050 Individuals 6,558 1,932 42,484 56,008 6,150 46,777 7, ,872 Determinatins made by Marketplace Individuals 5,813 1,454 41,571 27,715 2,002 45,223 4, ,610 Individuals determined 195 * , ,536 3, ,413 Individuals 5,618 1,447 40,890 5,073 1,324 25,687 1, ,197 Individuals ,962 3,922 1,063 2, Individuals , Plan Selectin 0 1,478 42, ,953 46, ,872 Qualified Health Plan Selectins (Active Only) Ttal Plan Sele 0 1,033 31, , ,902 % Of Submitte N/A N/A N/A N/A N/A N/A N/A N/A N/A By SEP cde es specific SEP ,540 0 * 50 0 * * All ther SEPs , , ,400 By Gender Female , , ,657 Male , , ,245 By Age Grup , ,598 0 * , , , , , , By Metal Level Catastrphic 0 * * Brnze , , Silver , , ,764 Gld * 1,141 0 * 150 Platinum * By Cst Sharing Reductin (CSR) Type 01: N CSR , , ,900 fr ,980 0 * * 0 0 * 03: Other CSR ,324 0 * * : , , ,001 January 23, 2018 Page 9 f 10

10 Attachment E, Table 4 (cntinued) Page 2 f 2 Sub Categry By State N AIAN Enrllments n Tribal Member At Least 1 AIAN Enrllment Detected but Nt All All AIAN Members Enrlled n N AIAN Enrllments n AI/AN Indicatr At Least 1 AIAN Enrllment Detected but Nt All All AIAN Members Enrlled n AK AL ,144 AR AZ * 615 DE * 93 FL , ,774 GA 0 * ,392 HI 0 * 51 0 * 121 IA 0 * 94 0 * 108 IL 0 * IN 0 * * 428 KS KY 0 * 69 0 * 161 LA 0 * ME 0 * * 259 MI MO MS 0 * 80 0 * 136 MT ,018 0 * 251 NC 0 * ,745 ND * 107 NE * 190 NH * 137 NJ 0 * 55 0 * 702 NM * 201 NV 0 * * 324 OH 0 * * 674 OK , OR PA 0 * SC 0 * SD * 93 TN TX , ,248 UT VA 0 * ,468 WI * 492 WV 0 * WY * 106 January 23, 2018 Page 10 f 10