Easy Enrollment for Health Insurance

The Affordable Care Act (ACA) created significant new opportunities for Americans to enroll in quality health insurance at much more reasonable costs. While millions have taken advantage of new coverage options, many remain uninsured, despite the enhanced affordability options. Policymakers and advocates have searched for ways to best reach this so-called “eligible but not enrolled” population, but Maryland’s innovative enrollment reaches beyond traditional ideas, connecting tax returns and health insurance outreach.

In 2022, the National Health Interview Survey estimated that 27.4 million Americans were without health insurance.¹ Studies estimate that more than one-third of the uninsured would be eligible for tax credit-based subsidies on the health insurance marketplace², and with current subsidy levels, 80% of enrollees will be able to find a plan for less than $10³. Yet, recent studies suggest that two-thirds of uninsured adults never visited the marketplace to see their options⁴. States have recognized that making the connection to coverage as easy as possible is key to reaching these remaining uninsured.

One strategy that first the federal government, and later states, adopted to encourage health insurance enrollment was the so-called “individual mandate” wherein a person was required to prove coverage or face a penalty⁵. Maryland recognized that while a mandate had some positive effect on enrollment, it wasn’t enough. Instead, Maryland paired the mandate with a new approach to connect the uninsured to enrollment assistance.

The method for implementing health insurance mandates is to utilize tax forms as a reporting vehicle and penalty processor. Maryland recognized that the tax form would also allow for contact and income information to be gathered for those that are uninsured. With simple calculations, the state could easily estimate the potential costs of coverage for the uninsured, and even pre-populate health insurance application forms with information from the tax form. This connection led to the creation of the Maryland Easy Enrollment Health Insurance Program, signed into law in 2019.

Maryland Easy Enrollment uses the individual mandate reporting form to offer an opportunity for those without insurance to allow Maryland’s health insurance marketplace, Maryland Health Connection, to find them coverage options. The opt-in process is relatively seamless for consumers, with a 4-step process:

• Step 1: Check the box. On the insurance reporting tax form, uninsured Maryland residents can check a box to allow the state Comptroller (the state’s tax authorities) to share information with Maryland Health Connection.
• Step 2: File taxes. Once the box is checked, residents can file their tax returns. Income, family size, and contact information is shared with Maryland Health Connection which will complete an application on behalf of a resident and compile a set of affordable health insurance options.
• Step 3: Receive a letter. Maryland Health Connection will contact Easy Enrollment program participants explaining their health insurance options and inviting them to login to a new account and make a health insurance selection. Residents have 35 days from the date of the letter to login and enroll.
• Step 4: Login and enroll in health coverage. Once a Maryland Easy Enrollment participant receives their letter from Maryland Health Connection, they can login to their account, review the options available for affordable health coverage, and enroll with one click if they choose.

Starting in 2021, Maryland Health Connection expanded outreach efforts, enlisting health insurance navigators to call everyone that received a letter with affordable coverage options to provide assistance. To date, over 100,000 Marylanders have checked the box and received information about affordable coverage options. 10% of those contacted enrolled in coverage by the beginning of the following year.⁶

The Maryland Easy Enrollment program has become a model for states who have started implementing their own programs. California, Colorado, Illinois, Maine, Massachusetts, New Jersey, New Mexico, Pennsylvania, and Virginia have implemented or are planning to implement an Easy Enrollment program. Unlike the Maryland model, many of the new easy enrollment programs do not leverage an individual mandate, but simply use tax filing forms to ask about health insurance.

While the Easy Enrollment programs are a key step forward in enrolling the uninsured in affordable coverage, they stop short of true autoenrollment without any consumer action needed. State officials have expressed a wariness for full automatic enrollment, especially in coverage through the health insurance marketplace. Subsidies in the marketplace are offered in the form of tax credits that must be reconciled for each tax year. State officials are concerned about automatic enrollment creating a tax liability for enrollees without their knowledge. For example, a taxpayer could have been uninsured in tax year 2022 because they were unemployed. Then in 2023, they get a job with affordable coverage, making them ineligible for the tax-credit based subsidies. If they were unaware of the autoenrollment for any reason, any tax credits would be due back to the federal government, with penalties, the following tax filing season. States are working with IRS officials to understand opportunities to support coverage without tax liabilities moving forward.

<sup>1. CDC, Health Insurance Coverage: Early Release of Estimates from the January – June 2022 NHIS. https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur202212.pdf
2. KFF, Distribution of Eligibility for ACA Health Coverage Among the Remaining Uninsured. https://www.kff.org/health-reform/state-indicator/distribution-of-eligibility-for-aca-coverage-among-the-remaining-uninsured/?dataView=0&currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
3. HHS, HHS Announces Continued Fast-Paced Enrollment with Nearly 5.5 Million Signing Up for Affordable Health Coverage in ACA Marketplace Since Start of Open Enrollment Period. https://www.cms.gov/newsroom/press-releases/hhs-announces-continued-fast-paced-enrollment-nearly-55-million-signing-affordable-health-coverage
4. Commonwealth Fund, Who Are the Remaining Uninsured, and Why Do They Lack Coverage? https://www.commonwealthfund.org/publications/issue-briefs/2019/aug/who-are-remaining-uninsured-and-why-do-they-lack-coverage
5. The federal government penalty was removed as part of the Tax Cuts and Jobs Act of 2017.
6. Maryland Health Benefit Exchange. Easy Enrollment Advisory Workgroup Report https://www.marylandhbe.com/wp-content/uploads/2022/12/MHBE-Easy-Enrollment-Final-Report-SB-802-Ch.-424-2-2019-and-HB-814-Ch.-423-2-2019-MSAR-12193.pdf</sup>