Association Between Having an Automatic Reenrollment Option and Reenrollment in the Health Insurance Marketplaces

Abstract

This cross-sectional study using health insurance marketplace data examines the association between an automatic reenrollment option and actual reenrollment rates.

Of the 11.4 million US health insurance marketplace enrollees in 2019, 3.4 million were automatically reenrolled based on their marketplace coverage in 2018.¹ Marketplace enrollees are automatically reenrolled in their current health plan the following year unless they actively change their enrollment status by discontinuing their coverage or selecting a new plan. Enrollees who actively select a plan have been reported to make better plan choices²; however, requiring enrollees to make a plan selection each year may be associated with their becoming uninsured.³ In January 2019, the Centers for Medicare & Medicaid Services requested public comments on eliminating automatic reenrollment for marketplace enrollees.⁴ While evidence suggests that administrative barriers to reenrollment are associated with reductions in Medicaid coverage,⁵ it is unknown whether elimination of automatic reenrollment is associated with decreases in reenrollment in the marketplaces.

Methods

We obtained 2014-2017 individual enrollment data from California’s marketplace, Covered California, through a public records act request.⁶ These data identify whether households had the option to automatically reenroll in Covered California. Households enrolled as of December 31 in a given year were able to automatically reenroll in their plan or a similar plan in the following year unless their insurer exited Covered California. Two insurers exited Covered California during the study period. Contra Costa exited Contra Costa County in 2015. United HealthCare exited other counties in 2017 (Figure). These exits divided Covered California households into groups that could automatically reenroll and groups that could not automatically reenroll. Our sample consists of 123 244 households in geographic areas and years that experienced insurer exit (rating area 5 in 2015; rating areas 1, 9, and 11-13 in 2017). This study was deemed exempt from review and approval by the University of Pittsburgh institutional review board.

Figure. Covered California Rating Areas Where Households Lost the Option to Automatically Reenroll Because of Insurer Exit.

Covered California is divided into 19 separate rating areas in which several insurers offer health plans.

We used multivariate linear regression to examine the association between household reenrollment and whether the household could automatically reenroll and adjusted for household characteristics, including the age of the oldest household member, household size, whether the household received a premium tax credit subsidy, the postsubsidy premium of the lowest-cost available plan, and indicators for geographic areas and years. We clustered SEs by geographic areas using the wild cluster bootstrap method to address the small number of clusters. Analyses were conducted in Stata SE 15 statistical package (StataCorp LLC). Statistical significance was defined as a 2-sided P < .05.

Results

Of the 781 households (0.63%) that could not automatically reenroll in Covered California because of insurer exit, unadjusted and adjusted reenrollment rates were 21.4% and 21.5%, respectively (Table). Both the unadjusted and adjusted reenrollment rates among the 122 463 households with the option to automatically reenroll were 51.2%. Losing the option to automatically reenroll was associated with a 30-percentage point decrease in enrollment both with adjusting for household characteristics (95% CI, 9.4%-52.0%; P < .001) and without (95% CI, 14.2%-46.8%; P < .001).

Table. Differences in Reenrollment Among Covered California Households With and Without an Automatic Reenrollment Option^a.

Status	Automatic Reenrollment Option, %b		Difference (95% CI)	P Value
	Yes (n = 122 463)	No (n = 781)
Unadjusted	51.2	21.4	29.8 (14.2-46.8)	<.001
Adjustedc	51.2	21.5	29.9 (9.4-52.0)	<.001

^aData are from 2014-2017 Covered California enrollment records. Observations are households in rating areas that experienced insurer exits.

^bHouseholds had the option to automatically reenroll in Covered California if they retained their coverage as of December 31 and their insurer did not exit Covered California. Households that discontinued their coverage are not included in the sample.

^cAdjusted reenrollment percentages were estimated using a multivariate linear regression (ie, a linear probability model) adjusting for the age of the oldest household member, the postsubsidy premium of the lowest cost plan available to the household, household size, whether the household received a premium tax credit subsidy, the rating area in which the household resides, and year. The SEs were clustered at the rating area level. We used the wild cluster bootstrap method to address the small number of clusters (ie, 6 rating areas).

Discussion

Elimination of automatic reenrollment would likely be associated with decreases in the number of enrollees who remain insured through the marketplaces. As an opt-out policy³ similar to that used in other health insurance markets such as Medicaid,² automatic reenrollment may be associated with increases in continuity of coverage in the marketplaces by reducing administrative barriers to reenrollment.

Although we found losing an automatic reenrollment option was associated with decreases in reenrollment, this association requires further study. The group that lost the automatic reenrollment option was relatively small. Households with different demographics or different experiences with insurers may have behaved differently if they had lost the option to automatically reenroll. Losing automatic reenrollment because of policy changes rather than insurer exit also may be associated with households behaving differently. Given the magnitude of our findings, it is critical that future studies continue investigating the association between automatic reenrollment and continuity of coverage.