King v. Burwell – subsidies upheld
Democratic Representative Ed Butler introduced a bill to create a state-run exchange in New Hampshire this year (the state currently has a partnership exchange), but it was defeated by the Republican dominated legislature in March. Since the state still uses the federally-run exchange, 32,000 people in New Hampshire would have lost their subsidies if the Supreme Court had ruled that subsidies could only be issued by state-run exchanges. But on June 25, the Supreme Court ruled that subsidies are legal in every state, even those that rely on the federally-run exchange.
Benefits extend beyond those receiving subsidies
This is obviously a huge win for the people of New Hampshire who currently have subsidized coverage through the exchange; the Kaiser Family Foundation had estimated that their premiums would have increased by 218 percent if the subsidies had been eliminated. But it’s also a win for everyone who buys individual insurance in the state, including those who don’t receive subsidies. The American Academy of Actuaries had projected market-wide rate increases of at least 35 percent if subsidies had been eliminated, and the overall size of the individual market pool would have dropped by about 70 percent.
As well as the citizens of New Hampsire, the King ruling is also a win for health insurers – their market is not going to destabilize now – and for medical providers, since their patients will still have insurance and be able to afford care.
In addition, New Hampshire expanded Medicaid under the ACA, but with a waiver that allows the state to start using Medicaid funds to subsidize private plans in the exchange for the newly eligible population in 2016, rather than continuing to cover them in the state’s Medicaid managed care program. Those funds would still be available in 2016 regardless of the outcome of the King case, but state leaders had expressed concern that the program could be jeopardized by the upheaval that would have been created in the exchange if subsidies had been eliminated.
2016 rates and carriers
In 2015, New Hampshire’s exchange had five carriers, up from just one in 2014. There will still be five carriers in 2016, although there’s one swap: Assurant is exiting the market (nationwide), but Ambetter (offered by Celtic) is joining the exchange in New Hampshire. In 2015, there were 42 individual plans available in the state, and that will increase to 51 in 2016. Dentegra will be joining the exchange aswell, bringing the total number of dental carriers from three to four.
Two carriers in the exchange – Minuteman Health and Maine Community Health Options – have requested double digit rate increases, although they have not yet been approved. Both carriers are CO-OPs created under the ACA, and both expanded into New Hampshire at the start of 2015, so their claims data for the state is very limited. But they both note in their rate justifications that the transition of the NH Health Protection Program population (those newly eligible for Medicaid under the ACA’s Medicaid expansion) to private plans in 2016 is a driving force in the higher rates they’ve requested for the coming year (the state will use Medicaid funds to subsidize premiums for the transitioning enrollees). Minuteman has requested an average rate increase of nearly 50 percent, although they’ve proposed a rate reduction for their catastrophic plan.
The rest of the carriers in the exchange have proposed rate changes of less than 10 percent, although no rates have been approved yet. It will be important for enrollees to actively shop around during the upcoming open enrollment, both because of the possible rate hikes from the CO-OPs, and also because there’s a new carrier in the exchange, and more plans available for 2016.
2015 enrollment totals
53,005 people in New Hampshire had enrolled in private plans through the exchange by February 22, when the second open enrollment period – and its extension – ended. Only 71 percent of them are receiving premium subsidies – the lowest percentage of any state where HHS is running the exchange.
The official HHS target for New Hampshire was 50,000 enrollees during the 2015 open enrollment period, so the exchange exceeded that target by more than three thousand people. However, by April 1, only 45,504 people had in-force policies in the New Hampshire exchange, as some enrollees didn’t pay their initial premiums, and others cancelled their coverage shortly after enrolling. All in all, the effectuation rate matches up with the national averages.
An additional 9,294 people in New Hampshire enrolled in Medicaid or CHIP through the exchange between November 15 and February 22. Medicaid enrollment continues year-round.
Open enrollment for 2015 has ended, so most applicants can only purchase a 2015 plan – on or off the exchange – if they have a qualifying event (Native Americans can enroll year-round, as can applicants who are eligible for Medicaid/CHIP). The next open enrollment period starts on November 1, for coverage effective January 1, 2016.
The New Hampshire Department of Insurance is an active participant in overall functionality of the New Hampshire exchange, which operates as a partnership between the state and HHS. The Department of Insurance has published an inclusive overview of exchange information on their website to serve as a resource for state residents.
Exchange grows from one carrier to five
For 2014, only one health insurance carrier — Anthem Blue Cross Blue Shield — applied to participate in the state-federal partnership exchange in New Hampshire, offering 14 health plan options. But that has changed significantly for 2015. The New Hampshire Obamacare exchange now includes policies from five carriers. Not all carriers offer plans in all counties, but there are an average of 38 plans available in each county, up from 10 in 2014.
Two of the new carriers participating in the New Hampshire exchange are ACA-created CO-OPs: Minuteman Health, based in Boston, and Maine Community Health Options (MCHO) that garnered 83 percent of the market share in neighboring Maine during the 2014 open enrollment. MCHO will have a limited presence in 2015, offering coverage in four NH counties: Coos, Carroll, Rockingham, and Strafford. But it plans to expand further in 2016.
The other new carriers are Harvard Pilgrim Health Care and Assurant.
And premiums are falling
One result of the increased competition is a sharp reduction in average premiums. The benchmark plan (second-lowest-cost silver plan) has changed as a result of the influx of carriers to the exchange, and the new benchmark plan is about 17 percent less expensive than the benchmark plan in 2014. This is among the sharpest drops in the country, and highlights the importance of competition in holding down premiums.
Avalere Health found that the average lowest-cost bronze plan in New Hampshire is 17 percent less expensive in 2015, and that the average lowest-cost silver plan is 18 percent less expensive. The silver drop is the largest in the nation, and the bronze drop is second only to Mississippi. All in all things look good for New Hampshire health insurance premiums in 2015.
Healthcare legislation in the 2015 session
A variety of healthcare reform bills were introduced in the 2015 legislative session in New Hampshire. They run the gamut from establishing a state-based single payer healthcare system to allowing individuals and small businesses to buy coverage from outside the state. There’s also a possibility that lawmakers will revisit the question of Medicaid expansion (Medicaid is currently expanded in New Hampshire under the ACA), although the current expansion law doesn’t sunset until 2016, so that issue could be postponed until next year’s session.
Increased network options
All 26 hospitals in the state will accept coverage from at least three of the five carriers in 2015, a change that will likely be very popular with the state’s residents. Network issues plagued the New Hampshire exchange in 2014, as Anthem only contracted with 16 of the state’s 26 hospitals in efforts to keep premiums as low as possible.
As a result, even though the exchange had just one carrier in 2014, premiums in New Hampshire were comparable to rates in states that have many carriers offering policies. But Anthem’s restrictions on its hospital and physician networks have been drawing fire, despite the low premiums that the narrow network allows.
In November, the New Hampshire Department of Insurance published a detailed explanation of 2015 network size and scope based on county and carrier for all of the carriers offering plans in the exchange. Provider network details are also available on each carrier’s website.
There’s a mix of broad and narrow networks available in New Hampshire for 2015, so shoppers can find the price and network combination that most appeals to them. Anthem is continuing to offer nearly the same network it had in 2014, and Harvard Pilgrim’s network is also relatively narrow. Assurant’s network is more broad, and although their plans were higher-priced than Anthem in 2014 and only available outside the exchange, they still got 9 percent of the individual market in 2014. Assurant believes that their broad network – which includes providers in other states – will help to draw enrollees in the exchange in 2015. And although Maine Community Health Options is not available in all areas of the state in 2015, they have a broad hospital network in anticipating of expanded coverage in 2016.
2014 enrollment numbers
40,262 people had completed their private plan Obamacare enrollments in the New Hampshire exchange by April 19. Another 7,235 exchange applicants were eligible for the state’s existing Medicaid coverage by mid-April.
For private plan enrollments, New Hampshire greatly exceeded CMS projections in 2014. The original projection for the New Hampshire exchange was 19,000 enrollees during the 2014 open enrollment; the final total is more than double that amount.
Anthem Blue Cross Blue Shield had 90 percent of the individual market share in New Hampshire prior to 2014, so it’s not especially unusual that they’re the only carrier that opted to participate in the exchange the first year.
Anthem has reported that more than 35,000 of the exchange enrollees are new customers for them. Given the carrier’s long-term dominance in the market, we can assume that a significant majority of the Obamacare enrollments in New Hampshire are for people who were previously uninsured. Anthem has also reported that almost 90 percent of their enrollees have paid their premiums.
Unique Medicaid expansion began mid-year
Residents were able to begin enrolling in New Hampshire’s expanded Medicaid program as of July 1, with policies effective August 15 (Medicaid enrollment during the winter and spring was only possible for people who qualified under the state’s pre-expansion guidelines).
The state estimated that roughly 50,000 people would be eligible for coverage under the expanded Medicaid program. By the end of September, three months after enrollment began for expanded Medicaid, 18,500 people had already enrolled, and that had grown to nearly 24 thousand people by November 19.
Medicaid expansion in New Hampshire was a contentious issue, but ultimately Governor Maggie Hassan prevailed in her efforts to expand Medicaid, albeit in a privatized fashion. Gov Hassan signed Senate Bill 413 into law on March 27, 2014, paving the way for New Hampshire to become the 26th state to accept Medicaid expansion.
For the first couple years, the program will look much the same as Medicaid expansion looks in the other 25 states. The state will use federal Medicaid funds to provide New Hampshire Health Protection Program coverage to residents with incomes below 138 percent of poverty.
But by 2016, the state plans to transition the program’s insureds to subsidized, private coverage, following the “private option” Medicaid expansion path that has been popular in several other states.
Risk pool and grandmothered plans
In November 2013, New Hampshire’s Insurance Commissioner Roger Sevigny announced that the state-run high risk pool (New Hampshire Health Plan) would remain in effect “until the federal marketplace is fully available (it had previously been scheduled to cease operations on December 31). The risk pool ceased operations on June 30, 2014, another sign that Obamacare (along with HealthCare.gov) is now working quite well in New Hampshire.
New Hampshire allowed existing 2013 health plans to renew until late 2014, but residents also had the option to cancel their existing plan and switch to a new ACA-compliant policy instead. Anthem Blue Cross Blue Shield announced in May 2014 that they will accept the government’s offer to further extend pre-ACA policies that were carried over from 2013.
Policy-holders with pre-2014 plans that had been scheduled to terminate between October 1 and December 1 will be allowed to renew those plans for one additional year, into 2015. Those insureds will also have the option to enroll in an ACA-compliant plan instead if they prefer.
The New Hampshire Health Plan, which runs the state’s high-risk insurance pool, was approved in September 2013 for a federal grant to help facilitate education and outreach for the exchange. In addition, Planned Parenthood and Bi-State Primary Care were both awarded grants to serve as navigators for NH residents who have questions or need personal assistance with the enrollment process.
Covering New Hampshire, an organization dedicated to educating consumers in New Hampshire and helping them enroll in coverage, is focusing additional efforts on targeting young men during the 2015 open enrollment, since they were under-represented during the 2014 open enrollment period.
Legislation and exchange history
The exchange creation process in New Hampshire has been a legislative battle. In February 2013, Gov. Hassan announced that New Hampshire would operate its health insurance marketplace as a partnership with the federal government.
Prior to the 2012 elections, New Hampshire seemed firmly on a path to relying on the federally facilitated exchange. Former Democratic Gov. John Lynch had no effective means to push back against a Republican-dominated state Legislature that was united against a state-run exchange.
And in 2011, lawmakers passed a bill (enacted into law without Lynch’s signature) that prohibited any sort of penalties for New Hampshire residents who fail to obtain health insurance – in direct conflict with the ACA’s individual mandate and shared responsibility penalty. The law has no real impact however, because the IRS (a federal agency, not under state control) is responsible for assessing the ACA’s penalties, and because the ACA is a federal law that cannot be superseded by state law.
But the 2012 elections gave control of the state House to Democrats, put more Democrats in the Senate, and kept the governor’s office in Democratic hands. The political shift and a law that allowed the state to take on specific exchange functions enabled the state to adopt a partnership model.
New Hampshire is responsible for plan management and consumer assistance, and the federal government is managing all other marketplace functions. The NH Health Exchange Advisory Board holds monthly meetings, the minutes of which are available here.
New Hampshire health insurance exchange links
New Hampshire Department of Insurance: Health Benefit Partnership Exchange Advisory Board
Includes meeting agendas and documents from November 2012 until the present.
State Exchange Profile: New Hampshire
The Henry J. Kaiser Family Foundation overview of New Hampshire’s progress toward creating a state health insurance exchange.
New Hampshire Consumer Assistance Program
Assists consumers who have purchased insurance on the individual market or who have insurance through an employer who only does business in New Hampshire.
(800) 852-3416 / firstname.lastname@example.org
Covering New Hampshire – a statewide effort by the New Hampshire Health Plan to inform residents of their coverage options in the exchange and the resources that are available for those who need assistance.