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Alabama health insurance exchange / marketplace

195k enrollees, with some attrition already subtracted

  • By
  • healthinsurance.org contributor
  • February 18, 2016

Enrollment up 38% since June 2015

195,055 people enrolled in private plans through the Alabama exchange during the 2016 open enrollment period, including renewals and new enrollees. This was nearly a 14 percent increase from the enrollment total at the end of the 2015 open enrollment period (171,641), and effectuated enrollment is less likely to drop off as sharply in the coming months as it did after the end of open enrollment last year.

That’s because HHS began accounting for attrition (unpaid premiums and plan cancellations) during open enrollment this time around, as opposed to waiting until after the end of open enrollment to begin subtracting enrollments that were never effectuated or were cancelled early in the year. In 2015, effectuated enrollment as of March 31 was 15 percent lower than the enrollment total as of late February. There will still be attrition in 2016, but it won’t be as sharp, since some of it was already baked into the 195,055 enrollment tally.

The enrollment total for 2016 includes renewals, but it also includes a significant number of new enrollees. As of mid-2015, there were 141,361 people with in-force private coverage through the Alabama exchange. The enrollment total as of February 1, 2016 is a 38 percent increase over the total as of June 2015.

The penalty for not having health insurance in 2016 will be much higher than it was in 2014 and 2015. Tax filers who owe a penalty for 2016 are expected to owe an average of $1,000, which is five times the average that they owed for being uninsured in 2014.

Open enrollment for 2016 has ended, so coverage is now only available if you have a qualifying event. But Native Americans can enroll year-round, as can anyone eligible for Medicaid or CHIP.

2016 rates and carriers

Three carriers offered individual plans through the Alabama exchange in 2015, and that is still the case in 2016.

Alabama is one of just five states that doesn’t conduct a state-based review of proposed rate changes. In Alabama, HHS is responsible for reviewing proposed rates. According to Healthcare.gov’s rate review tool, final 2016 rate changes for Alabama exchange plans were:

  • Humana: average rate increase of just under 9 percent
  • Blue Cross Blue Shield of Alabama: average rate increase of 28 percent (the carrier is predicting losses of $135 million for 2015, mostly as a result of ACA-compliant coverage).
  • UnitedHealthcare: average rate increase of 24.5 percent (their actuarial memo states that the plans in question were sold outside the exchange in 2015, but the notes on the rate review page indicate that the premiums apply on the exchange. Healthcare.gov’s rate review tool does not indicate any other on-exchange individual product from UnitedHealthcare, and UnitedHealthcare’s plans do show up when browsing plans in Alabama on Healthcare.gov).

Although Blue Cross Blue Shield of Alabama (which has the majority of the market share in 2015) raised rates by an average of 28 percent in 2016, the average benchmark plan in Alabama increased in price by just 12.5 percent. Benchmark plan rate changes don’t really tell us much in terms of how individual consumers’ rates will change, since the benchmark plan is just the second lowest-cost Silver plan, and isn’t necessarily the same plan from one year to the next.

But the change in benchmark premium does give us an indication of how premium subsidies will change; in Alabama, average subsidies are higher in 2016, but not by enough to offset the rate hikes on many BCBS plans. This highlights how important it is for existing enrollees to shop around during open enrollment and actively select a plan, rather than relying on auto-renewal.

How to rates compare to other states?

According to a new analysis by GoBankingRates, Alabama has the third-most-expensive individual health coverage in the country in 2016, when premiums are combined with deductibles, copays for office visits, and the cost of emergency care under the plan. For their analysis, they compared the lowest-cost-silver plan in a major metropolitan area for a 40-year-old non-smoker who earns $40,000/year.

If we only consider premiums – and don’t take into account cost-sharing – Alabama’s average benchmark premiums for a 27-year-old are 19th out of the 38 states that use Healthcare.gov. But although Alabama’s premiums are very much in line with the national average, the GoBankingRates analysis accounts for cost-sharing, which was higher than the average across other states.

Insurance executive compensation now a secret

Under a law passed in Alabama in 2015 (SB147, which became Act Number 2015-227 when it was signed into law in May), insurance executive compensation in Alabama is now kept confidential, and is not subject to open records requests, freedom of information requests, or subpoena.

The legislation was sponsored by Slade Blackwell (R, Mountain Brook), and passed with nearly unanimous support. It applies to all insurance companies in the state, but it primarily impacts Blue Cross Blue Shield – by far the dominant carrier in the state. That’s because national carriers, including Humana and UnitedHealthcare (the other two exchange carriers in Alabama) have to report executive compensation to the IRS and the SEC. But Blue Cross Blue Shield of Alabama (a state-based carrier) does not file with the SEC and doesn’t have to disclose executive compensation to the IRS.

Reporter John Archibald described the new law as “royal treatment” for BCBS of Alabama, and it’s certainly concerning that executive compensation for the carrier is now protected from the public eye. This is especially troubling given the fact that BCBS of Alabama has requested rate increases that average 28 percent for 2016. But residents of Alabama are still protected by the ACA’s medical loss ratio, which requires carriers to spend at least 80 percent (85 percent in the large group market) of premiums on medical care and “quality improvements,” with administrative expenses – including executive compensation – coming out of the remaining 20 percent (15 percent in the large group market).

2015 enrollment numbers

171,641 Alabamians signed up for qualified health plans (QHPs) through HealthCare.gov during 2015 open enrollment, according to the U.S. Department of Health and Human Services (HHS). That was a significant increase over the 97,870 residents who enrolled during the 2014 open enrollment period.

As expected, not all enrollees paid their initial premiums through, and other enrollees transitioned off their plans for various reasons during the year. In addition, HHS got better at enforcing documentation requirements for immigration status and financial eligibility for subsidies. By the end of June, 141,361 people in Alabama had in-force private plan coverage through the exchange.

91 percent qualified for premium subsidies. Those subsidies averaged $268 per month, reducing the average monthly premium from $360 to $92.

In addition to premium subsidies, nearly 73 percent of Alabama exchange enrollees also received cost-sharing subsidies in 2015. Cost-sharing subsidies, which lower the out-of-pocket amounts that insureds must pay when they receive care, are only available for people with household incomes up to 250 percent of poverty, and only available when the enrollee selects a Silver plan. Cost-sharing subsidies are strongest for enrollees with incomes up to 200 percent of poverty, and for those with incomes under 151 percent of poverty, the cost-sharing subsidies effectively result in coverage that’s even better than a regular Platinum plan.

Nationwide, 56 percent of exchange enrollees are receiving cost-sharing subsidies, so Alabama is far above average in that regard. Only Mississippi has a higher percentage (77 percent) of exchange enrollees with cost-sharing subsidies.

Of the 171,641 people who originally enrolled in the Alabama exchange during open enrollment, 85 percent (146,482 enrollees) had household incomes under 251 percent of poverty, and were thus eligible for cost-sharing subsidies. And 84 percent of those enrollees (122,624 people) selected silver plans and obtained the cost-sharing subsidies. It’s important to note that bronze plans are less expensive than silver plan, and that sometimes leads lower-income enrollees to select bronze instead. But the bronze plans come with much higher out-of-pocket costs that can be prohibitively expensive when medical care is needed, and silver plans with built-in cost sharing subsidies generally present a much better value for eligible enrollees.

Subsidies safe in Alabama …

Alabama uses Healthcare.gov – rather than operating a state-run exchange – which means that the outcome of the King v. Burwell lawsuit was crucial for the state. Subsidies would have disappeared for more than 128,000 people in Alabama if the Supreme Court had ruled that subsidies could only be provided through state-run exchanges.

Fortunately for the residents, insurance carriers, and medical providers of Alabama, the Supreme Court ruled in June 2015 that subsidies are legal in every state, regardless of whether the exchange is state- or federally-run. Not only will subsidies remain available, but the entire individual market will be significantly more stable than it would have been if subsidies had been eliminated. Had that happened, the Urban Institute estimated that premiums in the individual market – for people NOT currently receiving subsidies – would have climbed by 55 percent (in addition to regular annual rate hikes), and the total number of people with individual health insurance would have plummeted by about 70 percent.

But many Alabama leaders disappointed by ruling

Despite the actuarial predictions of the market collapse that would have happened if subsidies had been eliminated, along with the direct impact on the people of Alabama who would have lost their health insurance, many of the state’s leaders – including the Governor – expressed dismay that the subsidies were upheld by the Supreme Court. U.S. Congresswoman Terri Sewell (D, 7th District) was pleased with the Court’s opinion, but most of her colleagues mentioned after the ruling that they will continue to push for repeal of the ACA.

Penalties increased again for 2016

The individual mandate, which says you must have health insurance or pay a penalty, is one of the least popular features of Obamacare. But it was designed to be phased in over three years, in order to be less of a financial burden at the start, when people were just learning about the new regulations.

Many uninsured Americans are eligible for an exemption from the penalty.

For those who do have to pay, penalties increased again for 2016 (penalties for 2016 will be assessed when people file their 2016 tax returns in early 2017). Those who don’t qualify for an exemption will have to pay the greater of:

  • 2.5% of annual household income above the tax filing threshold. The maximum penalty under this calculation method is the national average premium for a bronze plan. In July 2015, the IRS announced that the maximum 2015 penalty would be $2,484 for a single individual and $12,420 for a family of five or more. This was slightly higher than the maximum in 2014, and 2016’s maximum is likely to be higher still, given the national average rate increases we saw for 2016
  • $695 per adult or $347.50 per child under 18. The maximum penalty per family using this method is $2,085.

Use the healthinsurance.org penalty calculator to see how much you may owe. Now that the penalty has ratcheted into it’s highest position for 2016 (it will only adjust based on inflation in future years), it is much steeper than it was in 2014 and 2015. Especially for people who qualify for premium subsidies, it’s almost certainly a better financial bargain to get health insurance. Remaining uninsured will not only subject people to the incredible financial uncertainty that goes along with being uninsured, it will also result in a significant penalty when 2016 tax returns are filed in early 2017.

Coverage for small businesses

Through the federal Small Business Health Options Program (SHOP) exchange, small businesses with 50 or fewer employers can now shop online for health insurance coverage. Small employers and non-profit organizations can shop on their own or work through a broker or agent. After the employer defines the plan to offer, employees enroll online through the SHOP.

There is no defined open enrollment period for the SHOP marketplace. Small employers can set up a plan anytime of the year.

Nearly 125,000 found coverage in 2014

Nearly 98,000 Alabama residents signed up for qualified health plans (QHPs) during 2014 open enrollment. That was about 21 percent of estimated 464,000 people eligible to use the marketplace, according to the Kaiser Family Foundation. Nationally, about 28 percent of eligible people enrolled in a health plan through the ACA marketplaces. In addition, Kaiser also reported 22,564 Alabamans qualified for either Medicaid or the Children’s Health Insurance Program (CHIP) under existing eligibility criteria.

Alabama’s uninsured rate dropped 3.2 percentage points from 2013 to 2014, falling to 14.5 percent according to the Gallup-Healthways Well-Being Index. By the first half of 2015, it had fallen even further, to 12 percent.

How Alabama is handling health care reform

The federal government operates the health insurance marketplace in Alabama, based on Gov. Robert Bentley’s November 2012 decision against a state-run marketplace. Bentley cited annual operating costs of up to $50 million as his reason for opting for a federally operated exchange.

The decision against a state-run exchange came somewhat as a surprise. While the Republican governor consistently opposed many provisions of the Affordable Care Act, he repeatedly expressed support for a state health insurance exchange. He supported exchanges during his campaign for governor, and as governor, he used an executive order to establish the Alabama Health Insurance Exchange Study Commission. In November 2011, that commission unanimously recommended Alabama implement a state-run exchange. However, bills to establish a state-run exchange failed to pass in both the 2011 and 2012 sessions.

Alabama residents had more choices and slightly higher prices during the 2015 open enrollment period. Historically, Alabama’s health insurance market has been considered one of the least competitive in the nation.

Humana and Blue Cross and Blue Shield of Alabama, which dominates the health insurance market in the state, sold individual health insurance through the federal marketplace in Alabama for 2014. UnitedHealthcare joined the exchange for 2015, and its plans are now available through the marketplace in all 67 Alabama counties. Previously, United policies were available only outside the marketplace.

A study by the Commonwealth Fund shows Alabama premiums increased just 3 percent from 2014 to 2015, which is much less than the increases seen in the years leading up to the passage of the Affordable Care Act. Rates for individual health insurance increased about 10 percent each year between 2008 and 2010. But for 2016, the average increase will be much more significant, hovering around 24 percent.

Alabama has not expanded Medicaid. Gov. Bentley opposed Medicaid expansion, and his position became the subject of campaign ads, editorials, billboards, and websites during 2014. Late in 2014, Bentley reintroduced a discussion on Medicaid expansion. Bentley said his administration will explore options to obtain federal Medicaid funding for a state-designed solution with a work requirement for recipients. Conservative groups promptly accused Bentley of flip-flopping.

An August 2014 study published by the Urban Institute shows the impacts of not expanding Medicaid. In Alabama, about 254,000 people will not qualify for Medicaid coverage through 2016. In terms of financial impact, the authors calculated that while Alabama would spend $1.08 billion to expand Medicaid over a ten-year period, the state is losing out on $14.4 billion in federal spending and state hospitals are losing $7.0 billion in reimbursement over the same period.

Alabama health insurance exchange links

HealthCare.gov
800-318-2596

Alabama Department of Insurance – Health Insurance Reform Information Center

State Exchange Profile: Alabama
The Henry J. Kaiser Family Foundation overview of Alabama’s progress toward creating a state health insurance exchange.

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