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Alabama health insurance

Alabama's exchange gains a second insurer for 2018; enrollment for 2018 coverage continues until December 31, 2017

Alabama 2018 enrollment update

Alabama insurance overview

Alabama had just one insurer offering plans in the exchange for 2017 (Blue Cross Blue Shield of Alabama), but Bright Health has joined the exchange for 2018 in the Birmingham metro area. Residents in the rest of the state continue to have only BCBSAL as an option in the exchange, but BCBSAL already covered the majority of the state’s enrollees, even when other insurers also offered plans in the years prior to 2017.

With a federally facilitated health insurance exchange and refusal to expand Medicaid, Alabama is among states more resistant to the Affordable Care Act. These decisions have surely impacted the health of its residents as well as their access to healthcare.

Alabama health ratings

The Commonwealth Fund’s Scorecard on State Health System Performance, 2015, rated Alabama 47th among the 50 states and District of Columbia, and the state retained that same ranking in the 2017 edition of the Scorecard. Alabama’s state score was based on 4th quintile placement for four categories, Avoidable Hospital Use & Costs, Healthy Lives, Prevention & Treatment, and Equity, as well as 3rd quintile placement for the Access category. Despite coming in 37th for the percentage of uninsured adults ages 19 to 64, the state was among the top five (third place) for its percentage of uninsured children ages 0 to 18. The state also ranked top in the nation in terms of the percentage of “home health patients who get better at walking or moving around.” More details on Alabama’s 2017 score can be found here.

Similarly, Alabama came in 47th, in the 2017 edition of America’s Health Rankings. Alabama’s performance was negatively impacted by a relatively high uninsured rate, but was positively affected by a low rate of binge drinking and a high rate of high school graduation.

For yet another look at health indicators that might explain Alabama’s health rating, check out the 2016 listing of Key Health Data About Alabama compiled by Trust for America’s Health. A county-by-county analysis provided by the Robert Wood Johnson Foundation and the Population Health Institute at the University of Wisconsin allows you a more microscopic view of Alabama’s health and access to healthcare.

How the ACA has helped Alabama

While it may not be seeing the nation’s largest improvements, Alabama is seeing improvements under the Affordable Care Act. According to US Census data, the uninsured rate in Alabama in 2013 was 13.6 percent, and that had fallen to 9.1 percent by 2016. The national uninsured rate was 8.6 percent by 2016, but Alabama has rejected federal funding to expand Medicaid, leaving an estimated 75,000 people in the coverage gap, with no realistic access to health insurance.

The vast majority (94 percent) of Alabama residents who enrolled in qualified health plans (QHPs) through Alabama’s health insurance exchange (i.e., Healthcare.gov) in 2017 received financial assistance to cover a significant portion of their premiums. Average premium subsidies in Alabama in 2017 amounted to more than $518 per month.

2018 rates and carriers for Alabama

Alabama had just one on-exchange insurer in 2017 — Blue Cross Blue Shield of Alabama. But Bright Health is also offering plans in the Birmingham metropolitan area for 2018.

Since Bright Health is new to the state, they have no applicable rate increase. But Blue Cross Blue Shield of Alabama’s average rate increase for 2018 was 15.6 percent, despite the fact that the cost of cost-sharing reductions was added to silver plan premiums for 2018. This is a smaller average rate increase than most states saw for 2018. And some residents who get premium subsidies have access to plans for 2018 that have much lower after-subsidy premiums than they had in 2017, since the spike in silver plan premiums means that premium subsidies are also growing substantially for 2018.

AL enrollment in qualified health plans

The Kaiser Family Foundation in 2013 estimated Alabama’s potential market size to be 464,000 people and that 270,000 of them would qualify for tax credits to help lower their premiums. As of April 2014, there were 97,870 people enrolled in qualified health plans (QHPs) through Alabama’s health insurance exchange.

Alabama’s 2016 exchange enrollment was up 14 percent over 2015, with 195,055 enrollees. Forty-three percent of those enrollees were new to the exchange for 2016.

For 2017, enrollment declined to 178,414. Enrollment declines were widespread for 2017 in states that use HealthCare.gov, due in part to the nascent Trump Administration’s decision to reduce marketing and outreach in the final days of open enrollment in January 2017.

For 2018 coverage, enrollment in Alabama’s exchange stood at 170,211 as of December 23, 2017. Open enrollment had already ended on December 15, but Alabama residents can continue to enroll until December 31, due to the hurricane-related special enrollment period that applies statewide.

Alabama and Obamacare

In 2010, Alabama’s Congressional delegation opposed the health reform law. Sens. Jeff Sessions and Richard Shelby both voted no on the law while six Alabama representatives voted no in the House. Sessions has since been appointed Attorney General by President Trump, and a highly watched special election resulted in Doug Jones — a Democrat — winning Sessions’ former seat. Shelby remains in the Senate, so Alabama’s Senate delegation is split now, with one Democrat and one Republican. In the House of Representatives, Alabama has six Republicans and one Democrat. All of Alabama’s Republican Representatives voted yes on the American Health Care Act, which was the 2017 legislation that would have repealed major portions of the ACA. That bill ultimately died when it failed to pass in the Senate.

At the state level, then-Governor Robert Bentley indicated early on that he would support a state-run health insurance exchange, but ultimately sided with the state legislature, which decided to cede exchange control to federal government. Bentley was replaced in 2017 by Gov. Kay Ivey, who is strongly opposed to the ACA. The state has not accepted federal funding to expand Medicaid under the ACA.

Alabama continues to reject Medicaid expansion

Alabama’s opposition to the Affordable Care Act also meant that the state opted to not accept Obamacare’s Medicaid expansion. As a result, 75,000 of Alabama’s uninsured nonelderly population fall into the coverage gap, with no access to financial assistance with their health insurance. However, changes to Alabama Medicaid have been made and proposed.

In May 2014, Alabama submitted a Section 1115 demonstration waiver proposal to CMS. The proposal, which is called Alabama Medicaid Transformation, was approved in February 2016. The waiver calls for Medicaid funds to be distributed on a per-patient basis to regional care organizations (RCOs), which will use preventive care and early interventions to keep patients out of the hospital. RCOs that spend less than their per-patient allocation may keep their remaining funds; those that exceed their allocation must cover additional costs themselves.

On February 9, 2016, Democratic State Senator William Beasley introduced SB 182, which called for straightforward Medicaid expansion as outlined in the Affordable Care Act. The bill died however, after failing to advance out of committee.

Under Alabama’s current requirements, average monthly Medicaid enrollment has grown 11 percent from before the ACA through October 2017. See Medicaid.gov for a full overview of Alabama’s Medicaid and CHIP programs.

Other reform provisions in Alabama

The Affordable Care Act established a federal loan program to encourage the creation of nonprofit, consumer-run health insurance issuers – called Consumer Operated and Oriented Plans (CO-OPs).  By January of 2013, 24 CO-OPs had received loans totaling $1.98 billion. However, most of these CO-OPs struggled with low enrollment or faced financial difficulties in their infancy, due in large part to the fact that Republican lawmakers made the ACA’s risk corridors program retroactively budget neutral. Heading into 2018, only four CO-OPS remained operational.

Alabama did not create a CO-OP.

Is there a high-risk pool in AL?

Before the ACA reformed the individual health insurance market, coverage was underwritten in nearly every state, including Alabama.  Because pre-existing conditions were a factor in eligibility for coverage, some people were unable to purchase a private plan at all, or were only able to get one that excluded their pre-existing conditions.

The Alabama Health Insurance Plan (AHIP) was created in 1998 to give applicants an option for coverage if they were ineligible to purchase individual health insurance because of their medical history.  But unlike risk pools in many other states, AHIP was only available to applicants who were HIPAA eligible, coming off of a group plan with no more than a 63-day gap in coverage.

Under the ACA, all new health insurance policies became guaranteed issue starting on January 1, 2014. This change largely eliminated the need for high risk pools and MCHA stopped enrolling new members as of January 1, 2014.  In March 2014, the Alabama Senate passed SB 123, allowing AHIP to “cease operations upon allowing current participants enough time to transition out of the plan.” By 2017, the AHIP website was no longer operational.

Medicare enrollment in the state of Alabama

Alabama Medicare enrollment reached 968,010 in 2015, about 20 percent of the state’s population compared with 17 percent of the population enrolled in Medicare nationwide.

Historically, Alabama has had the second-highest percent of Medicare recipients listed as disabled, 24 percent, tied with Mississippi and just below Kentucky’s 25 percent. The other 76 percent of Alabama Medicare beneficiaries qualify based on age alone.

As of 2014, Medicare paid about $9,150 annually per Alabama enrollee each year. Based on data available for 2009, the state ranked 19th in overall spending with $8.04 billion annually.

Alabama Medicare recipients can opt to enroll in Medicare Advantage plans instead of original Medicare if they wish to gain additional benefits beyond what traditional Medicare coverage offers. 25 percent selected Medicare Advantage in 2015, compared with 31 percent nationwide.

Forty-seven percent of Alabama Medicare beneficiaries (455,086) are enrolled in Medicare Part D plans, which provide stand-alone prescription drug coverage.

Alabama health insurance resources

State-based health reform legislation

Recent Alabama legislation related to healthcare reform:

  • SB147 was signed into law and became Act Number 2015-227 in May 2015. This legislation ensures that insurance executive compensation in Alabama will be kept confidential. As such, it is not subject to open records requests, Freedom of Information Act (FOIA) requests, or subpoena.

Here’s a summary of other recent Alabama bills related to healthcare reform (the 2017 legislative session in Alabama ended on May 19):

More Alabama coverage

Exchange

News, history, and enrollment info for your state marketplace

Medicaid

Your state’s Medicaid expansion, eligibilty, contacts

Medicare

Insurance for those over 64 (off-site)