Latest news and updates
- Open enrollment for 2019 coverage in Georgia ended on December 15.
- Enrollment is still open for Georgians with qualifying events.
- Short-term health plans are available in Georgia with initial plan terms up to 364 days.
- All four insurers remained in the exchange.
- Average rate hike for 2019 is less than 4%.
- Insurers are adding the cost of CSR to Silver plan rates for 2019.
- The impact of new insurers joining the exchange: It’s more complicated than it seems.
- Nearly 481k enrolled for 2018.
- Legislation to protect broker commissions
- Four insurers offered plans for 2018, down from five in 2017.
- Humana left the exchange at the end of 2017.
- Anthem offering coverage in 85 out of 159 counties in 2018, but that’s dropping to 75 in 2019.
- All counties had at least one insurer for 2018; 14 counties have two.
- Average 2018 rate increase would have been 31.5% if CSR funding had continued.
- But elimination of CSR funding drove average premiums significantly higher.
- Georgia insurers took varying approaches to the CSR funding issue in 2018.
Georgia exchange overview
Georgia uses the federally run health insurance exchange, so enrollments are completed via HealthCare.gov. Enrollment dropped by 16 percent in 2017, which was considerably more than the national average (across all states that use HealthCare.gov, enrollment was down about 5 percent). But for 2018 coverage, enrollment in Georgia’s exchange only fell about 2.6 percent, versus a national average of about 3.6 percent
Average rates increasing by less than 4% for 2019
For 2019 coverage, open enrollment ended December 15, 2018. All plans selected during open enrollment will take effect January 1, 2019.
Georgians may, however, still be able to purchase ACA-compliant coverage after December 15 if they have a qualifying life event.
All four of Georgia’s current exchange insurers filed plans for 2019. In late August, updated filings were made public (although the updated filings were not added to ratereview.healthcare.gov, and Georgia does not use SERFF). Georgia’s exchange insurers proposed the following average rate changes:
- Alliant: a 10 percent decrease (the initial filing had been for a 5.8 percent increase)
- Ambetter from Peach State Health Plan (a Centene company): 8.8 percent increase (the initial filing called for a 7.7 percent increase). Ambetter is expanding their coverage area to cover the counties where Anthem is leaving the exchange at the end of 2018.
- Anthem Blue Cross Blue Shield of Georgia: 0.3 percent decrease (the initial filing had called for a 2.2 percent increase). Anthem is returning to a large chunk of northern Georgia in 2019, including the Atlanta metro area (except for Clayton and Rockdale counties), but they’re leaving several of the rural counties where they offered coverage in 2018. Anthem offered plans in 85 counties for 2018. According to the Public Use Files that CMS published in late October 2018, Anthem is leaving 41 of those counties at the end of 2018, but joining 31 other counties. So in total, they’ll offer plans in 75 counties in 2019, down from 85 in 2018. But their plans will be available to more people, due to their re-entry into some of the more populated counties they had exited at the end of 2017. In all 85 counties where Anthem offered plans in 2018, they were the only insurer offering plans. But in 30 of the 31 counties that Anthem is joining for 2019, they will have competition from at least one other insurer. In the 41 counties where Anthem is leaving, Ambetter will offer coverage in 2019.
- Kaiser: 14.7 percent increase (unchanged from the initial filing)
At ACA Signups, Charles Gaba has pegged the average rate increase for 2019 at just under 4 percent. But the average benchmark premium is increasing by just 0.3 percent. Premium subsidies are based on the cost of the benchmark premium in each area, so it’s particularly important for enrollees in Georgia to carefully comparison shop during open enrollment, as they might find that their subsidy isn’t growing by as much as their overall premium, and switching to a different health plan might provide a better value (detailed examples are explained in the next section).
Kaiser’s rate increase is the most significant for 2019, but Kaiser is the only one of the four insurers that didn’t add the cost of cost-sharing reductions (CSR) to their premiums for 2018. Their rate filing for 2019 notes that a significant portion of their rate increase is due to the fact that they are adding the cost of CSR to their on-exchange silver plans, starting in 2019.
For 2019, as was the case for 2018, Georgia’s insurance commissioner did not instruct insurers on how to add the cost of cost-sharing reductions (CSR) to premiums. In 2018, the other three insurers took varying approaches to handling the fact that the federal government was no longer reimbursing insurers for the cost of CSR. Alliant added the cost to on-exchange silver plans, Anthem added the cost to all silver plans, and Ambetter spread the added cost across all of their ACA-compliant plans at all metal levels.
For 2019, Alliant is continuing to add the cost of CSR to on-exchange silver plans. And Ambetter is switching to the “silver loading” strategy, with the cost of CSR added to the rates for silver plans in 2019, albeit both on- and off-exchange silver plans.
Anthem’s rate filing didn’t indicate how they’ve handled the cost of CSR for 2019, but they confirmed by phone that they have added the cost of CSR to all silver plans. A 40-year-old in Baldwin County who earns $20,000 can get a bronze plan from Anthem in 2019 for 52 cents per month after the premium subsidy is applied; free or ultra-low-cost bronze plans become available when the cost of CSR is added to silver plans, making the premium subsidies (which are based on the cost of silver plans) disproportionately large.
While the CSR approach varied significantly across Georgia’s four insurers for 2018, it’s much more uniform for 2019:
- Kaiser: Adding the cost of CSR to on-exchange silver plans.
- Alliant: Adding the cost of CSR to on-exchange silver plans.
- Ambetter: Adding the cost of CSR to on- and off-exchange silver plans.
- Anthem: Adding the cost of CSR to all silver plans. Anthem does not sell any silver plans off-exchange-only. So while their silver plans are available both on- and off-exchange, the plans are identical and the cost of CSR has been added uniformly to the silver plans.
Anthem will no longer offer coverage in the following counties after the end of 2018: Appling, Bacon, Ben Hill, Bibb, Bleckley, Brantley, Bryan, Bulloch, Camden, Candler, Coffee, Dodge, Dooly, Effingham, Evans, Glynn, Houston, Irwin, Jeff Davis, ones, Liberty, Long, McIntosh, Meriwether, Miller, Monroe, Montgomery, Peach, Pierce, Pulaski, Putnam, Screven, Tattnall, Telfair, Toombs, Treutlen, Troup, Twiggs, Wayne, Wheeler, and Wilcox.
But Anthem has rejoined the following counties for 2019, after exiting them at the end of 2017: Banks, Bartow, Chattooga, Cherokee, Cobb, COweta, Dawson, Dekalb, Douglas, Fannin, Fayette, Floyt, Forsyth, Franklin, Fulton, Gilmer, Gwinnett, Habersham, Hall, Hart, Henry, Lamar, Lumpkin, Pickens, Pike, Polk, Rabun, Stephens, Towns, Union, and White.
An Urban Insitute study predicted that the elimination of the individual mandate penalty at the end of 2018 and the expansion of short-term plans and association health plans would drive up rates in Georgia to a larger degree than in many other states (by an average of 19.5 percent, versus a national average of 16.5 percent — and that was in addition to the normal rate increases we would have seen without those changes).
How the shifting plan options will change your premium subsidy — some real-life examples
Sometimes the easiest way to understand the annual changes in premiums and plan options is to consider real-life examples. Let’s consider two counties in Georgia: Gordon, and Hancock. We’re going to look at example prices for a 45-year-old earning $35,000 (we’ll keep the person the same age in both 2018 and 2019, to compare apples to apples and avoid the inevitable premium increase that happens every time we get another year older). So all of the numbers in this example are specific to a 45-year-old who earns $35,000… if an applicant earns more or less than that, or if they’re older or younger than 45, the numbers will be different.
- In Gordon County, Ambetter and Alliant are offering plans in 2019, whereas Alliant was the only exchange insurer in 2018.
- The subsidy amount in 2018 was $499/month.
- There were six plans available in 2018. After the subsidy was applied, their premiums ranged from $56/month to $315/month.
- The benchmark plan (Alliant SoloCare Silver PPO 40010) was about $769/month before the subsidy, and $271/month after the subsidy.
- The subsidy is much smaller in 2019, at just $141/month.
- There are 22 plans available for 2019. After the subsidy is applied, they range in price from $218/month to $630/month.
- The benchmark plan in 2019 (Ambetter Balanced Care 4) is about $419/month before the subsidy, and $277/month after the subsidy.
- ALL of the Ambetter plans available in 2019 are less expensive than any of the Alliant plans. There are eight Alliant plans for sale in 2019, and they’re the eight most expensive options out of the 22 available plans.
- In Hancock County, only Blue Cross Blue Shield is offering plans as was the case in 2018.
- The subsidy amount in 2018 was $373/month.
- There were 13 plans available in 2018. After the subsidy was applied, their premiums ranged from $160/month to $726/month.
- The benchmark plan (BCBS’s Pathway X HMO 5300) was about $644/month before the subsidy, and $271/month after the subsidy.
- The subsidy amount in 2019 is $479/month.
- There are eight plans available in 2019, ranging in price from $0/month to $501/month. Three of the plans have $0 premiums, and one is just 77 cents/month.
- The benchmark plan (BCBS’s Pathway X HMO 2100 Online Plus) is $756/month before the subsidy, and $277/month after the subsidy.
These data include several key takeaway points:
- The after-subsidy price of the benchmark plan is the same for enrollees with equal incomes, regardless of where they live (and regardless of how old they are; a 60-year-old in Gordon County who earns $35,000 in 2019 will get a subsidy of $509/month, but his after-subsidy cost for the benchmark plan will be the same $277/month that our 45-year-old enrollees would pay).
- When an insurer is the only one participating in the exchange in a given area, they can design their plan offerings so that the second-lowest-cost silver plan (ie, the benchmark plan, on which subsidies are based) is priced much higher than the lowest-cost silver plan, the bronze plans, and even, in some cases, gold plans (as described above, this is a more recent phenomenon, triggered by the Trump Administration’s decision to eliminate funding for cost-sharing reductions, and the workaround that states and insurers implemented that involves adding the cost of CSR to silver plan rates). This is the case in Hancock County in 2019, and it’s why there are several free or very low-cost options available to some subsidizied enrollees. Anthem has adjusted their plan offerings so that their second-lowest-cost plan is a much more expensive option (it has a $2,100 deductible, instead of the $5,300 deductible policy that was the second-lowest-cost plan in 2018). So although Anthem’s average premiums decreased slightly for 2019, they picked a higher-priced plan and made it the second-lowest-cost silver plan, which has resulted in larger subsidies for everyone in that area. This strategy doesn’t work as well in areas with multiple insurers, though, as they don’t know which insurer will have the benchmark plan until the rates are finalized.
- When an area gains a new insurer, enrollees will find that their premium subsidy drops sharply if the new insurer undercuts the existing market and offers lower-cost plans, including a new lower-cost benchmark plan (Phoenix, Arizona is another example of this). And if the new insurer doesn’t have a wide spread between their lowest-cost plans and the benchmark plan, people will end up paying more, after the subsidy, for the lowest-cost plans (but if they already had the benchmark plan and they switch to the new benchmark plan, their premiums will remain mostly unchanged, as long as their income doesn’t change). That’s what’s happened in Gordon County for 2019, with Ambetter’s entry into the market. Ambetter’s plans are less expensive than Alliant’s but they don’t have as much of a price difference between their lowest-cost plan and the second-lowest-cost silver plan they offer (which is the new benchmark plan, since Alliant’s silver plans are much more expensive). That’s why our example person could get a plan in Gordon County for $56/month in 2018, but has to pay at least $218/month in 2019.
- But the entry of a new, lower-cost insurer is beneficial to those who don’t get premium subsidies. If our 45-year-old applicant in Gordon County earns $60,000 instead of $35,000, he’ll have to pay full price. In 2018, the full price options ranged from $555/month to $813/month. But in 2019, they range from $359/month to $771/month. So this particular applicant will save nearly $200/month if he switches from the lowest-cost 2018 option to the lowest-cost 2019 option.
480,912 people enrolled in coverage through the Georgia exchange by December 23 — a year-over-year decrease of about 2.6 percent, as 493,880 people had enrolled during the prior year’s open enrollment.
As was the case in every state that uses HealthCare.gov, open enrollment for 2018 coverage ended December 15 in Georgia. But HHS announced in late September that residents of areas declared by FEMA as eligible for “individual assistance” or “public assistance” would have a special enrollment period to sign up for coverage. The special enrollment period continued through December 31, 2017.
The entire state of Georgia was deemed eligible for individual assistance or public assistance or both, so all Georgia residents were eligible for the SEP, as were people who had lived in Georgia during Hurricane Irma and subsequently relocated to another state.
Effectuated enrollment in Georgia’s exchange as of early 2018 stood at 409,510. Effectuated enrollment is always lower than the number of people who initially sign up, as some enrollees never pay their intial premiums, or cancel their coverage early in the year.
2018: Four participating insurers, but most counties have just one insurer; Anthem stayed in 85 counties
Georgia had five insurers participating in the exchange in 2017, and only one of them opted not to return for 2018. As was the case in most states, however, insurer participation in localized: most of southern Georgia had just one insurer (Blue Cross Blue Shield of Georgia, an Anthem company) offering plans in the exchange in 2017, while most of the northern part of the state had two or more participating insurers.
In 2018, although there are four insurers offering plans in the Georgia exchange, only 14 of the state’s 159 counties have two insurers participating in the exchange; the rest of the counties have a single insurer offering coverage.
Humana exited Georgia’s market, and is no longer offering individual health insurance anywhere in the nation. In Georgia’s exchange, Humana plans were only available in 2017 in Atlanta, Columbus, Macon, and Savannah. Humana had the largest percentage rate increase in the Georgia exchange for 2017, and their total exchange enrollment across 11 states was only about 150,000 people in 2017. So their exit at the end of 2017 was not unexpected, and did not have a dramatic impact.
Blue Cross Blue Shield of Georgia (an Anthem company) was the only insurer offering coverage in 96 of Georgia’s 159 counties in 2017, and their continued participation in exchanges across the country was uncertain in the spring and summer of 2017. In May 2017, Blue Cross Blue Shield of Georgia filed plans to once again offer coverage statewide in 2018, but they indicated in June that they were planning to withdraw their filing and not offer 2018 coverage.
By early August, however, Anthem had reached an agreement with Georgia Insurance Commissioner Ralph Hudgens, in which they agreed to continue to offer coverage in 85 Georgia counties. The 85 counties are mostly rural areas that would have had no other insurer offering coverage in the exchange if Anthem had exited altogether. The Georgia Office of the Insurance Commissioner confirmed that those 85 counties were specifically selected in the agreement between Hudgens and Anthem due to the fact that they would have been left with no insurer in 2018 if Anthem had proceeded with their initial plan to exit the Georgia exchange altogether.
Alliant also remained in the exchange, with plans available in northern Georgia, and the other two Georgia insurance carriers — Kaiser and Ambetter — also continued to offer plans in the exchange, so Humana was the only insurer that left the exchange at the end of 2017.
A full list of the counties where each insurer is offering plans in the Georgia exchange is available here. The counties shaded in yellow in the Ambetter column are new for Ambetter in 2018 (Ambetter’s 2017 service area included the 24 counties that aren’t shaded in yellow on the 2018 coverage area list). There are no counties without an insurer in the exchange in 2018, which would not have been the case if Anthem hadn’t agreed to remain in the exchange in 85 Georgia counties.
Earlier in the year, Anthem had indicated that they were considering exiting a large number of the areas/states across the country where they currently offer coverage — a scenario that was obviously of great concern in a state like Georgia where there are no other options in much of the state. By late April, Anthem had said that they were planning to participate in the exchanges in 2018, assuming the Trump Administration continued to fund cost-sharing reductions (CSR). But by early August, Anthem had announced that they would exit the exchanges in Indiana, Wisconsin, Ohio, and Nevada, and would scale back their participation in Georgia and California.
Ultimately, the Trump Administration did not continue to fund CSR, but Anthem ended up adding the cost of CSR to their silver plan premiums for 2018 (details below), making it possible for them to continue to offer coverage without losing money on CSR benefits.
31.5 percent rate increase if CSR funding had continued. But instead, insurers proposed increases in excess of 50% to cover the cost of CSR.
The four insurers in Georgia’s exchange filed rates earlier in 2017, but revised them upward later in the summer (in the list below, the previous filings have been crossed out). In late September 2017, Commissioner Hudgens announced that the state had completed its review of the proposed rates and submitted them to CMS for final approval. For each insurer, there were two average proposed premium increases. The smaller one was based on the assumption that cost-sharing reduction (CSR) funding would continue in 2018, while the larger one was based on the assumption that it wouldn’t. At that point (late September), Congress had not appropriated funding for CSR, but the Trump Administration had had also made no official decision on the matter.
Two weeks later, the Trump Administration announced that funding for CSR would end immediately. Fortunately, most states (including Georgia) had already instructed their insurers to either base 2018 premiums on the assumption that CSR funding would end, or to have backup rates ready to go.
Georgia’s Insurance Commissioner sent the following average rate increases to CMS for approval (before it was clear that CSR funding would not continue):
18.6 percent31 percent if CSR funding continued; 53 percent if it didn’t
- Ambetter from Peach State Health Plan (a Centene company):
12.4 percent23.8 percent if CSR funding continued; 51 percent if it didn’t (Ambetter expanded their coverage area from 24 counties in 2017 to 44 counties in 2018). Ambetter had 133,943 members on ACA-compliant plans in 2017.
- Anthem Blue Cross Blue Shield of Georgia: 40.6 percent if CSR funding continued; 57.5 percent if it didn’t. BCBSGA had 79,366 members on ACA-compliant plans in 2017.
25 percent30.6 percent if CSR funding continued; 56.7 percent if it didn’t.
At that point, Charles Gaba of ACA Signups calculated a weighted average rate increase of 31.5 percent if CSR funding continues, and 54.2 percent if it didn’t. Gaba also pointed out that Hudgens has been blatant in his desire to obstruct the ACA, saying in 2013: “Let me tell you what we’re doing (about ObamaCare),” Georgia Insurance Commissioner Ralph Hudgens bragged to a crowd of fellow Republicans in Floyd County earlier this month: “Everything in our power to be an obstructionist.”
The Kaiser Family Foundation estimated in early 2017 that if cost-sharing subsidies weren’t funded for 2018, silver plan premiums nationwide would have to increase by 19 percent to make up for the lack of federal funding. But in Georgia, the impact was projected to be more significant, with a 23 percent average increase, in addition to the regular rate increases driven by other factors. That’s just about exactly what we saw in the filings, with a difference of 22.7 percentage points between the two sets of rates.
Which rates were implemented?
Ultimately, insurers had to decide which set of rates to use before it was clear that CSR funding would end. According to the Atlanta Journal-Constitution, three of the carriers — Alliana, Ambetter, and Anthem — opted to finalize the higher rates that were based on the assumption that CSR funding would end, while Kaiser opted to finalize the lower rate increase.
In most states, insurance commissioners gave insurers more explicit instructions — both in terms of whether to add the cost of CSR to premiums, and if so, how to go about doing it. But Georgia is one of just a handful of states where the insurers ultimately took varying approaches to the CSR issue. The following average rate increases were implemented for 2018 (these are pre-subsidy rate hikes; for most enrollees, larger subsidies will cover all or most of the rate increase):
- Alliant: 53 percent (cost of CSR has been added to on-exchange silver plans)
- Ambetter: 50.8 percent (cost of CSR has been spread across the premiums for all ACA-compliant Ambetter plans)
- Anthem: 57.5 percent (cost of CSR has been added to silver plans)
- Kaiser: 30.8 percent (rates were based on the assumption that CSR funding would continue, so the cost of CSR was not added to premiums)
In late October, Avalere Health published a comparison of average premium changes from 2017 to 2018 in each state, and Georgia has among the largest increases. Avalere’s analysis found that the average silver plan in Georgia (before any subsidies are applied) is 48 percent more expensive in 2018, the average bronze plan is 33 percent more expensive, and the average gold plan is 44 percent more expensive. For perspective, the national averages are 34 percent, 18 percent, and 16 percent, respectively.
Enrollees are still able to obtain premium subsidies and cost-sharing subsidies for 2018 — nothing has changed about eligibility for either one. Premium subsidies are significantly larger for 2018, as they grow to keep pace with the premiums for the second-lowest-cost silver plan in each area. And despite the fact that the federal government has cut off funding for CSR, the CSR benefits themselves are still available to silver plan enrollees with income between 100 percent and 250 percent of the poverty level.
Legislation to protect broker commissions, but only during open enrollment
Georgia lawmakers have passed legislation to require broker commissions in some cases, although the minimum amount that brokers must be paid has not been specified. Similar, but more detailed, legislation had failed in 2016.
HB838 passed the Georgia house in February 2016 by a huge margin (144 – 17), and was sent to the Senate, where it was ultimately tabled in late March. If it had been enacted into law, the legislation would have required health insurance carriers to pay broker commissions (at least 5 percent for group plans and at least 4 percent for individual plans) when brokers are used to enroll people in health plans.
But in 2018, another bill, HB64, passed both chambers of the Georgia legislature by wide margins, and headed to Governor Deal for his signature. The 2018 bill is a compromise — it only requires broker commissions for plans sold during open enrollment (not during special enrollment periods), and it does not set a specific level for commissions, leaving that up to the insurance commissioner and health insurers. And Rep. John Meadows, a licensed insurance agent who co-sponsored HB838, did not co-sponsor HB64. His sponsorship on HB838 had raised concerns about a potential conflict of interest in 2016.
The bills were in response to several national carriers cutting back or eliminating broker commissions, particularly for plans sold during special enrollment periods in 2016. Humana reduced broker commissions to three percent for bronze and catastrophic plans as of March 2, 2016, and eliminated commissions entirely for all other metal levels (Humana is no longer offering ACA-compliant plans anywhere in the country, and left Georgia’s market at the end of 2017). Anthem eliminated commissions in Georgia – and nine other states – for 2016 plans with effective dates of April 1, 2016 or later (ie, purchased outside of open enrollment), and UnitedHealthcare eliminated commissions as of January 1, 2016.
Carriers have balked at what they see as lax enforcement of special enrollment period eligibility for plans sold through Healthcare.gov, and the commission reductions have generally been seen as an effort by carriers to reduce enrollment outside of open enrollment. To address carrier concerns, CMS announced in February 2016 that Healthcare.gov would begin requiring documented proof of a qualifying event in order to grant special enrollment periods (SEPs). HealthCare.gov also announced a pilot program beginning in 2017 to further step-up eligibility verification for SEPs, which was ultimately expanded to cover all SEP enrollments.
The Georgia exchange and the Trump Administration
Although the future of the ACA is uncertain, nothing has changed for the time being. Subsidies are still available in the exchange, and coverage is still guaranteed-issue, regardless of pre-existing conditions. The individual mandate penalty has been repealed by the GOP tax bill that was enacted in late 2017, but that repeal doesn’t take effect until 2019. People who are uninsured in 2018 will still face a penalty on their tax returns in early 2019, unless they’re eligible for an exemption. So for the time being, nothing has changed.
But a lot went on in 2017 with regards to health care reform. Here’s a summary:
In early May, Republicans in the House of Representatives passed the American Health Care Act (AHCA; H.R.1628), after adding several amendments tailored to winning over reluctant representatives, both conservative and moderate. The bill then headed to the Senate, where 13 Republican Senators were tasked with writing the Senate’s version of the health care reform bill.
Senate Republicans unveiled their bill, the Better Care Reconciliation Act (BCRA), in June, and introduced an amended version of the bill a few days later in order to incorporate a continuous coverage requirement (the initial BCRA did not have any incentives or penalties to encourage people to remain continuously covered). Both versions are available side by side here.
Senate Majority Leader, Mitch McConnell (R, KY), had hoped for a vote before the July 4 recess, but there wasn’t enough support to pass the bill at that point. During the recess, lawmakers were inundated with constituents voicing opposition to the bill, and support had eroded further by the time the Senate reconvened after the recess. Ultimately, Senate Republicans tried to pass three different Senate versions of H.R.1628, but all three failed in late July: The BCRA, the Obamacare Repeal Reconciliation Act, and the Health Care Freedom Act (aka “skinny” repeal).
Senate Republicans attempted to revive the repeal process in September, with the Graham-Cassidy-Heller-Johnson amendment, but it was pulled before a vote when it became clear that it would not get 50 votes. The reconciliation process could only be used until September 30, so it’s over for the time being. But Republican lawmakers have vowed to try again, as soon as possible, to repeal the ACA.
In addition to legislative uncertainty, there have been concerns about the stability of the individual health insurance market under the Trump Administration. The elimination of funding for cost-sharing reductions resulted in much higher premiums for 2018, and insurers were also concerned that the Trump Administration would not adequately enforce the individual mandate, leading healthy enrollees to drop out of the insurance markets. As noted above, the individual mandate has officially been repealed (the only aspect of the ACA that Republican lawmakers repealed in 2017), but the repeal doesn’t take effect until 2019.
GOP leadership in Georgia announced that they were prioritizing the formation of a “repeal Obamacare” task force in early January, devoted to handling Georgia’s response to whatever comes next for health care reform on the federal level. The task force conducted its first public meeting in early March.
HHS estimates that 581,000 people in Georgia gained health insurance coverage from 2010 to 2015, as a result of the ACA. But Georgia hasn’t expanded Medicaid under the ACA, so the state has not taken full advantage of the ACA’s provisions. There are currently an estimated 240,000 people in the coverage gap in Georgia. Their situation is already dire, and is unlikely to be significantly improved under any of the reform proposals that Congressional Republicans have put forward.
Four organizations in Georgia received a total of $3.7 million in navigator grants in September 2016. They provided outreach and exchange enrollment assistance throughout the state for 2017 enrollment: Boat People SOS, Inc., Georgia Association for Primary Health Care, Inc., Georgia Refugee Health and Mental Health, and Community Health Works (Insure GA Works).
493,880 people enrolled in private plans through Georgia’s exchange during the 2017 open enrollment period, including renewals and new enrollees. 404,821 of them had effectuated coverage as of February.
The average full-price premium in Georgia’s exchange is $431/month in 2017. But 87 percent of the enrollees qualified for premium subsidies, and their average after-subsidy premium is just $122/month. By February, among those who had effectuated their coverage, 90 percent were receiving premium subsidies that averaged $358 per month.
Kaiser Family Foundation data indicates that about 41 percent of the total population eligible to enroll in Georgia’s exchange had done so by 2016. And HHS estimates that there were 95,000 people who had coverage in the off-exchange market (directly through insurance carriers) in Georgia in 2016, but who would be eligible for subsidies if they switched to the exchange.
Open enrollment ended January 31, 2017; coverage for 2017 is now only available in most cases to enrollees who have a qualifying event, although Native Americans and people who are eligible for Medicaid/CHIP can enroll year-round.
Former Georgia lawmaker heads HHS
Representative Tom Price, a Republican from Georgia, was appointed by Trump as Secretary of Health and Human Services. Price now has a key role in the Trump Administration’s efforts to repeal and replace Obamacare, as Price’s Empowering Patients First Act (HR 2300, as introduced in 2015) is a detailed look at his healthcare reform proposal.
Senate confirmation hearings for Price took place in mid-January, and focused heavily on the health care reform proposals he has put forth in prior legislation and budget proposals. For the most part, Price declined to provide specific answers in terms of how Trump’s executive order or upcoming repeal/replace legislation would impact people who have obtained health insurance as a result of the ACA. But once the AHCA was on the table, Price said that “nobody will be worse off financially” under the AHCA (untrue). In May, Price said that people would “absolutely not” lose their Medicaid coverage under the AHCA (also untrue).
2017 rates and carriers
The second-lowest-cost silver plan in the exchange (the benchmark plan) is important, as subsidies are tied to its premium, and almost 90 percent of Georgia exchange enrollees were receiving premium subsidies in 2016.
Across all the state that use HealthCare.gov, the average benchmark premium (before any subsidies are applied) for a 27-year-old in 2017 is $296/month. In Georgia, it’s a little lower, at $273/month. But that’s a 15 percent increase from 2016, which means subsidies are larger too, to offset the increase in the average benchmark premium.
Four of the nine carriers that previously offered exchange plans in Georgia exited the exchange at the end of 2016: UnitedHealthcare, Cigna, Aetna, and Harken (more details below).
- Blue Cross Blue Shield of Georgia: Initially proposed 15.1 percent, but with Aetna’s exit, and the assumption that many of Aetna’s existing enrollees would switch to BCBSGA, the carrier said they were reconsidering their rate proposal, and the possibility of filing a new proposal. Their new rate filing had an average rate increase of 21.4 percent, which was approved by regulators.
- Humana: 67.5 percent (coverage area was reduced for 2017 to Atlanta, Columbus, Macon, and Savannah areas); approved as requested, at 67.5 percent. Humana is exiting the individual market nationwide at the end of 2017.
- Kaiser Permanente: 18 percent requested; approved average rate increase was 17.6 percent
- Ambetter from Peach State Health Plan: 7.4 percent to 8.3 percent requested, depending on whether dental/vision included; approved average increase is 13.7 percent.
- Alliant: 18 percent requested; approved average rate increase was 21 percent
Other than BCBS of Georgia, none of the carriers refiled rates after the initial filings were submitted.
Blue Cross Blue Shield of Georgia is the only carrier that is offering exchange plans in all 159 counties in Georgia for 2017. The Atlanta metro area has plans available from all five carriers, but some rural areas of the state have far fewer choices for people shopping in the exchange.
The proposed Cigna-Anthem merger and the previously-proposed Aetna-Humana merger would have an impact on the Georgia market, since all four companies offer plans in the Georgia exchange in 2016 (BCBS of Georgia is an Anthem company). The Georgia Department of Insurance had scheduled a hearing for July 2016 regarding the Aetna-Humana merger, but postponed it after federal officials filed a lawsuit to block the merger (along with the Cigna-Anthem merger) on antitrust grounds. A federal judge blocked the merger in January 2017, saying that the benefits of the merger wouldn’t be enough to outweigh the antitrust concerns.
Aetna’s exit from the exchange in 11 out of 15 states has been linked to the US Department of Justice’s lawsuit to block the carrier’s merger with Humana. In the ruling that blocked the Aetna-Humana merger, U.S. District Judge John Bates said that Aetna misled the public last summer when they said that their decision to exit several exchanges was purely a business decision to avoid financial losses. Instead, he said the exchange exits were “specifically to avoid judicial scrutiny” regarding the merger with Humana.
Cigna and Aetna are not participating in the Georgia exchange in 2017, although Anthem and Humana are.
Aetna, Cigna, Harken & United exited exchange at the end of 2016
Aetna offered plans in 67 of Georgia’s 159 counties in 2016, but they exited the exchange at the end of 2016. They had somewhere between 70,000 and 90,000 on-exchange enrollees in Georgia.
UnitedHealthcare did not participate in the Georgia exchange in 2014, but joined the exchange for 2015 and continued to offer plans for 2016. In April 2016, a Georgia state insurance office spokesperson confirmed that UnitedHealthcare would exit the exchange in Georgia for 2017, and would also leave the Arkansas exchange. This was not unexpected, given that United had hinted at the possibility of eventually pulling out of the exchanges in the fall of 2015, and had cut broker commissions in most states for 2016 in an effort to reduce sales.
UnitedHealthcare’s market share in the Georgia exchange was relatively small in 2015, with 825 enrollees in plans through UnitedHealthcare Life Insurance, and 9,933 in plans from UnitedHealthcare of Georgia. Their broker commission cuts for 2016 likely translated to a similarly small market share for 2016.
According to Atlanta’s NPR station, Cigna has about 1,500 exchange enrollees in 14 counties in Georgia in 2016. In order to continue to have coverage through the exchange, those enrollees needed to select new coverage for 2017, as Cigna exited the exchange in the state at the end of 2016.
Harken Health joined the exchange in the Atlanta area for 2016, but exited at the end of the year and was not offering exchange plans in Georgia (or in Illinois, where they offered exchange plans in the Chicago area in 2016) in 2017. Harken is continuing to offer off-exchange plans in the Atlanta area.
During the 2016 open enrollment period, enrollment in private plans through the Georgia exchange totaled 587,845 people, including new enrollees and renewals. Of the 38 states using Healthcare.gov, only Florida, Texas, and North Carolina had higher enrollment for 2016. For perspective, Georgia’s enrollment a year prior, at the end of the 2015 open enrollment period, stood at 541,080 people.
By March 31, 2016, effectuated enrollment stood at 478,016. Of those, 89.4 percent were receiving premium subsidies that averaged $291 per month.
Open enrollment ended on January 31. Applicants who experience a qualifying event can still enroll in a plan for 2016, or switch to a different plan. Medicaid and CHIP enrollment continue year-round, and Native Americans can enroll in plans through the exchange year-round.
The penalty for being uninsured is significantly higher in 2016 than it was in 2014 and 2015. Uninsured residents who experience a qualifying event will be able to avoid the penalty for the remainder of the year if they enroll during their special enrollment period (the penalty is prorated for the number of months the person is uninsured during the year).
2016 rate hike lower than national average
Healthcare.gov enabled browsing for 2016 plans on October 26, a week before the start of open enrollment. They also released a report showing average price changes for the benchmark plans in each state (benchmark plans can be different from one area of a state to another, since rates and plan availability vary by region). The benchmark plan is the second-lowest-cost Silver plan, but it can be a different plan than the one that held that spot the prior year.
Across the 37 states that used Healthcare.gov in 2015, the average benchmark premium increase for 2016 was 7.5 percent. In Georgia, it was lower, at 6.1 percent. Kaiser Family Foundation did their own analysis using premiums for a 40-yer-old non-smoker in metropolitan areas across the country. In Atlanta, they found a slight decrease (-0.4 percent) in the benchmark premium.
The majority of the carriers that sell individual plans in the Georgia exchange requested rate increases of ten percent or more for at least some of their plans, and the state used outside actuaries to review the rate proposals in an effort to lower them. Industry officials in Georgia noted that “many plans” in the state submitted 2016 rate increases under ten percent, but those weren’t available to the public until rates were finalized.
For 2015, the average rate increase in Georgia was just one percent. For 2016, the average was considerably higher, although there were some carriers that still had modest rate increases in 2016. I requested approved rate changes from the Georgia Office of Insurance and Safety Fire Commissioner; for plans sold in the exchange, the approved filings indicated the following average rate changes for 2016:
- Aetna Health: 17.3 percent
- Blue Cross Blue Shield of Georgia: 16.4 percent
- Cigna: 3.73 percent
- Harken Health Insurance (new to exchange for 2016)
- Humana: filing indicated two different approved “overall rate impacts:” 19.8 percent for HMO plans and 21.8 percent for POS plans (just slightly lower than the 19.9 and 21.9 percent rate increases that they originally proposed).
- Kaiser Permanente: 2.7 percent
- Peach State Health Plan (new plans in 2016, so no rate change listed)
- UnitedHealthcare HMO: 13.2 percent (down from the 18.64 percent increase that they originally proposed)
- Alliant: 27 to 29 percent (down from the 37.85 percent they had requested) Alliant’s approved rate filing was not among the data that Georgia provided following my open records request, but the approved rate change was reported by The Telegraph.
Time Insurance exited the health insurance market nationwide at the end of 2015, but Harken Health Insurance joined the Georgia exchange, so there are still nine carriers offering plans in 2016.
For most people, subsidies have covered a portion of the rate hikes. But subsidies are tied to the benchmark premiums, which only increased by an average of 6.1 percent in Georgia for 2016. Since rate changes for some plans were considerably higher, it was particularly important for enrollees to shop around during open enrollment rather than simply letting their coverage auto-renew.
At the end of 2015 open enrollment, 541,080 Georgians had signed up for qualified health plans (QHPs) through HealthCare.gov, but not all of them paid their initial premiums or opted to keep their coverage long-term. By the end of March, there were 452,815 people with in-force coverage through the Georgia exchange, and enrollment dropped again during the second quarter of the year, with 417,890 effectuated enrollments as of June 30 (Healthcare.gov stepped up enforcement of documentation requirements for immigration and financial status in 2015, which caused many people to lose coverage and/or subsidies).
90 percent of them were receiving premium subsidies, and 67 percent were receiving cost-sharing subsidies (available to people with household incomes up to 250 percent of poverty, as long as they select a silver plan). Georgia’s subsidy utilization was higher than the national average; nationwide, 85 percent of exchange enrollees were receiving premium subsidies, and 57 percent were receiving cost-sharing subsidies as of mid-2015.
Fifty-five percent of Georgia enrollees were new to the marketplace in 2015. Various experts indicated that enrollment exceeded expectations. According to Kaiser, 50 percent of Georgians who were eligible to enroll through the marketplace have selected a health plan.
More than 350,000 of Georgia’s enrollees were from the Atlanta/Sandy Springs/Roswell metropolitan area. Only the Miami/Fort Lauderdale/West Palm Beach area had higher enrollment than the greater Atlanta area.
King v. Burwell – subsidies are safe
Fortunately for exchange enrollees in Georgia – as well as hospitals, insurance carriers, and people who purchase coverage without subsidies – the Supreme Court ruled on June 25 that subsidies are legal in states like Georgia that use Healthcare.gov. If subsidies had been struck down, 415,000 people in Georgia would have lost their subsidies and their coverage would likely have become unaffordable.
It would also have become unaffordable for many people who aren’t receiving subsidies, as the entire individual market would likely have seen a rate increase of 55 percent – in addition to the regular annual rate increases – if subsidies had been eliminated. Since coverage would have become unaffordable for so many, healthy enrollees would have been likely to drop their coverage, leaving a sicker pool of insureds and triggering a “death spiral.” It was possible that the individual market could have shrunk in size by 70 percent if subsidies had dried up.
New insurers join exchange in 2015
Georgia consumers shopping for health insurance on the marketplace had nearly double the number of insurers to choose from in 2015 as they did in 2014. In addition, three companies — as opposed to one in 2014 —offered policies statewide. A health insurance expert at Georgia State University said the influx of statewide competition would help reduce disparity in premium costs seen among different regions of the state.
Nine insurers offered plans in the Georgia health insurance marketplace for 2015, including four who were new to the exchange for 2015. The returning companies from 2014 were: Alliant Health Plans, Blue Cross, Humana, Kaiser Permanente, and Peach State Health Plans (Ambetter). The new entrants to the marketplace for 2015 were Cigna, Coventry, UnitedHealthcare, and Time Insurance.
2015 premiums up just 1 percent
Georgians paid an average of 1 percent more for health plans on the marketplace in 2015 compared with 2014. The overall average was weighted and considered all metal tiers. The average cost of bronze policies was down 4 percent, and the average cost of silver and gold policies was down 1 percent. But the average cost of platinum policies was up 33 percent (very few enrollees nationwide select platinum plans due to their cost).
Given that southern Georgia had some of the highest premium costs in the nation for 2014, the modest average increase was welcome news for the second year of Obamacare.
Facts and figures from 2014 enrollment
More than 316,500 Georgians enrolled in qualified health plans (QHPs) during 2014 open enrollment. That’s nearly 30 percent of the estimated 1,063,000 Georgians considered eligible to enroll in the insurance marketplace by the Kaiser Family Foundation.
Among Georgia residents selecting a QHP, 87 percent qualified for financial assistance, compared to 85 percent nationally. A report released in June 2014 by the U.S. Department of Health and Human Services showed the average monthly premium, after tax credits, for Georgia consumers was $54. Sixty percent of enrollees pay $50 or less per month after subsidies. Georgia’s $54 average is the second-lowest in the nation — after Mississippi, where the average monthly premium after subsidies is just $23.
Ten percent of Georgia residents selected a bronze plan (20 percent nationally), 73 percent selected a silver plan (65 percent nationally), 6 percent selected a gold plan (9 percent nationally), 9 percent selected a platinum plan (5 percent nationally) and 2 percent selected a catastrophic plan (2 percent nationally). Thirty-one percent of Georgia enrollees were between the ages of 18 and 34.
Background on the marketplace in Georgia
Georgia opted to use the federal health insurance marketplace, HealthCare.gov. State government officials such as Gov. Nathan Deal and Insurance Commissioner Ralph Hudgens vocally opposed the Affordable Care Act. Hudgens implemented a requirement that navigators, who help consumers use the marketplace, pass the test that insurance agents are required to take. That requirement is much more stringent than required by the health care reform law, and Hudgens openly stated it was intended as obstructionism. At the end of its 2014 session, the Georgia Assembly passed a bill that prohibits establishing a state-run marketplace, disallows the use of taxpayer money for navigator programs, and forbids government employees from advocating for Medicaid expansion.
Georgia’s director of Enroll America, Dante McKay, said that lack of access to navigators hurt enrollment in rural Georgia counties in 2014. McKay also said the amount of federal funding Georgia received for navigators was among the lowest of all the states on a per uninsured person basis in 2013 — and the amount decreased in 2014.
No Medicaid expansion yet
Georgia has not expanded its Medicaid program, and is among 19 states still refusing federal funding to expand coverage. Gov. Deal has repeatedly said Medicaid expansion would cost the state too much, and the General Assembly passed bills that give it authority over any changes to the state’s Medicaid rules. By not expanding Medicaid, the state is leaving up to 282,000 low-income residents in a coverage gap — unable to qualify for either Medicaid or subsidies through the marketplace.
SB368 was introduced in February 2016, and represents the first time a Medicaid expansion bill has gained a hearing by the General Assembly in Georgia. The bill doesn’t actually mention Medicaid expansion, but instead calls for a “premium assistance” to help purchase private health insurance through the exchange for people with incomes up to 138 percent of poverty, and would require them to pay up to 5 percent of their income. If SB368 were to be approved by the legislature, it would have to also be approved by CMS under an 1115 waiver, since it’s not the same as the straight expansion of Medicaid called for in the ACA.
Uninsured rate declining, but still progress to be made
Georgia’s uninsured rate in 2014 was 19.1 percent; the national average was 13.8 percent. By the first half of 2015, the state’s uninsured rate had dropped to 15.3 percent – still well above the national average, but much better than the 21.4 percent uninsured rate that Georgia had in 2013. There is no doubt that if Medicaid were to be expanded, Georgia’s uninsured rate would drop significantly.
A report published in February 2016 by the Robert Wood Johnson Foundation found that the number of Georgia children without health insurance decreased by 53,000 in 2014. That was the fourth-largest drop in the country, but Georgia still had the tenth-highest uninsured rate among children in 2014, with eight percent of the state’s children uninsured.
A Families USA report published in January 2016 found that among working US adults, the uninsured rate dropped by an average of 19 percent in 2014. But in states that didn’t expand Medicaid, the drop was lower. In Georgia, the reduction in the uninsured rate for working adults was just 13 percent, compared with more than 30 percent in the eight states that had the highest reduction.
Georgia health insurance exchange links
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.