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).
Four organizations in Georgia received a total of $3.7 million in navigator grants in September 2016. They provide outreach and exchange enrollment assistance throughout the state: Boat People SOS, Inc., Georgia Association for Primary Health Care, Inc., Georgia Refugee Health and Mental Health, and Community Health Works (Insure GA Works).
2018: Likely four participating insurers
Georgia has five insurers participating in the exchange in 2017, and only one of them has said they won’t return for 2018. As is the case in most states, however, insurer participation in localized: most of southern Georgia has just one insurer (Blue Cross Blue Shield of Georgia) offering plans in the exchange in 2017, while most of the northern part of the state has two or more participating insurers.
Humana is exiting Georgia’s market, and will no longer offer individual health insurance anywhere in the nation after the end of 2017. In Georgia’s exchange, Humana plans are 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 is only about 150,000 people this year. Their exit at the end of 2017 is not unexpected, and is not likely to have a dramatic impact.
In three of the areas where Humana offers plans in 2017, there will still be at least two other insurers offering plans in 2018, assuming the other insurers remain in the exchange. However, in Macon-Bibb County, Humana and Blue Cross Blue Shield of Georgia are the only two insurers currently offering plans, so Humana’s exit will reduce Macon-Bibb County to just one exchange insurer in 2018.
Blue Cross Blue Shield of Georgia (an Anthem company) is the only insurer offering coverage in 96 of Georgia’s 159 counties, and their continued participation in exchanges across the country has been uncertain in the spring of 2017. In mid-May, however, Blue Cross Blue Shield of Georgia filed plans to once again offer coverage statewide in 2018.
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 would obviously be of great concern in a state like Georgia where there are no other options in much of the state. However, by late April, Anthem had said that they were planning to participate in the exchanges in 2018, assuming the Trump Administration continues to fund cost-sharing subsidies. The ongoing lawsuit over cost-sharing subsidies has been delayed another 90 days, with the next status report now due in August — after insurer rate filings are due nationwide.
Alliant also plans to return to the exchange, with plans available in northern Georgia.
As of May 23, the other two Georgia insurance carriers — Kaiser and Ambetter — had not filed plans for 2018, but the Georgia Office of the Commissioner of Insurance noted that they do expect both insurers to file plans, which would make Humana the only insurer to leave the exchange at the end of 2017. Georgia regulators have a suggested rate filing deadline of May 16 this year, but technically insurers have until June 21 to file. The later they wait, however, the more challenging it could be for the insurers to respond to the review process and make any necessary corrections before Georgia’s Insurance Commissioner has to send the filings to CMS in August.
493,880 people enrolled in private plans through Georgia’s exchange during the 2017 open enrollment period, including renewals and new enrollees.
The average full-price premium in Georgia’s exchange is $431/month in 2017. But 87 percent of the enrollees are receiving premium subsidies, and their average after-subsidy premium is just $122/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.
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.
In early May, Republicans in the House of Representatives passed the American Health Care Act (AHCA), after adding several amendments tailored to winning over reluctant representatives, both conservative and moderate. The bill then headed to the Senate, where lawmakers indicated that they were going to write their own bill instead of trying to amend the House bill.
There are 13 Republican Senators who have been tasked with writing the Senate’s version of the health care reform bill; the House and Senate versions will have to be reconciled before any legislation can be sent to the president, and the Senate has indicated that it could take several weeks for them to complete their version of the bill.
In addition to legislative uncertainty, there are also concerns that more health insurers might exit the exchanges or the entire individual market if the Trump Administration doesn’t take steps to stabilize the markets nationwide. Cost-sharing subsidies are the most pressing issue, as the Trump Administration had not committed — as of early May — to funding them beyond May. Insurers are also concerned that the Trump Administration will not adequately enforce the individual mandate, leading healthy enrollees to drop out of the insurance markets.
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 309,000 people in the coverage gap in Georgia. Their situation is already dire, and is unlikely to be significantly improved under the AHCA (they would be eligible for premium tax credits, but the credits are unlikely to be enough to make coverage affordable for them, and the out-of-pocket costs associated with private plans — as opposed to Medicaid — would also make coverage somewhat unrealistic). But the existing Medicaid population in Georgia could also face eligibility cuts and benefit reductions if the current version of the AHCA were to be enacted.
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 wis 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).
Failed legislation to protect broker commissions
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 five percent for group plans and at least four percent for individual plans) when brokers are used to enroll people in health plans.
The bill was 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. 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 the lax enforcement of special enrollment period eligibility for plans sold through Healthcare.gov, and the commission reductions are 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.
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