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Alaska health insurance marketplace: history and news of the state’s exchange

Premiums decreased in 2021 for fourth consecutive year; COVID/ARP enrollment window continues through August 15, 2021, with new subsidies available

Sadie Cove, Alaska | Image: Tamela /

Key takeaways

Alaska exchange overview

Premera was the only insurer offering coverage in Alaska’s individual market from 2017 through 2019. But the market is much more stable than it once was – largely as a result of the state’s new reinsurance program. As a result of the more stable market environment, Moda returned to Alaska’s exchange in 2020 in the Anchorage area, and expanded their coverage area for 2021 to include Fairbanks North Star Borough, Ketchikan Gateway County, and Prince of Wales Hyder County. Premera’s plans continue to be available statewide.

For 2021, average premiums decreased in Alaska, for the fourth year in a row. In 2016, Alaska’s exchange had the highest average benchmark premiums in the country, by a wide margin. But for 2021, there are several states where overall average premiums are higher than Alaska’s.

Because the poverty level (FPL) is higher in Alaska (and Hawaii) than it is in the continental US, premium subsidies extend to households with higher incomes in Alaska. The income limits for expanded Medicaid are also higher in Alaska due to the higher poverty level.

Although the American Rescue Plan has temporarily eliminated the 400% of FPL income limit for subsidy eligibility, Alaska residents were already eligible for premium subsidies with incomes above the limit that applies in the continental United States. For 2021 coverage, before the American Rescue Plan, subsidy eligibility ended in the continental U.S. at an income of $51,040 for a single person and $104,800 for a family of four; in Alaska, those limits were $63,800 and $131,000, respectively. The American Rescue Plan has eliminated those caps for 2021 and 2022. Instead, people with income above 400% of the poverty level are eligible for a subsidy if the cost of the benchmark plan would otherwise exceed 8.5% of their household income.

When can I enroll in health insurance in Alaska?

Because of the ongoing COVID pandemic and the additional premium subsidies that are available under the American Rescue Plan, there’s a one-time enrollment window that continues through August 15, 2021 (Alaska is also allowing people to enroll in plans directly through the state’s two insurers during this window, but subsidies are not available if a person enrolls directly through an insurer). Although a qualifying event would normally be necessary in order to enroll or change plans at this time of year, that’s not the case during the COVID/ARP enrollment window.

This enrollment window is an opportunity for people to take advantage of the ARP’s larger premium subsidies. People with off-exchange coverage can switch to the exchange (subsidies are only available via the exchange), and some people will find that it’s in their best interest to switch plans during the COVID/ARP enrollment window.

During the first several weeks of the COVID/ARP enrollment window, 1,164 Alaska residents enrolled in coverage. This was more than three times the normal enrollment pace during that time of year. And that enrollment total is from mid-February through the end of March, which was before the ARP’s additional premium subsidies were available on Enrollment can be expected to pick up even more now that the additional subsidies are available.

After August 15, 2021, the normal rules will again apply. Alaska residents will need a qualifying event to enroll or make changes to their coverage for 2021, and open enrollment for 2022 coverage will start on November 1, 2021.

Moda returned for 2020 in south-central Alaska, and expanded coverage area for 2021; Average premiums decreased again for 2021, for the fourth year in a row

Moda returned to Alaska’s exchange for 2020, and expanded its coverage area for 2021 to include Fairbanks North Star Borough, Ketchikan Gateway County, and Prince of Wales Hyder County. Premera Blue Cross Blue Shield continues to offer coverage statewide.

Alaska law does not allow the state to publicly share rate filing details — via the Alaska Division of Insurance or on SERFF — until after the policies take effect, which means they aren’t publicized for ACA-compliant individual market health plans until January 1 each year, which is after the open enrollment period has ended. Preliminary filings are posted on the federal rate review site as of August each year, but some of the pertinent data are redacted, including membership numbers.

For 2021, the following average rate changes were implemented by Alaska’s individual market insurers:

  • Premera: Average rate decrease of 7.13% (Premera initially proposed an average rate decrease of 4.15%)
  • Moda: Average rate increase of 0.68% (Moda initially proposed an average rate increase of 0.11%)

Moda’s rate filing is redacted, but Premera’s indicates that they had 15,783 enrollees as of mid-2020. That’s the lion’s share of the individual market in Alaska, so overall average rates declined by nearly as much as Premera’s rate decrease (on-exchange, total enrollment stood at 16,232 as of mid-2020; the individual market also includes off-exchange enrollees, but enrollment in off-exchange plans is quite low, especially in states like Alaska where premiums are higher than average).

The average 2021 premium for plans selected during open enrollment in Alaska was $697/month (before any subsidies were applied; very few people pay full-price). The year before, for 2020 coverage, it had been $739/month.

CMS also reported that the average benchmark plan premium for 2021 would be 6% lower in Alaska than it was in 2020 (versus a 2% drop across all the states that use From 2017 to 2021, the average benchmark premium has decreased by 27% in the state.

For perspective, here’s a summary of how premiums have changed over the years in Alaska’s individual marketplace:

  • For 2015, average rates increased by 31%. Alaska insurance officials announced significant premium increases: 35% to 40% for policies sold by Premera Blue Cross and 22% to 29% for policies sold by Moda Health. According to the Commonwealth Fund, Alaska had the biggest average premium increase in the nation in 2015, at 31%. But Insurance Commissioner Lori Wing-Heier confirmed that the rate increases were justified. The state’s small population and limited marketplace enrollment makes for a small risk pool. With high claim costs and few people to spread those costs across, insurance companies raised rates to cover their expenses.
  • For 2016, average rates increased by 39%. The average rate increase for Moda was 39.6%, and the average rate increase for Premera was 38.7%. Alaska’s average premiums were already the highest in the country in 2015, and they became dramatically higher than the rest of the country as of 2016.
  • For 2017, average rates increased by 7.3%, but Moda left the state’s market. On July 18, 2016—the same day Governor Walker signed H.B.374 (a bill to create a reinsurance program) into law—Premera announced that they had filed rates with an average increase of 9.8% for 2017. The rate increase was significantly lower than the carrier’s rate increases were in 2015 and 2016, and Premera attributed that to the new reinsurance program. A month later, on August 19, Premera filed a new rate proposal, requesting an average rate increase of just 7.3% for 2017. State regulators approved the 7.3% average rate increase a few days later, and the rates took effect in January 2017. Average rate increases for 2017 were higher for people who had Moda plans in 2016, as Moda’s rates were lower than Premera rates in 2016, and enrollees had no choice but to switch to Premera—with rates an average of 7.3% higher than Premera’s 2016 rates—for 2017. For perspective, for a 40-year-old in Anchorage, the lowest-priced plan from Moda in 2016 was $579 per month, while the lowest-priced plan from Premera was about 12% higher, at $649 per month. Members who had Moda plans saw overall rate increases that amounted to an average of 7.3% higher than the 2016 Premera rates. But as is always the case, premium subsidies absorbed some or all of the rate increases for people who were subsidy-eligible.
  • For 2018, average rates decreased by 22%. Premera initially filed an average rate decrease of 22%, which included the assumption that cost-sharing reduction (CSR) funding would be eliminated by the federal government in 2018. Then Premera announced in mid-September 2017 that their revised rate proposal called for a 26.5% average decrease, including an assumption that CSR funding would continue. The overall rate decrease in the revised filing was attributed to the new reinsurance program. However, the smaller premium decrease (which was still substantial) was implemented after all, as the Trump administration announced in October 2017 that CSR funding would end immediately. According to Alaska Public Media, rates for silver plans in 2018 were about 5% or 6% higher than they would have been if CSR funding had continued. There was still an overall decrease in premiums, as the reinsurance program was a much more significant factor than the CSR funding cut.
  • For 2019, average rates decreased by 3.9%, but Premera discontinued all of their ACA-compliant individual market plans as of December 31, 2018 and replaced them with new plans that took effect January 1, 2019. The new Premera plans were all PPOs, but coverage is provided at the out-of-network level for providers outside of Alaska and Washington, even if the member uses a BlueCard medical provider. Premera also added adult preventive dental benefits to some plans, potentially changing the prices that some enrollees paid. In August 2018, Premera and Governor Walker’s office announced that Premera had filed for an average rate decrease of 3.9%. Before any subsidies were applied, that meant average premiums had dropped from $1,043/month in 2017 to $770/month in 2019. (at ACA Signups, Charles Gaba estimates that rates would have dropped even more in Alaska in 2019 — by nearly 10% — if the individual mandate penalty hadn’t been eliminated and if short-term and association health plans hadn’t been expanded.)
  • For 2020, average premiums decreased by 0.3%, and Moda rejoined the marketplace in the Anchorage area (the Municipality of Anchorage, the Kenai Peninsula Borough, and the Matanuska-Susitna Borough). Although the average rate decrease was small, it was the third year in a row with declining premiums in Alaska’s marketplace. The stabilizing market and decreasing premiums are due in large part to Alaska’s reinsurance program (details below), which took effect in 2017 and began receiving federal pass-through funding in 2018. For 2020, Alaska’s reinsurance program reimbursed insurers a total of $69,000,000 in reinsurance claims. Insurers in Alaska’s individual market continue to add the cost of cost-sharing reductions (CSR) to on-exchange silver plans rates for 2020. Plans that are only sold off-exchange do not include the cost of CSR in their premiums.

Insurer participation in Alaska’s exchange

From 2014 through 2016, plans were available in Alaska’s exchange from both Moda and Premera. But for 2017 through 2019, Premera was the only insurer offering individual market plans in Alaska, including on the exchange (WyomingDelaware, Mississippi, and Nebraska also had just a single insurer offering plans in their exchanges for 2019, but for 2020, Bright Health joined the exchange in Nebraska and Molina joined the exchange in Mississippi; for 2021, Mountain Health CO-OP joined the exchange in Wyoming, so Delaware is the only remaining state with just a single participating exchange insurer).

In 2014, Premera had 58% of the individual market in Alaska, Moda had 36%, and the remaining 6% were distributed across Time, Celtic, and Aetna. These figures included grandfathered plans, grandmothered plans, and ACA-compliant plans both on and off exchange (Time, Celtic, and Aetna were only available outside the exchange).

By 2015, Premera’s market share had dropped to 43%, and Moda’s had increased to 51%. Moda’s total individual market enrollment in 2015 was 14,825, but had dropped to under 10,000 people by January 2016, when Moda briefly exited the individual market (described in more detail below).

Moda Health Plan Inc. had a tumultuous couple weeks in early 2016, although they ended up remaining in Alaska’s market until the end of that year. In October 2015, Moda had exited the market in Washington and California, in order to focus on Oregon and Alaska.

On January 28, 2016, the Alaska Division of Insurance announced that Moda Health’s financial losses and dwindling capital reserves had reached the point where the carrier could no longer sell or renew policies in the individual market in Alaska (Oregon, the only other state where Moda was still operating, came to the same conclusion).

At that point, there were about 9,800 people in Alaska with individual plans from Moda. On February 8, regulators in Alaska and Oregon reached an agreement with Moda that allowed the carrier to resume selling and renewing coverage in the individual markets in both states. Part of the agreement was a commitment from Moda to continue to service individual market policy-holders until at least the end of 2016, which they did. But Moda’s plans were no longer available after the end of 2016, and Alaska’s exchange—and individual market—has only had plans from Premera ever since.

But for 2020, Moda rejoined the exchange, providing additional options for residents who purchased their own health insurance in Anchorage, the Kenai Peninsula, and the Mat-Su Borough. Delta Dental of California invested $152 million in Moda earlier in 2019, obtaining a 49.5% stake in the company. While Alaska’s regulators had concerns about Moda’s financial health in 2016 and 2017, they have noted that those concerns are no longer an issue after the infusion of capital in the agreement with Delta Dental of California.

Moda expanded its coverage area into three additional counties for 2021. Although Premera is still the only participating insurer in most of the state, residents in some of the more populated areas can now choose between Moda and Premera.

Enrollment in Alaska’s exchange

As has been the case in the majority of the states that use, enrollment in Alaska’s health insurance exchange peaked in 2016. That year, 23,029 people enrolled in private plans (QHPs) through the Alaska exchange.

From 2017 through 2020, enrollment declined each year. But it increased in 2021, as was the case in the majority of the country:

  • 19,145 people enrolled for 2017. That was 17% lower than enrollment had been in 2016. There was about a 5% decline in average enrollments for 2017 across all the states that use, so Alaska’s percentage drop-off in enrollments was one of the biggest in the country. But despite smaller-than-average percentage rate increase for 2017, Alaska still had by far the most expensive health insurance in the country in 2017, and the possibility of GOP legislation to repeal the individual mandate penalty resonated more with Alaska residents than it did in states where unsubsidized coverage is more affordable.
  • 18,313 people enrolled for 2018
  • 17,805 people enrolled for 2019
  • 17,696 people enrolled for 2020
  • 18,184 people enrolled for 2021

From 2014 through 2016, enrollment in Alaska’s exchange had increased each year, as was true in most states. Only 12,890 people enrolled for 2014, the first year that the exchanges were operational. The next year, for 2015 coverage, 20,897 signed up for plans in Alaska’s exchange. Enrollment peaked in 2016, at more than 23,000.

No longer the highest premiums in the country

Although Alaska had the highest health insurance premiums in the country in the first few years of ACA implementation (and that continued to be the case through 2017), their percentage rate increase for 2017 was much lower than the national average, due to the state-based reinsurance program that Alaska implemented in 2016. And they had a sharp premium decrease for 2018, due to the success of the reinsurance program.

For 2018, Alaska received approval, via a 1332 waiver, for federal funding that covers the bulk of the cost of the reinsurance program. Federal funding for the reinsurance program will continue through 2022, under the terms of the five-year waiver. And somewhat ironically, Alaska’s individual market claims ended up at a ten-year low in 2017, resulting in a $25 million contribution to the state’s reinsurance program from Premera.

By 2018, with decreasing rates in Alaska and steadily increasing rates in most of the rest of the country, Iowa, Tennessee, West Virginia, and Wyoming all had average premiums that were significantly higher than Alaska’s. In 2019, Delaware, Iowa, Nebraska, West Virginia, and Wyoming all had higher average premiums than Alaska.

For 2020, Premera implemented a slight average rate decrease of 0.03%. Nationwide, insurers reduced rates by about 0.16% for 2020, so the slight rate decrease for Alaska’s existing plans was in line with the national trend.

For 2021, Alaska’s overall average rates decreased again, by roughly 6-7%. Several states have higher average premiums than Alaska in 2021.

State shores up individual market with reinsurance program, receives federal funding with a 1332 waiver; federal funding was higher than expected in 2018

Even with the high premiums in the individual market in Alaska, insurers continued to lose money. In the first half of 2015, Premera — which insured about 8,500 people in the individual market in 2015 — had roughly $45 million in claims in the individual market, but $11 million of that came from just 37 members. And in a sparsely-populated state with small enrollment in each plan, the impact of spreading those costs across the pool of insureds results in astronomical rate hikes for everyone.

Premera is the only carrier that remained in Alaska’s exchange after the end of 2016, and the expectation was that they were going to have to raise rates by at least 40% for 2017 in order to cover claims costs. Premera made it clear that they could not continue to absorb losses in the individual market.

In February 2016, Alaska’s Insurance Commissioner, Lori Wing-Heier, presented lawmakers with a summary of the state of the health insurance market in Alaska. Wing-Heier explained that the small group market was doing well, but that the individual market was struggling. In addition to the possibility of a state reinsurance program, Wing-Heier also floated the idea of combining the individual and small group markets into a single risk pool (this is allowed under the ACA, but only Massachusetts and Vermont have done so thus far). She also mentioned the possibility of creating a regional exchange in partnership with other states in the western US, or drafting a 1332 waiver proposal to implement the ACA in an Alaska-specific way (1332 waivers are available to every state, but most have not pursued them; Alaska did ultimately submit a waiver proposal, along with several other states. Alaska’s waiver proposal was approved in July 2017).

In an effort to address the problem caused by the very small individual market in Alaska, legislation was introduced in March 2016 to create a supplemental reinsurance program for Alaska that would help to cover the individual market’s largest claims (the reinsurance program covers claims that insurers would otherwise face when insureds have one of 33 high-cost medical conditions). The legislation was passed in June 2016 by the Republican-dominated legislature, and Governor Bill Walker signed H.B.374 into law in July 2016. Although it had the effect of shoring up Obamacare in the state, lawmakers were quick to point out that they were still opposed to the ACA, but considered the legislation to be the best way to avoid having the state’s individual health insurance market collapse altogether.

H.B.374 utilized an existing 2.7% assessment on all insurers (including home and auto) that was being sent to the general fund, and directed it instead into a reinsurance fund for the individual market. Prior to 2014, the Alaska Comprehensive Health Insurance Association—a high-risk pool—was the only way people with serious pre-existing conditions could get coverage in the non-group market; instead of funding ACHIA, the money is now used to fund the reinsurance program. Insureds whose claims end up being covered under the reinsurance program are still covered by the same individual market coverage as everyone else; they are not enrolled in separate plans, so this is different from the way ACHIA used to work.

H.B.374 was a temporary program, and was only funded by the state for 2017. For 2017, the reinsurance program received $55 million of the $64 million that was collected by the existing insurance assessment in 2015; in the first quarter of 2017, Alaska’s reinsurance program paid about $5 million in claims. But ironically, 2017 claims ended up being the lowest in a decade in Alaska’s individual market, and Premera agreed in December 2017 to make a one-time deposit of $25 million into the Alaska Reinsurance Program Fund, helping to cover its costs in future years.

In an effort to garner long-term funding from the federal government (as opposed to taxing Alaska insurance companies), in November 2016, the state posted a draft proposal of a 1332 waiver, and opened a one-month public comment period. The official waiver proposal was sent to HHS in late December 2016. The waiver requested five years of federal pass-through funding for the Alaska Reinsurance Program, with an option to renew after that.

The state proposed that the federal money that would otherwise be used for premium subsidies (to offset the higher premiums that would apply without the reinsurance program) be funneled instead into the reinsurance program (this is why it’s called “pass-through” funding). They estimate that 1,485 additional people will have coverage in Alaska’s individual market from 2018-2022 with the reinsurance program. But the cost of the program is substantial. Their waiver proposal projected that the reinsurance program would result in a $51.6 million reduction in premium subsidy payments from the federal government in 2018, and Alaska sought permission to use that money to fund the state reinsurance program, with supplemental funding appropriated by the state.

In January 2017, just before Trump took office, then-Secretary of HHS, Sylvia Burwell, wrote to Alaska Governor Bill Walker, noting that the state’s 1332 waiver was complete and under review. The letter indicated that the 1332 waiver was likely to be approved, although the state would need to pass additional legislation first in order to ensure ongoing state funding for the reinsurance program beyond the end of 2017.

Alaska’s 1332 waiver proposal was approved in July 2017. The approval was conditioned upon lawmakers passing legislation to fund the state’s portion of the cost of the reinsurance program for 2018. Alaska lawmakers passed H.B.57 in 2017, which provides $55 million in funding for the reinsurance program, to be used over five years. The state expected to pay $11 million in 2018, and expected the federal government to pay $48 million. The federal government’s projected spending on Alaska’s reinsurance program will grow with time, reaching $76 million in 2022 (and the state will pay $14 million), the last year that the waiver is valid.

But Wing-Heier noted that the exact amounts that the federal government will pay are uncertain, as they’re based on enrollment — the more people who enroll, the more funding the state will receive, as the federal government will be spending less on each person’s premium subsidies than they would have spent without the reinsurance program in place. And in early 2018, the state found out that the federal government would actually pay $58.5 million in 2018 instead of $48 million, leaving the state to cover just $1.5 million, instead of the $11 million the state had expected to fund.

Prior to developing the reinsurance program, Alaska lawmakers and the state Division of Insurance spent months considering possible fixes to the impending “death spiral” in Alaska’s individual health insurance market. Although subsidies offset the high premiums for those who are eligible for subsidies, they do nothing for the people whose income puts them just a little over the subsidy-eligible level (in 2017, the average subsidy in Alaska was $976 per month, compared with an average of $371 per month nationwide; the dramatically higher subsidy amount was necessary in Alaska in order to bring premiums down to the same level as the rest of the country, but it’s noteworthy that in 2018, the average subsidy amount in Alaska was much lower, at $718/month, while the national average premium subsidy had grown to $520/month).

But although Alaska led the way with reinsurance and several other states have subsequently followed suit, Erin Mershon, writing at RollCall, has an excellent explanation of how challenging it was to get Alaska’s reinsurance program approved by state lawmakers, and how ongoing state-based funding requirements could present challenges.

80th percentile rule: protecting patients, or driving up costs?

Since 2004, Alaska has had a regulation known as the 80th percentile rule, which applies to all individual plans as well as fully-insured large and small group plans (it does not apply to self-insured plans, which is the preferred insurance approach for very large employers). When out-of-network care is billed to insurers, the insurers are required to pay an amount that is at least as much as the 80th percentile of billed charges for that service in that geographical area. In other words, if you rank all the providers’ charges in a given area for a given service from highest to lowest, the 80th percentile would be an amount that’s higher than 80% of the charges on the list.

The 80th percentile rule was implemented to protect consumers from unaffordable balance billing from out-of-network providers. As an example, let’s consider what would happen without the 80th percentile rule if a provider charges $2,000 for a service, but an insurance company — with which the provider is not in network — says that the usual and customary charge is $300. In that case, the provider can bill the patient for the other $1,700 (balance billing does not happen with in-network providers, because the provider agrees to accept the insurer’s negotiated rates as payment in full; for in-network providers, the patient only has to pay their normal cost-sharing, in terms of copays, deductible, and coinsurance).

So the 80th percentile rule was implemented to ensure that health insurance plans pay out-of-network providers an amount that’s mostly in line with what providers in a given area are charging, and that’s well above the median charge (which would be the 50th percentile when all of the charges are arranged from highest to lowest).

But the problem that arises is that providers can increase their charges over time, and insurance company reimbursements have to keep pace with the cost increases. This serves to disincentivize providers from joining insurance networks, and drives up the cost of insurance. The Alaska Division of Insurance held a public hearing in January 2017 to consider the possibility of changing the 80th percentile rule. But the 80th percentile rule was still referenced in the filing instructions for 2019 coverage.

Notably, Alaska also requires health plans to cover out-of-network care — utilizing the 80th percentile rule for determining payment. Alaska also requires health plans to eliminate the possibility for “surprise” balance billing from out-of-network providers when a patient is at an in-network facility and is treated by an out-of-network provider without being given an option of an in-network provider (including a scenario in which no in-network provider is available).

The result of the 80th percentile rule and Alaska’s approach to out-of-network care is that providers get paid regardless of whether they contract with insurance companies, but it may be inadvertently driving up the cost of care. And even though the insurance plan pays at the 80th percentile, the remaining balance that’s billed to the patient can still be substantially higher than it would be in other areas of the country.

Alaska’s position on exchange, Medicaid expansion

After the ACA was enacted, Alaska refused all federal funding to evaluate and implement a health insurance marketplace, and it was one of the first states to announce it would leave responsibility for its marketplace in the hands of the federal government. While former Gov. Sean Parnell officially announced his decision in July 2012, he had previously made his opposition to the Affordable Care Act well known.

Parnell also opposed expanding the Medicaid program. Medicaid expansion was originally an integral, mandatory portion of the ACA, but in 2012 the Supreme Court ruled that Medicaid expansion would be optional, paving the way for states to keep their Medicaid programs as-is and essentially condemn their low-income residents to the coverage gap. Parnell rejected an expansion in late 2013, saying that Alaska wouldn’t be able to afford the program if the federal government were ever to cut funding (the federal government paid 100% of the cost through 2016, and has committed to always paying at least 90%).

However, the new governor — Bill Walker, an Independent who was formerly a Republican — vowed to reverse the course on Medicaid expansion. Walker took office Dec. 1, 2014, and announced his intention to authorize expansion within his first 90 days in office.

In late February 2015, the House Finance Committee stripped Medicaid funding from Walker’s budget and called for Walker to introduce legislation to expand Medicaid. The administration countered that Democratic legislators had already introduced such a bill.

In July 2015, Governor Walker announced that he would use his executive power to expand Medicaid, since lawmakers had rejected the inclusion of Medicaid expansion in the state budget, and had also ended the 2015 legislative session without a vote on the bill that would have expanded Medicaid. Walker noted that he had tried all of the other options for working with the Republican-controlled legislature on the issue, and had eventually run out of possibilities.

Under Walker’s executive authority, Medicaid expansion took effect in September 2015 in Alaska. GOP lawmakers filed a lawsuit to block expansion, but the case was dismissed in March 2016. The Alaska House of Representatives filed an appeal, but dropped it in June 2016, and Medicaid expansion has remained in effect in Alaska.

Alaska health insurance exchange resources

State of Alaska Insurance Department: Affordable Care Act

HHS: How the ACA Is Making a Difference

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