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

ACA open enrollment period for 2022 coverage is underway; Average pre-subsidy rate increase of 3% in Delaware

Cape Henlopen State Park, Lewes, Delaware | Image: K.A. / stock.adobe.com

Delaware exchange overview

Delaware’s exchange is a partnership between the state (Choose Health Delaware) and HHS, with residents enrolling through HealthCare.gov. Delaware is responsible for plan management and consumer assistance while the federal government handles all other functions. A total of 25,320 people enrolled in coverage through Delaware’s marketplace during the open enrollment period for 2021 coverage. And nearly 5,900 additional people enrolled in coverage through Delaware’s exchange during the COVID/American Rescue Plan special enrollment period that continued through mid-August 2021. Two health insurance companies offered coverage in the exchange in 2017, but that dropped to just one – Highmark BCBS of Delaware – in 2018, and Highmark continues to be the only insurer offering plans in the state’s exchange for 2022. Highmark already covered more than half of Delaware’s exchange enrollees as of 2017, but nearly 12,000 people with Aetna coverage had to select new plans from Highmark for 2018. Delaware received federal approval to implement a reinsurance program for 2020, and also enacted legislation to codify ACA consumer protections into state law. Highmark had already proposed a premium reduction for 2020, and the rate decrease was even more significant once the reinsurance program was approved. Highmark implemented another small rate decrease for 2021, but has increased premiums by an average of 3% for 2022.

When is open enrollment for health insurance in Delaware?

Open enrollment for 2022 health plans began November 1, 2021 in Delaware, and will continue until January 15, 2022. If you enrolled or made a plan change by December 15, 2021, your new coverage will take effect January 1, 2022. Enrollments and plan changes completed between December 16 and January 15 will have coverage effective February 1, 2022. The open enrollment period is a great opportunity to take advantage of the larger and more widely available premium subsidies created by the American Rescue Plan. If you have questions about open enrollment, you can read more in our comprehensive guide to open enrollment. You may still be able to enroll in coverage for 2021 if you experience a qualifying life event or if you’ve received unemployment compensation at any point in 2021

Which health insurance carriers offer 2022 coverage in the Delaware marketplace?

As of 2022, Highmark is still the only insurer that offers exchange plans in Delaware. Delaware is the only state in the country with just one participating exchange insurer, although there are partial areas of other states that have just a single insurer offering plans. Although Aetna rejoined the marketplaces for 2022 in several states where they had previously exited, they did not rejoin Delaware’s marketplace.

Average approved rate increase of 3% for 2022

For 2022 coverage, Highmark has increased its overall average premiums by 3%, after initially proposing an average increase of 4%. Average rate changes only tell part of the story, however. They don’t account for premium subsidies, which offset premium costs for the majority of Delaware’s exchange enrollees. They also don’t account for the fact that premiums increase with age, even if an insurer doesn’t increase its overall average rates. For perspective, here’s a look at how premiums have changed in Delaware’s exchange in prior years:

  • 2021: Average decrease of 1%. Highmark proposed an overall average rate decrease of half a percent for 2021. But after the rate review process was complete, Delaware’s Insurance Commissioner, Trinidad Navarro, announced that Highmark’s average premiums would decrease by 1% for 2021. Without Delaware’s reinsurance program, the overall rate change would have been an increase rather than a decrease.
  • 2020: Average decrease of 19%. Highmark initially proposed an average rate decrease of 5.85% for 2020, but this was before the state enacted legislation to create the reinsurance program. The 1332 waiver proposal that Delaware submitted to CMS in July noted that with the reinsurance program in place, premiums were expected to be 13.7% lower in 2020 than they would otherwise have been. Ultimately, a 19% average rate decrease was approved for Highmark’s plans, which was very much in line with the state’s initial projections (ie, the 5.9% decrease that Highmark had proposed, in addition to the 13.7% estimated decrease due to the reinsurance program).Unsubsidized premiums in Delaware were among the highest in the country in 2019. The average unsubsidized premium in Delaware was $842/month, versus $612 across all of the states that use HealthCare.gov. So the sharp decrease from the reinsurance program was badly needed, for people who don’t receive premium subsidies.
  • 2019: Average increase of 3%. When the Delaware Department of Insurance published final rates for 2019, the approved average rate increase for Highmark was just 3%. The final rate approval notice clarifies that the cost of CSR was added only to silver plan rates for 2019, as opposed to the broad load strategy that was used for 2018. And the approved rate notice also clarified that the cost of CSR was not added to premiums for plans purchased outside the exchange, which means that Highmark only added the cost of CSR to on-exchange silver plans. That’s the best approach for consumers, as it allows people who don’t qualify for premium subsidies to purchase an off-exchange plan (if they want a silver plan) and not have the added cost of CSR baked into their premiums.In 2018, the Delaware Insurance Department has been working on regulations to limit short-term health insurance plans to three months in duration and prohibit renewals. Highmark’s initial filing had included higher rates (a 1% load) to offset the fact that the risk pool was expected to be sicker once the federal regulations were relaxed to allow much longer short-term plans (the Trump administration implemented that rule change in August 2018). But Delaware regulators stepped in to prevent that, ensuring a more stable individual market (since healthy people don’t have the option to leave the ACA-compliant market and switch to year-long short-term plans instead).
  • 2018: Average increase of 25%. Highmark Blue Cross Blue Shield of Delaware had the majority of the market share in the state’s exchange in 2017, and they became the only available option as of 2018, with Aetna’s exit from the marketplace.The Trump Administration’s lack of commitment to funding the ACA’s cost-sharing reductions (CSR) was a driving factor in the rates that insurers filed for 2018. Insurers in most states — including Delaware — added the cost of CSR to premiums for 2018. The Trump Administration announced in mid-October that CSR funding would end immediately. (In Delaware, a broad load approach was used for 2018, with the cost of CSR spread across all plans. Only a few other states took this approach — ColoradoMississippiWest Virginia, and Indiana. Only Mississippi and Indiana are continuing to use it as of 2022.)Highmark initially proposed an average rate increase of 33.6%, but ultimately agreed to a 25% average rate increase. Their rate filing noted that the average rate increase would have been about 16.8% if CSR funding had continued and if the federal government had been robustly enforcing the individual mandate.
  • 2017: Average increase of 30%. In Delaware, the approved average rate increases for 2017 amounted to about 23% for Aetna, and almost 33% for Highmark. The weighted average increase was about 30%.Initially, Delaware Insurance Commissioner Karen Weldin Stewart had approved a lower-than-requested rate for Highmark, and forwarded that on to CMS for review. But in light of the carriers opting to leave exchanges in numerous states around the country, CMS urged Delaware to accept Highmark’s initial rates, and the state agreed. As a result, no carriers left the Delaware exchange at the end of 2016, while most other states saw at least some insurers exit their exchanges.Highmark, which also offers coverage in the exchanges in Pennsylvania and West Virginia, recorded their first profitable year in the ACA-compliant market in 2017, after losing a billion dollars in the ACA-compliant market from 2014 through 2016
  • 2016: Average increase of 22%. The approved rate increases for 2016 included a 22.4% average increase for Highmark (which had 95% of the individual market share in Delaware at that point) and a 17% increase for Aetna. Across the whole market in Delaware, the overall weighted average increase was about 22% for 2016.
  • 2015: Average increase of 3%. A study released in December 2014 by The Commonwealth Fund showed just a 3 percent increase in average marketplace premiums for Delaware between 2014 and 2015. The weighted analysis looked at rates across all metal tiers and in urban/suburban/rural areas of most states.

Delaware law caps insulin out-of-pocket at $100 per month on state-regulated health plans

Delaware HB263, enacted in July 2020, caps out-of-pocket costs for insulin at $100 per month on all individual and group plans that are regulated by the state of Delaware (note that states to not regulate self-insured group plans). Plans are also required to include at least one insulin product in the lowest tier (ie, least expensive) of the plan’s covered drug list. The rule took effect for plans issued or renewed after the end of 2020.

Delaware codifies ACA consumer protections into state law

In August 2019, Delaware Governor John Carney signed SB35, codifying various ACA consumer protections into Delaware state law and joining several other states that have taken similar action over the last few years. Although the ACA remains the law of the land, Delaware’s new law ensures that if the ACA is ever repealed or changed, its consumer protections will remain in effect in Delaware. This includes provisions such as guaranteed-issue coverage (regardless of medical history), coverage for essential health benefits, a ban on lifetime and annual benefit maximums, limits on out-of-pocket costs, and rules regarding the factors that insurers can use to set premiums. Governor Carney also signed legislation that ensures adult Medicaid enrollees in Delaware will have dental coverage.

Delaware’s reinsurance program took effect in 2020

In June 2019, Governor Carney signed HB193 into law, paving the way for Delaware to create a reinsurance program in order to stabilize the state’s individual insurance market. The legislation called for an assessment on insurers in the state, plus federal pass-through funding to cover the cost of the reinsurance program. Reinsurance programs work by paying a portion of high-cost claims, which reduces costs for insurers (in 2020, Delaware’s reinsurance program paid 75% of claims that were between $65,000 and $215,000; in 2021, it paid 80% of claims that were between $65,000 and $335,000). Because their claims costs are lower, insurers can charge lower premiums. This results in higher enrollment among people who have to pay full-price, and it also means that the federal government spends less on premium subsidies, as the subsidies don’t have to be as large in order to bring net premiums down to an affordable level. States can use a 1332 waiver in order to request pass-through funding, which means the state (instead of the federal government) gets to keep the savings that result from the premium subsidies being smaller. The state then uses that money to fund the reinsurance program. Several states have implemented reinsurance programs over the last couple of years, and have seen improvement in their individual markets as a result. Delaware estimated that the reinsurance program would cost about $44 million in 2020, and that 80% of that would be covered by the federal pass-through funding, with the state generating the other 20% via a health insurer assessment. CMS determined that Delaware’s pass-through funding would amount to $21.7 million in 2020, which was less than the state had initially projected. But the pass-through funding for 2021 came to nearly $39 million. Delaware submitted a 1332 waiver proposal to CMS in July 2019, and it was approved in mid-August. With the reinsurance program in place, Delaware projected that premiums in the individual market to be 13.7% lower in 2020 than they would otherwise have been, and that enrollment in the individual market would increase by as much as 2.3%, thanks to smaller premiums for people who don’t get premium subsidies (for those who do get subsidies, the subsidies shrink commensurately with the cost of the benchmark plan). As noted above, overall average premiums decreased by 19% in Delaware in 2020.

Enrollment grew in 2020 and 2021, after declining for three years in a row

25,320 people enrolled in plans through Delaware’s exchange during the open enrollment period for 2020 coverage, up from 23,961 the year before. And 2020’s enrollment was also an increase; total enrollment is 12% higher than it was in 2019, although it’s still lower than it was in 2016, when more than 28,000 people enrolled during the annual open enrollment period. The enrollment drops in recent years were not unexpected. For 2019, a significant factor was the elimination of the individual mandate penalty. In many states, the expansion of short-term plans also played a role in declining enrollment for 2019, but Delaware regulators implemented emergency regulations that limit short-term plans to just three months in duration, eliminating the option for people to use them as long-term coverage alternatives to ACA-compliant plans. There was a window, however, from early October until the end of November, when residents in Delaware were able to purchase longer short-term plans, and some may have done so in order to obtain coverage for much of 2019. The enrollment increase in 2020 and 2021 also was not unexpected, as Delaware’s new reinsurance program resulted in lower premiums for people who don’t get premium subsidies, making coverage more affordable for that population. Enrollment in individual market plans through Delaware’s exchange has reached the following totals during open enrollment each year:

Although enrollment in the exchange dropped about 20% from 2016 through 2019, Delaware’s 1332 waiver proposal noted that total individual market enrollment in the state (including on-exchange and off-exchange enrollment) had dropped by 37% in that same time period. Off-exchange enrollees don’t get premium subsidies, but the state’s new reinsurance program has made their coverage more affordable, potentially resulting in enrollment gains outside the marketplace as well.

No discrimination against transgender enrollees

In March 2016, Delaware became the 15th state to prohibit health insurance companies from discriminating against transgender enrollees. The rules apply both on and off exchange, and in the individual and group market. The bulletin issued by Insurance Commissioner Karen Weldin Stewart specifically notes that while the plan that constitutes the Essential Health Benefits benchmark plan in Delaware for 2016 did have an exclusion for “change of sex surgery” (except for correcting a congenital defect), the bulletin detailing the ban on transgender discrimination supersedes the benchmark plan design, and that insurers may not issue such a blanket exclusion.

Specialty drugs costs are capped under Delaware law

Delaware is one of several states that have taken steps to limit patients’ out-of-pocket costs for prescription drugs. Delaware law limits specialty drugs to $150/month copays or coinsurance. The regulations apply on and off-exchange, and to employer-sponsored plans that are regulated by the state (self-insured plans are regulated by the federal government under ERISA instead). And Delaware insurance plans are not allowed to designate all drugs in a particular drug class as specialty drugs, so patients shouldn’t have a situation in which their only available drugs are specialty drugs.

Delaware opted to stay with federally-run exchange

In the months leading up to the Supreme Court’s 2015 ruling on King v. Burwell, Delaware devised a back-up plan. Because Delaware uses the federally-run marketplace (the state has a partnership exchange, which is a variation of the federally-run exchange), subsidies were in jeopardy in the state. If the King plaintiffs had prevailed, an estimated 18,000 people would have lost their subsidies in Delaware.  And statewide, the entire individual market would have seen spiraling premiums over the next few years as healthy individuals dropped coverage that became unaffordable without subsidies. To avoid that outcome, the state submitted a proposal for transitioning from a state-federal partnership exchange to a federally-supported state-based marketplace (Oregon, Nevada, Arkansas, Kentucky, and New Mexico use that model as of 2019, with state-run exchanges that utilize Healthcare.gov for enrollment). And on June 15, 2015, HHS issued conditional approval for Delaware’s plan (Pennsylvania and Arkansas also got conditional approval for state-run exchanges as contingency plans in case the Court had sided with King). At that point, Delaware was the only state with a Democratic governor and Democratic majority in both congressional chambers that didn’t have a state-run exchange, in large part because the state’s small population would make it financially difficult to sustain an exchange. But then on June 25, the Supreme Court ruled that subsidies are legal in every state, including those that use the federally-run marketplace, meaning that subsidies would continue to be available in Delaware regardless of whether the state runs its own exchange. Initially, it was unclear whether Delaware would continue with their plan to implement a supported state-based marketplace. The state issued a press release immediately after the King verdict was announced, stating that they would continue to evaluate the possibility of transitioning the exchange, and make a decision later in the summer. But in August 2015, Delaware officials announced that they would continue to operate as a state-federal partnership exchange, noting that it would be more cost-effective than operating their own exchange.

Delaware health insurance exchange links

Choose Health Delaware 800-318-2596 HealthCare.gov 800-318-2596 Health Benefit Exchange information Exchange information from the Delaware Health Care Commission Who Serves on the Delaware Health Care Commission? State Exchange Profile: Delaware The Henry J. Kaiser Family Foundation overview of Delaware’s progress toward creating a state health insurance exchange.


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.

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