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For the time being, Georgia uses the federally run health insurance exchange, enrolling residents through HealthCare.gov. Ten carriers are offering 2023 plans through the exchange (there were eleven in 2022, but Bright Health stopped offering coverage after the end of 2022).
Georgia had planned to stop using HealthCare.gov and simply not have a health insurance exchange at all as of the 2023 plan year. This was approved by the Trump administration, but approval was suspended by the Biden administration in 2022. So Georgia residents still have access to the HealthCare.gov enrollment platform and call center. However, the state has debuted its own “Georgia Access” page that directs consumers to insurers and web brokers, without mentioning subsidies or HealthCare.gov. And starting in the fall of 2023, Georgia hopes to be running its own exchange platform.
During open enrollment for 2023 coverage, 879,084 Georgians enrolled in private individual-market plans through the Georgia exchange. This was by far a record high, eclipsing the previous record high of 701,135 enrollees the year before.
For the time being, Georgia uses the federally-run health insurance marketplace, HealthCare.gov. But the state is planning to run its own marketplace platform starting in the fall of 2023, assuming federal approval is granted for the transition.
In late 2020, Georgia received approval from the Trump administration (under a 1332 waiver) to stop using HealthCare.gov as of the 2023 plan year, and instead transition to a network of web brokers and health insurance companies to enroll in health coverage. This approach would have made Georgia the only state in the country without a health insurance exchange/marketplace.
But this was challenged in the court system and re-evaluated by the Biden administration. The Biden administration ultimately notified Georgia officials that the 1332 waiver approval was suspended as of August 2022, and that residents in Georgia would continue to use HealthCare.gov to enroll in 2023 coverage.
However, the state still rolled out its new Georgia Access platform, billed as an “informational website” and run by the Georgia Office of Insurance. The page makes no mention of HealthCare.gov or the substantial subsidies that most people can receive when they enroll in coverage through HealthCare.gov.
But the state is working to turn the Georgia Access platform into a state-run exchange/marketplace by the fall of 2023, for use starting with the 2024 coverage years. To that end, Georgia’s S.B.65 was signed into law in May 2023, giving the Office of Commissioner of Insurance and Safety Fire authority to create and operate a state-run exchange (Georgia had previously enacted legislation in 2014 that prohibited the state from running its own exchange, so S.B.65 reversed that rule).
Also in February 2023, Georgia submitted a letter to CMS declaring its intent to create an exchange, along with an exchange blueprint letter.
Given Georgia’s previous efforts to undermine the exchange, patient advocates have expressed concerns about the state’s ability to operate a successful exchange that works in the best interest of consumers. A substantial list of patient advocacy groups sent a letter to CMS in March 2023, asking them to reject Georgia’s plan to transition to a state-run exchange, especially on the accelerated timeframe Georgia had proposed.
It’s noteworthy that one objection is no longer relevant: In the updated federal rules for 2024, CMS no longer requires states to submit an exchange blueprint at least 15 months before the exchange becomes operational for open enrollment. Instead, states just need to have their blueprint approved prior to the open enrollment when they plan to begin using the state-run exchange.
Georgia also received federal approval to operate a reinsurance program, which took effect for the 2022 plan year. Reinsurance is not controversial; 17 states have implemented reinsurance programs, which are successfully keeping premiums in check. Reinsurance is less useful, however, now that the American Rescue Plan and Inflation Reduction Act have temporarily eliminated the “subsidy cliff” and thus made more people eligible for premium tax credits (subsidies). Reinsurance lowers the cost of full-price coverage, but fewer people are having to pay full price with the ARP in place (if not extended again by Congress, the ARP’s subsidy enhancements will expire at the end of 2025, making reinsurance more important again).
The open enrollment period for individual/family coverage runs from November 1 through January 15 in Georgia.
If Georgia begins operating its own state-run exchange platform in the fall of 2023, the state will have flexibility to set its own enrollment deadline, as long as it’s no earlier than December 15.
Outside of the open enrollment window, enrollments and plan changes are possible if you qualify for a special enrollment period.
Most of the time, special enrollment periods are linked to a qualifying life event. But some special enrollment periods (such as the enrollment opportunity for Native Americans, or for people earning under 150% of the poverty level) are not tied to a specific qualifying event. There is also a special enrollment period from March 31, 2023 through July 31, 2024, for anyone who loses Medicaid during that time frame.
If you have questions about opportunities to enroll in health coverage, you can learn more in our guide to open enrollment and guide to special enrollment periods.
For 2023 coverage, there are ten insurers that offer exchange plans in Georgia. There were 11 in 2022, which was a record high for Georgia’s exchange. But Bright Health stopped offering individual/family coverage after the end of 2022.
The following insurers offer plans in the Georgia exchange for 2023, with plan availability varying from one location to another:
Insurer participation in Georgia’s exchange has varied considerably over the years:
For 2023, according to ratereview.healthcare.gov, the following average rate changes were approved for 2023:
According to ACA Signups, the weighted average rate increase is about 10% for 2023. But as is always the case, weighted average rate changes don’t paint a full picture:
For perspective, here’s a summary of how rates have changed in Georgia’s exchange over the years (more details below for some notable years):
Georgia’s exchange reached a new record high enrollment for 2023, with 879,084 people signing up for private plans through the exchange during the open enrollment period that ended on January 15, 2023.
Here’s a summary of how enrollment has changed in Georgia over the years (all numbers are based on total enrollment at the end of open enrollment; effectuated enrollment is always lower, as some enrollees don’t pay their premiums or cancel their plans early in the year):
11 insurers currently offer dental plans through the Georgia marketplace. Learn about dental coverage options in Georgia.
Georgia is planning to run its own exchange starting in the fall of 2023, for coverage effective in 2024 and future years. This is outlined in the state’s letter of intent and its exchange blueprint, both of which were submitted to CMS in February 2023. Georgia also enacted legislation in 2023 that grants the Office of Commissioner of Insurance and Safety Fire the ability to create and run a state-based exchange (this is a reversal of 2014 legislation that had prohibited the state from running its own exchange).
If CMS approves Georgia’s proposals, the state’s Georgia Access platform would become a full-fledged state-run exchange by the fall of 2023. Currently, Georgia Access is just an informational website that the state debuted in late 2022, with links to various insurers and health insurance brokers.
But the state’s exchange blueprint confirms that “consumers will have the ability to apply for, receive eligibility determinations, shop, compare, and select a QHP (qualified health plan) via a self-service State consumer portal.”
Consumer and patient advocates have expressed reservations about Georgia’s ability to operate a successful exchange, given the state’s previous efforts to dismantle the exchange altogether. A group of patient advocacy organizations wrote a letter to CMS in March 2023, asking them to reject Georgia’s proposal to operate a state-run exchange, particularly given the accelerated timeframe Georgia had proposed.
But one of their objections is no longer relevant: CMS used to require states to submit an exchange blueprint at least 15 months before a state-run exchange would be in use. But under the federal rules for 2024, CMS no longer requires that. Instead, a state just has to have its blueprint approved prior to the open enrollment when they plan to begin using the state-run exchange. In Georgia’s case, that would be anytime prior to November 1, 2023, when open enrollment begins for 2024 coverage.
Here’s the backstory on Georgia’s health coverage reform progress:
Georgia enacted SB106, the Patients First Act, in March 2019. The legislation authorized the state to submit an 1115 waiver proposal to the federal government with a proposal to partially expand Medicaid to cover people with income up to 100% of the poverty level (the legislation allowed the proposal to go up to that amount, but not above it). SB106 also authorized the state to submit a 1332 waiver to the federal government with a proposal or proposals for modifying the state’s individual health insurance market.
The Trump administration ultimately approved both the 1115 waiver (for partial and conditional Medicaid expansion with a work requirement) and the 1332 waiver (for a reinsurance program effective in 2022 and the “Georgia Access Model” for the exchange starting in 2023; this would have involved the state no longer having a health insurance exchange, and relying instead on a network of web brokers and insurers to enroll people in coverage).
As of early 2023, only the reinsurance program was fully in effect in Georgia. But the state did still set up its own insurance platform in addition to HealthCare.gov, and is planning to convert that into a fully state-run exchange by the fall of 2023. Georgia is also planning to move ahead with partial Medicaid expansion (and a work requirement) in mid-2023.
The Biden administration ultimately suspended the Georgia Access Model in 2022, so the state still uses HealthCare.gov for the 2023 plan year. However, the state still rolled out its new Georgia Access platform in late 2022, described as an “informational website” and run by the Georgia Office of Insurance. The page makes no mention of HealthCare.gov or the significant subsidies that most people can receive when they enroll in coverage through HealthCare.gov.
Instead, it provides links to 17 “healthcare partners” that consumers can use to enroll in health coverage. These partners are a mix of web brokers (like HealthSherpa and Via Benefits) and insurers (like Aetna and UnitedHealthcare). The majority of them are approved enhanced direct enrollment entities, which means that they can enroll applicants directly in coverage through the exchange, with subsidies, even though the consumer doesn’t actually use the exchange website.
But some of the “healthcare partners” included on the Georgia Access site are not enhanced direct enrollment entities, which means they cannot enroll people directly in on-exchange plans. And the majority of the partners are insurers, which means they will show consumers only their own plans, instead of the full range of plans available in each area.
Some of the partner web brokers also offer non-ACA-compliant health coverage, such as short-term health insurance. Unless a consumer is quite savvy and understands exactly what they need and what’s available to them, there are concerns that people could be confused and inadvertently purchase a non-ACA-compliant plan without fully understanding the drawbacks.
But Georgia is planning to convert Georgia Access into a fully state-run exchange in time for the 2024 plan year. The state submitted its letter of intent and exchange blueprint in February 2023, and will go live with the exchange in the fall of 2023 if CMS approval is granted. Although the current site does not provide any way for consumers to compare plans or enroll in coverage (just links to other websites that can be used for those purposes), Georgia’s blueprint letter indicates that they plan to make those changes and roll out the new platform in the fall of 2023.
In early 2022, Georgia officials opted to cease implementation of the state’s planned partial Medicaid expansion after the Biden administration revoked approval for the work requirement (as had been the case for every other state where a Medicaid work requirement was previously approved by the Trump administration). But Georgia also filed a lawsuit in early 2022 against the Biden administration in response to the rule changes.
In August 2022, a judge sided with Georgia, allowing the state to move forward with the Georgia Pathways program. And the Biden administration had not appealed that decision as of early 2023. In late 2022, Gov. Kemp announced that the Pathways program would begin in July 2023
Although only the reinsurance program was in effect as of the 2023 plan year, the partial Medicaid expansion is expected by mid-2023 and Georgia has rolled out its new Georgia Access website, although HealthCare.gov is also still in use in the state. Here’s an overview of what was included in Georgia’s 1115 and 1332 waivers:
Georgia is one of 12 states where Medicaid has not yet been expanded as of early 2023 (South Dakota will expand Medicaid in July 2023, and North Carolina is expected to expand Medicaid by early 2024). Under the 1115 waiver that was approved by the Trump administration, Georgia planned to partially expand Medicaid as of mid-2021, granting coverage to non-elderly adults earning up to 100% of the poverty level.
As described above, this was postponed by two years, and is now expected to take effect in mid-2023. The state only anticipates that 50,000 people will gain coverage under the partial Medicaid expansion, and there are an estimated 269,000 people stuck in Georgia’s coverage gap (only Florida and Texas currently have more people in the coverage gap). The low coverage projection under Georgia’s proposal is due in large part to the fact that the program calls for a work requirement, as well as premiums for some enrollees.
The details of Georgia’s proposed 1115 waiver were unveiled in November 2019. It called for a partial expansion of Medicaid, and would cover people with income under the poverty level — as long as they are compliant with a work requirement, and in some cases, paying premiums for their coverage. Georgia’s proposed partial expansion of Medicaid and Medicaid work requirement were approved by CMS in October 2020, although the Trump administration rejected the state’s proposal for the enhanced federal funding that can only be obtained if a state fully expands Medicaid, covering people with income up to 138% of the poverty level. Instead, Georgia will receive its normal federal matching rate for the newly eligible population, and people with income over the poverty level will continue to be eligible for premium subsidies to offset the cost of private individual market coverage. It’s projected that if Georgia were to fully expand Medicaid, the expansion would cover at least 400,000 low-income Georgia residents. But the state’s modified expansion is expected to cover only a fraction as many people.
(Wisconsin provides Medicaid coverage for people with income up to the poverty level, but they do not receive the enhanced federal funding for that population, since they haven’t fully expanded Medicaid up to 138% of the poverty level. Utah took a similar approach for most of 2019; CMS rejected Utah’s proposal for full federal Medicaid expansion funding despite partial expansion, so Utah transitioned to full Medicaid expansion as of 2020.)
Georgia also unveiled its 1332 waiver proposal in November 2019, calling for a variety of changes that would affect the state’s individual insurance market. SB106 had included a few examples of changes that could be proposed with a 1332 waiver, the most likely of which was reinsurance, which is what numerous other states have implemented via 1332 waivers (this is the primary recommendation from the Georgia Budget and Policy Institute, although they also had additional recommendations for ways the state could utilize a 1332 waiver).
On November 1, 2020, CMS granted approval for Georgia’s 1332 waiver proposal. Georgia’s 1332 waiver includes a reinsurance program, but while most states that have thus far implemented 1332 waivers have used them only for reinsurance programs, Georgia’s 1332 waiver went beyond that. Under the terms of the 1332 waiver, Georgia had planned to transition away from HealthCare.gov as of 2023, and simply not have an exchange. That has not happened, but Georgia now has its own “Georgia Access” website in addition to HealthCare.gov. And by the fall of 2023, Georgia plans to be operating a fully state-run exchange.
Georgia’s reinsurance program took effect in 2022, covering a portion of high-cost medical claims between $20,000 and $500,000 (the proposal initially called for the reinsurance program to take effect in 2021, but the state announced in mid-2020 that the program was being delayed by one year and this was approved by CMS in November 2020).
The reinsurance program targeted a 10% reduction in overall average premiums across the state, but like a model that has been successfully implemented in Colorado, Georgia uses the reinsurance program to offset a higher percentage of claims in areas of the state where premiums are the highest, in order to bring down premiums the most in those areas. Reinsurance programs are a tried and true way of bringing down premiums for people who have to pay full price for their coverage, and they can serve to boost enrollment in the ACA-compliant market by making coverage affordable for that segment of the population.
While the American Rescue Plan’s subsidy enhancements are in effect (through 2025, due to an extension under the Inflation Reduction Act), reinsurance is not as important as it used to be. That’s because the American Rescue Plan eliminated the “subsidy cliff” and increased the number of people who are eligible for subsidies. So there aren’t as many people who have to pay full price for their coverage. But if the ARP’s subsidy enhancements aren’t extended by Congress, reinsurance will once again be an important tool for keeping coverage affordable as of 2026, for people who earn more than 400% of the poverty level (the normal cap for subsidy eligibility, which was temporarily eliminated by the ARP).
As noted above, Georgia is planning to debut a fully state-run exchange in the fall of 2023, which residents will use (instead of HealthCare.gov) to enroll in coverage for 2024. The state plans to use the existing Georgia Access platform, but it will be upgraded to include plan comparison and enrollment functionality (it’s currently just an informational website that directs visitors to other websites where they can view plans and sign up for coverage).
But it’s also important to understand what Georgia was initially proposing, and what they would have implemented if the Biden administration hadn’t suspended the initial approval.
Under the terms of the Trump administration’s approval of Georgia’s proposal, the Georgia Access Model — in which the state relies on web brokers, agents, brokers, and insurance companies to enroll people in health coverage, instead of using HealthCare.gov — was slated to take effect for the 2023 plan year. Georgia had initially proposed a 2022 start, and that was still the proposal after the state made some significant modifications to the proposal as of mid-2020. But CMS noted that in order to ensure a smooth transition, and after communication with Georgia officials, the program had been pushed to 2023.
Moving away from HealthCare.gov without creating a centralized state-run exchange would have gone well beyond what other states have done with 1332 waivers. The Georgia Access Model faced a lawsuit within a few months of gaining federal approval, and the Biden administration began reconsidering the Georgia Access Model in the fall of 2021, ultimately suspending it in August 2022.
However, Georgia did debut its Georgia Access website in late 2022. The website directs visitors to 17 “healthcare partners” that include insurers and web brokers. The Atlanta Journal-Constitution notes that the state spent $31 million on the Georgia Access program, including the website and marketing.
Before the Biden administration suspended the state’s transition away from HealthCare.gov, there were concerns that what Georgia planned to do would simply not meet the ACA’s requirements for 1332 waivers, despite the approval from CMS under the Trump administration. It’s also noteworthy that nearly all of the initial public comments that were submitted regarding the Georgia Access Model were negative, and encouraged the state to keep the HealthCare.gov platform. The new round of public comments, submitted in late 2021 and early 2022, were also overwhelmingly opposed to the idea of jettisoning the exchange.
Georgia’s proposal initially called for the state to receive the same federal funding that would have been used for subsidies via HealthCare.gov, but with the money instead being distributed by the state to help residents cover the cost of qualified health plans (ie, the same sort of plans that are currently available on HealthCare.gov) as well as “non-QHPs” which would have lesser benefits but would still be part of the same risk pool and not medically-underwritten. But the modifications made to the proposal in mid-2020 scaled this back considerably.
The state planned to stop using HealthCare.gov and switch to a system that would have relied on web brokers and insurers, but it planned to let the federal government continue to handle premium subsidies. The state’s system would have sent subsidy eligibility information to the federal government, which would have continued to issue premium subsidies just as it already did, only for QHPs. Consumer advocates noted that while there were still concerns, the modifications the state made during the waiver approval process “will reduce the harmful impacts that consumers would have felt under the original proposal.”
The entities that would have been enrolling people in health coverage in Georgia — in lieu of a health insurance exchange — would have included some that also offer non-QHPs (such as short-term health plans, fixed indemnity plans, etc), which could have potentially led to consumer confusion. And while it’s true that many of these web brokers already use the enhanced direct enrollment pathway to enroll people in on-exchange health plans via their own websites, that would have essentially been the only option as of 2023, rather than simply being an alternative to HealthCare.gov.
Without the HealthCare.gov platform — where only QHPs can be offered — residents would have potentially had a harder time ensuring that the coverage they’re buying is actually compliant with the ACA. The waiver approval noted that brokers in Georgia earn an average of “only” $8.42 per member per month in commissions when they sell short-term health plans, versus an average of $6.88 per member per month when they sell QHPs. The CMS Office of the Actuary notes that “as long as there is not a major change in commission structure [they] would not expect broker behavior to change drastically.” But even at those amounts, brokers are earning 22% more by selling short-term health insurance, which is not an inconsequential difference.
It may be true that broker behavior wouldn’t “change drastically,” but consumers in Georgia would have lost access to HealthCare.gov, leaving them with only web brokers, agents, brokers, and insurers as their means of enrolling in coverage. In short, this would have been a subtraction rather than an addition: The web brokers, agents, brokers, and insurers already exist, and many do an excellent job of helping people enroll in plans via the enhanced direct enrollment pathway. But Georgia’s 1332 waiver wouldn’t have added anything new to the mix — it would have simply taken away the current exchange platform and the services it provides.
There were also concerns that people who qualify for Medicaid would have been lost in the shuffle under the new system. Georgia has not yet expanded Medicaid, but the HealthCare.gov platform does still direct people to Medicaid and CHIP if they’re eligible under the state’s current rules. But there are no commission payments for enrolling someone in Medicaid, and brokers/agents only get paid on commission. So there is little incentive for them to help people enroll in Medicaid or CHIP.
Federally-funded Navigators work with HealthCare.gov in Georgia, but would no longer be available once the state no longer has the HealthCare.gov platform available for consumers to use; states that run their own exchanges must also fund and operate their own enrollment assistance programs. And the state’s waiver approval included some negativity about the existing Navigator program, noting that “the Navigator program has simply had limited impact on reducing the overall uninsured rate in Georgia, suggesting there may be a more effective way to reach and engage consumers. In fact, one of the key criticisms of HealthCare.gov and the implementation of the Navigator program is that it has squeezed local agents and brokers out of the market with government-funded competition.” But it’s worth noting here that a big part of the reason for Georgia’s stubbornly high uninsured rate has been the state’s failure to expand Medicaid under the ACA.
Anthem and Georgia Farm Bureau teamed up to offer Georgia FARM plans starting in the fall of 2019, with coverage effective dates starting in October that year. The Georgia FARM plan is self-funded as a multiple employer welfare arrangement (MEWA), but utilizes stop-loss coverage from Anthem.
Georgia FARM plans are available to small businesses — including sole proprietors without any additional employees — that are involved in various “farming-related industries.” The eligible list is extensive and has been expanded to include industries such as HVAC, painters, book binders, clothing, and a wide range of retailers. All enrolling employees must be members of the Georgia Farm Bureau.
The plans are medically underwritten, in that premiums depend on applicants’ medical history and a small group’s claims history. But pre-existing conditions are covered and the Georgia FARM plans are guaranteed-issue.
Farm Bureau partnerships with insurers exist in several other states; Georgia’s is somewhat unique, although it is similar to the plan that debuted in Ohio in 2016.
Tennessee and Iowa, for example, have Farm Bureau plans that are available to any Farm Bureau member (ie, there is no requirement that the enrollee be actively involved in agriculture) and are designed for healthy people who would otherwise be enrolling in individual market coverage. In both cases, the state has said that the coverage isn’t technically insurance, and thus is not regulated under state insurance laws and does not have to comply with the ACA’s regulations.
In Nebraska, Farm Bureau debuted an association health plan in 2018, with a limited annual open enrollment window, guaranteed-issue coverage, and no medical underwriting (it transitioned to short-term coverage once the Trump administration’s relaxed rules for AHPs were overturned in court, and no longer appears to be available as of 2022).
Georgia FARM’s approach differs from both of these. It does not seem to be using an association health plan model, since those are not currently allowed to enroll sole proprietors (unless they have at least one additional employee enrolling in the plan). But the plan is guaranteed-issue and covers pre-existing conditions, so it also does not appear to be using the Tennessee/Iowa approach of relying on pre-ACA-style medical underwriting. The underwriting guide notes that sole proprietors without any other employees are not eligible for small group coverage (in keeping with ACA rules) and that “Any business structure only employing a husband and wife is not eligible for Small Group coverage on our SMART and ACA plans.” But it goes on to say that they “may be eligible for Georgia FARM depending on SIC code.“
Anthem has noted that the plan is in compliance with Georgia Department of Insurance requirements, and Georgia’s governor and insurance commissioner have both indicated their support for the FARM plans.
Although medical underwriting allows the FARM plans to provide lower-cost coverage for healthy groups, consumer advocates also worry that the ACA-compliant market could end up with an overall sicker risk pool if sole proprietors and small groups with fairly healthy employees opt to switch to the FARM plans.
In late September 2017, Commissioner Hudgens announced that the state had completed its review of the proposed 2018 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, 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):
At that point, Charles Gaba of ACA Signups calculated a weighted average rate increase of 31.5% if CSR funding continued, and 54.2% 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): 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% to make up for the lack of federal funding. But in Georgia, the impact was projected to be more significant, with a 23% 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.
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 increases; for most enrollees, larger subsidies covered all or most of the rate increase):
In late October, Avalere Health published a comparison of average premium changes from 2017 to 2018 in each state, and Georgia had among the largest increases. Avalere’s analysis found that the average silver plan in Georgia (before any subsidies are applied) was 48% more expensive in 2018, the average bronze plan was 33% more expensive, and the average gold plan was 44% more expensive. For perspective, the national averages were 34%, 18%, and 16%, respectively.
Premium subsidies were 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 cut off funding for CSR, the CSR benefits themselves have continued to be available to silver plan enrollees with income between 100% and 250% of the poverty level.
The following year, for 2019 coverage, Kaiser’s rate increase (an average of 14.7%) was more significant than the increases Georgia’s other insurers implemented. But Kaiser had been 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 noted that a significant portion of their rate increase was due to the fact that they began 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 address 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 continued to add the cost of CSR to on-exchange silver plans. And Ambetter switched 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. While the CSR approach varied significantly across Georgia’s four insurers for 2018, it became much more uniform for 2019:
Anthem offered plans in 75 counties in 2019, down from 85 in 2018. But their plans were 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 joined for 2019, they had competition from at least one other insurer. In the 41 counties where Anthem left after the end of 2018, Ambetter offered coverage in 2019.
An Urban Institute 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%, versus a national average of 16.5% — and that was in addition to the normal rate increases we would have seen without those changes).
Georgia lawmakers passed legislation in 2018 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 was signed into law by Governor Deal. The 2018 bill was 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 had balked at what they saw 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.
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.
In Georgia, at least seven insurers sell short-term health insurance plans.
Georgia plans to implement a partial Medicaid eligibility expansion in mid-2023, with a work requirement.
Since 2011, Georgia has required Medigap insurers to make their plans available to people under the age of 65.
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