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Georgia health insurance marketplace 2022 guide
Exchange sees record-high enrollment for 2022, five new insurers, and average rate decreases (due in part to new reinsurance program)
Georgia health insurance marketplace overview
Frequently asked questions about Georgia's ACA marketplace
Georgia opted to use the federal health insurance marketplace, HealthCare.gov. State government officials such as former Gov. Nathan Deal and former 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 was 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.
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.
But this is being challenged in the court system and re-evaluated by the Biden administration. Georgia did not respond to the Biden administration’s request for additional information, so the administration officially began reconsidering the state’s 1332 waiver in late 2021, with a public comment period that continued through early January 2022. It appears unlikely that Georgia will be able to move forward with eliminating the official exchange platform under the Biden administration, but the situation is still up in the air as of early 2022.
Georgia also received federal approval to operate a reinsurance program, which took effect for the 2022 plan year. Reinsurance is not controversial; 14 states have already implemented reinsurance programs, which are successfully keeping premiums in check. Reinsurance is less useful, however, now that the American Rescue Plan has 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 by Congress, the ARP’s subsidy enhancements will expire at the end of 2022, making reinsurance more important again).
The open enrollment period for 2022 coverage ran from November 1, 2021 to January 15, 2022.
Outside of that window, enrollments and plan changes for 2022 coverage 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.
As of 2022, there are 11 insurers that offer exchange plans in Georgia. Five of them are new for 2022: Friday Health Plans, Bright Health, Aetna, UnitedHealthcare, and Cigna (Aetna, UHC, and Cigna all participated in Georgia’s exchange previously, but left at the end of 2016).
The following insurers offer plans in the Georgia exchange as of 2022, with plan availability varying from one location to another:
- Ambetter from Peach State Health Plan (Centene)
- Blue Cross Blue Shield Healthcare Plan of Georgia
- Friday Health Plans (new for 2022)
- Bright Health (new for 2022)
- Aetna/CVS (new for 2022)
- UnitedHealthcare (new for 2022)
- Cigna (new for 2022)
Eleven insurers offering plans is a record high for Georgia’s exchange. There were nine participating insurers in 2015, but that had dropped to just four by 2018.
Insurer participation in Georgia’s exchange has varied considerably over the years:
- 2014: Five insurers offered coverage (Alliant Health Plans, Blue Cross Blue Shield of Georgia, Humana, Kaiser Permanente, and Peach State Health Plans/Ambetter)
- 2015: Nine insurers offered coverage, including four newcomers: Cigna, Coventry/Aetna, UnitedHealthcare, and Time Insurance
- 2016: Nine insurers offered coverage. Time/Assurant only offered exchange plans for one year, as they exited the health insurance market nationwide at the end of 2015. But Harken Health Insurance joined the Georgia exchange for 2016, so there were still nine carriers offering plans in 2016.
- 2017: Five insurers offered coverage. Several insurers left Georgia’s exchange at the end of 2016, including UnitedHealthcare, Aetna, Cigna, and Harken Health. Although there were still five participating insurers, most of southern Georgia had just one insurer (Blue Cross Blue Shield of Georgia, an Anthem company) offering plans in the exchange in 2017, while most of the northern part of the state had two or more participating insurers.
- 2018: Four insurers offered coverage. Humana exited Georgia’s market at the end of 2017, and stopped offering individual health insurance anywhere in the U.S. Although there were four insurers in the Georgia exchange for 2018, coverage areas were localized and most areas of the state only had a single insurer offering coverage. Anthem had considered withdrawing from the marketplace, but ultimately agreed to continue to offer coverage in 85 Georgia counties. The 85 counties were mostly rural areas that would have had no other insurer offering coverage in the exchange if Anthem had exited altogether. Alliant also remained in the exchange, with plans available in northern Georgia, and the other two Georgia insurance carriers — Kaiser and Ambetter — also continued to offer plans in the exchange, so Humana was the only insurer that left the exchange at the end of 2017.
- 2019: Four insurers offered coverage.
- 2020: Six insurers offered coverage, including two newcomers — Oscar and CareSource.
- 2021: Six insurers offered coverage.
- 2022: Eleven insurers offer coverage, including five new insurers (Friday Health Plans, Bright Health, Aetna, UnitedHealthcare, and Cigna. As noted above, Aetna, UHC, and Cigna had previously offered plans in the exchange, but exited at the end of 2016).
For 2022, according to ratereview.healthcare.gov, five of the existing insurers implemented average rate decreases for 2022:
- Alliant: 27.7% decrease
- Ambetter from Peach State Health Plan (Centene): 2.6% increase
- Blue Cross Blue Shield Healthcare Plan of Georgia: 6.4% decrease
- Kaiser: 5.5% decrease
- Oscar: 22.8% decrease
- CareSource: 10.2% decrease
As described below, Georgia has a new reinsurance program as of 2022, which was a significant factor that contributed to the lower premiums for 2022.
As noted above, there are also plans available from five additional insurers in 2022, with varying coverage areas.
Although there were some significant rate decreases for 2022, Ambetter has the largest market share and had a small overall average rate increase. Overall, the weighted average rate change for 2022, for existing insurers, amounted to a decrease of about 2.2% (the insurers had initially proposed an overall average increase of 0.7%, but some of the final rates were lower than initially proposed).
But as is always the case, weighted average rate changes don’t paint a full picture:
- They only apply to full-price plans, and most enrollees receive premium subsidies (as of February 2021, 90% of Georgia exchange enrollees were receiving premium subsidies, and that percentage is higher now that the American Rescue Plan has been implemented). For subsidized enrollees, the net rate change from one year to the next depends on their own plan’s rate change as well as changes in their subsidy amount (which depends on the cost of the benchmark plan and the enrollee’s projected income for the coming year).
- Overall average rate changes don’t account for the fact that premiums increase with age. A person who has individual market coverage for several years will continue to pay more each year — just due to the fact that they’re getting older — even if their health plan has average rate changes of 0% during that time.
- A weighted average looks at all of the plans and carriers together. But different insurers offer plans in each region, and each insurer’s rate change is different. So the specific rate change that applies to a given enrollee can be quite different from the average.
Enrollees in many areas of Georgia have more options from which to choose for 2022 coverage. This is beneficial in terms of plan choice, but it also makes it particularly important for enrollees to actively compare their plan options during open enrollment or any applicable special enrollment period. Here’s more about what to keep in mind when new insurers are entering the marketplace in a given area.
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):
- 2015: Average increase of 1%. 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.
- 2016: Average increase of 10.3%. The increases ranged from 2.7% for Kaiser to 29% for Alliant.
- 2017: Average increase of 32.8%. The increases ranged from 13.7 percent for Ambetter to 67.5 percent for Humana.
- 2018: Average increase of 54.2%. A significant portion of this was due to the Trump administration’s decision to eliminate CSR funding, but premium subsidies are much larger now as a result of that decision.
- 2019: Average increase of 3.9%. Average premiums would likely have dropped in 2019 if not for the elimination of the individual mandate penalty and the expansion of short-term health plans. The average benchmark premium (0n which premium subsidies are based) was only 1% higher for 2019 than it was for 2018.
- 2020: Average rate decrease of 0.9% for the four individual market insurers that already offered plans in 2019, plus the addition of two new insurers (Oscar and CareSource, both in the Atlanta metro area). Prior to 2020, CareSource provided Medicaid and CHIP (Peach Care for Kids) coverage in Georgia, but began offering exchange plans there as of 2020.
- 2021: Average rate increase of 4.8%. The average benchmark plan increased by 2% for 2021, and most of the state has at least one additional insurer offering coverage in the exchange (compared with 2020) due to coverage area expansions.
Georgia’s exchange reached a new record high enrollment for 2022, with 701,135 people signing up for private plans through the exchange during the open enrollment period that ended on January 15, 2022.
As is the case in most states that use HealthCare.gov, enrollment previously peaked in Georgia’s exchange in 2016. But although it declined in 2017, 2018, and 2019, it grew slightly in 2020, grew quite a bit in 2021, and ballooned for 2022.
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):
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Partial Medicaid expansion (postponed due to new rules under Biden administration), reinsurance, and the potential elimination of an exchange platform in Georgia
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 improving the state’s individual health insurance market.
The Trump administration ultimately approved both the 1115 waiver (for partial and conditional Medicaid expansion) and the 1332 waiver (for a reinsurance program effective in 2022 and the “Georgia Access Model” for the exchange starting in 2023; this would involve 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). But their future is uncertain under the Biden administration.
The Biden administration paused the implementation of the 1115 waiver and notified the state in late 2021 that federal approval had been revoked for the Medicaid work requirement and premium requirement. The state has postponed implementation of the partial Medicaid expansion and filed a lawsuit in early 2022 against the Biden administration in response to the rule changes.
A lawsuit challenging the Georgia Access Model was filed in January 2021 by Planned Parenthood Southeast and the Feminist Women’s Health Center; it was assigned to Judge James E. Boasberg of the federal district court for DC (Boasberg is the judge who overturned Medicaid work requirements in Arkansas, New Hampshire, and Michigan). In addition to the legal challenge, the Biden administration is re-evaluating the Georgia Access Model, in light of the American Rescue Plan and the executive orders that President Biden has signed in an effort to strengthen the ACA. The federal government accepted public comments starting in late November 2021, through January 9, 2022, and will use the comments to help determine whether the Georgia Access Model still conforms to the rules for 1332 waivers and the updated federal laws.
Here’s an overview of what’s included in Georgia’s 1115 and 1332 waivers:
1115 waiver: Partial expansion of Medicaid
As if 2922, Georgia is one of 12 states where Medicaid has not yet been expanded. 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.
This would mean that the state would technically no longer have a Medicaid coverage gap. But the state only anticipated that 50,000 people would gain coverage under the partial Medicaid expansion, and there are an estimated 269,000 people are 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 called 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 would receive its normal federal matching rate for the newly eligible population, and people with income over the poverty level would 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 their proposal for full federal Medicaid expansion funding despite partial expansion, so Utah transitioned to full Medicaid expansion as of 2020.)
As of 2022, Georgia’s partial Medicaid expansion implementation has been paused. The Biden administration withdrew approval for the work requirement and premium requirement in late 2021. And in early 2022, the state of Georgia sued the Biden administration over the rule changes. For the time being, nothing has changed about Medicaid access in Georgia; even the partial expansion of Medicaid has not been implemented.
1332 waiver: Reinsurance and the Georgia Access Model
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 newly approved 1332 waiver goes beyond that. Under the terms of the 1332 waiver (which is being re-evaluated by CMS in 2022), Georgia plans to transition away from HealthCare.gov as of 2023.
But unlike other states that have recently transitioned away from HealthCare.gov, Georgia does not plan to create a state-run exchange. Instead, residents will use existing web brokers and health insurers to sign up for health coverage, without a centralized exchange platform. The state has dubbed this approach the Georgia Access Model. Its future is uncertain, as it is being reconsidered by the Biden administration.
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 targets a 10% reduction in overall average premiums across the state, but like a model that has been successfully implemented in Colorado, Georgia’s plan is to use the reinsurance program to offset a higher percentage of claims in areas of the state where premiums are currently 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 2022), 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 2023, for people who earn more than 400% of the poverty level (the normal cap for subsidy eligibility, which was temporarily eliminated by the ARP).
Georgia Access Model (web brokers instead of HealthCare.gov) — being re-evaluated by the Biden administration in 2022
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 — will 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 will go 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. A new public comment period began in November 2021 and continued through January 2022, and the Biden administration may end up revoking approval for the state’s plan to move forward without a health insurance exchange.
There are concerns that what Georgia plans to do will 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 plans to stop using HealthCare.gov and switch to a system that relies on web brokers and insurers, but it will let the federal government continue to handle premium subsidies. The state’s system will send subsidy eligibility information to the federal government, which will continue to issue premium subsidies just as it does today, only for QHPs. Consumer advocates note that while there are 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 will be enrolling people in health coverage in Georgia — in lieu of a health insurance exchange — will include some that also offer non-QHPs (such as short-term health plans, fixed indemnity plans, etc), which could potentially lead 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 will essentially be 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 will potentially have a harder time ensuring that the coverage they’re buying is actually compliant with the ACA. The waiver approval notes 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 won’t “change drastically,” but consumers in Georgia will lose access to HealthCare.gov, leaving them with only web brokers, agents, brokers, and insurers as their means of enrolling in coverage. In short, this is 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 doesn’t add anything new to the mix — it just takes away the current exchange platform and the services it provides.
There are also concerns that people who qualify for Medicaid will be 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. And if and when Georgia’s proposed partial Medicaid expansion is granted approval, more low-income adults will be eligible for Medicaid in Georgia. But there are no commission payments for enrolling someone in Medicaid, and brokers/agents only get paid on commission. So there will be 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. Georgia enacted a law in 2014 that prohibits the state from establishing or operating a Navigator program. And the waiver approval includes 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 partners with Georgia Farm Bureau to offer medically underwritten plans
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).
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.
How Georgia's insurers handled the cost of CSR
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):
- Alliant: 31% if CSR funding continued; 53% if it didn’t
- Ambetter from Peach State Health Plan (a Centene company): 23.8% if CSR funding continued; 51% if it didn’t (Ambetter expanded their coverage area from 24 counties in 2017 to 44 counties in 2018). Ambetter had 133,943 members on ACA-compliant plans in 2017.
- Anthem Blue Cross Blue Shield of Georgia: 40.6% if CSR funding continued; 57.5% if it didn’t. BCBSGA had 79,366 members on ACA-compliant plans in 2017.
- Kaiser: 30.6% if CSR funding continued; 56.7% if it didn’t.
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 hikes; for most enrollees, larger subsidies will cover all or most of the rate increase):
- Alliant: 53% (cost of CSR was added to on-exchange silver plans)
- Ambetter: 50.8% (cost of CSR was spread across the premiums for all ACA-compliant Ambetter plans)
- Anthem: 57.5% (cost of CSR was added to silver plans)
- Kaiser: 30.8% (rates were based on the assumption that CSR funding would continue, so the cost of CSR was not added to premiums)
In late October, Avalere Health published a comparison of average premium changes from 2017 to 2018 in each state, and Georgia 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:
- Kaiser: Adding the cost of CSR to on-exchange silver plans.
- Alliant: Adding the cost of CSR to on-exchange silver plans.
- Ambetter: Adding the cost of CSR to on- and off-exchange silver plans.
- Anthem: Adding the cost of CSR to all silver plans. Anthem does not sell any silver plans off-exchange-only. So while their silver plans are available both on- and off-exchange, the plans are identical and the cost of CSR has been added uniformly to the silver plans.
Anthem 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).
Legislation to protect broker commissions, but only during open enrollment
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.
Georgia health insurance exchange links
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.
Other types of health coverage in Georgia
In Georgia, at least seven insurers sell short-term health insurance plans.
Georgia's partial Medicaid eligibility expansion takes effect in 2021, but with a work requirement and covering far fewer people than full expansion.
Since 2011, Georgia has required Medigap insurers to make their plans available to people under the age of 65.
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