- Special enrollment window in 2021 continues through August 15 (no qualifying event necessary)
- Georgia received CMS approval for 1115 and 1332 waivers to partially expand Medicaid, create a reinsurance program in 2022, and eliminate the use of HealthCare.gov in the state as of 2023. But the Biden administration has paused the 1115 waiver, and the elimination of the exchange has triggered a lawsuit and a possible re-evaluation by the Biden administration.
- 2021 rates and plans, plus a look back at rate changes in prior years.
- Anthem is partnering with Farm Bureau to offer medically underwritten plans for sole proprietors and small groups involved in agriculture.
- Short-term health plans can be sold in Georgia with initial plan terms up to 364 days.
- Georgia insurers took varying approaches to the CSR funding issue in 2018, but all were adding the cost of CSR to Silver plan rates by 2019.
- The impact of new insurers joining the exchange: It’s more complicated than it seems.
- A look at how insurer participation in Georgia’s exchange has changed over the years.
- Legislation enacted in 2018 to protect broker commissions.
Georgia exchange overview
Georgia uses the federally run health insurance exchange, so enrollments are completed via HealthCare.gov. In late 2020, Georgia received approval from the Trump administration 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 might be re-evaluated by the Biden administration; it’s unclear at this point whether Georgia will ultimately be able to move forward without having an official exchange platform.
Georgia has also received federal approval to operate a reinsurance program, which will take effect for the 2022 plan year. Reinsurance is not controversial; 14 states have already implemented reinsurance programs, which are successfully keeping premiums in check.
During the open enrollment period for 2021 health plans, 517,113 people signed up for private plans through the state’s exchange. That was more than 11% higher than the prior year, when 463,910 people enrolled, and the highest enrollment had been since 2016, when nearly 588,000 people enrolled.
After several years of insurer exits and fairly substantial rate increases, Georgia’s individual insurance market appears to be stabilizing. The average rate increase for 2019 was less than 4%, and average rates decreased slightly for 2020. And two new insurers — Oscar and CareSource — began offering coverage in Georgia’s exchange for 2020. For 2021, all six insurers continued to offer coverage, and average rates increased by less than 5%.
HHS estimated that 581,000 people in Georgia gained health insurance coverage from 2010 to 2015, as a result of the ACA. Georgia hasn’t yet expanded Medicaid under the ACA, so the state has not taken full advantage of the ACA’s provisions. There are currently an estimated 269,000 people in the coverage gap in Georgia — ineligible for premium subsidies because they earn too little, and ineligible for Medicaid because the state has not accepted federal funding to expand coverage. Georgia had planned to implement a partial expansion of Medicaid — with various strings attached — as of mid-2021, but the Biden administration has paused the implementation of this program, noting that the work requirement would be unrealistic during the ongoing COVID pandemic.
When can I enroll in health insurance in Georiga?
For people who purchase their own coverage in the individual/family market, enrollment and plan changes are normally limited to an annual open enrollment period in the fall, and special enrollment periods if and when a person experiences a qualifying event (these limited enrollment opportunities apply both on-exchange and off-exchange).
But because of the COVID pandemic and the enhanced premium subsidies created by the American Rescue Plan, there’s a one-time enrollment window in 2021 that runs through August 15. A qualifying event is not necessary during this window, and coverage will take effect the first of the month following enrollment. Georgia residents can use this window to newly enroll in coverage, or to switch from one plan to another (it’s advisable to contact the insurer first, to see if already-accrued out-of-pocket spending for 2021 will transfer to a new plan).
After August 15, a qualifying event will again be necessary in order to enroll or make a plan change for 2021. Open enrollment will start on November 1, 2021, for coverage effective January 2022.
Georgia has received federal approval for partial Medicaid expansion (without enhanced federal funding), reinsurance, and the elimination of an exchange platform in the state. But a lawsuit and reevaluation by the Biden administration stand in the way of implementation
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 has paused the implementation of the 1115 waiver. And 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 may also opt to re-evaluate the waiver approval before it’s slated to take effect.
Here’s an overview of what’s included in Georgia’s 1115 and 1332 waivers:
1115 waiver: Partial expansion of Medicaid
Georgia is currently one of 14 states where Medicaid has not yet been expanded (Oklahoma will expand Medicaid as of July 2021, under the terms of a ballot initiative passed by voters in 2020; Missouri is also supposed to expand Medicaid in mid-2021 as a result of a voter-approved ballot measure, but GOP lawmakers in the Missouri legislature are blocking funding, and the courts are likely to get involved).
Under the 1115 waiver that was approved by the Trump administration but paused by the Biden 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 no longer have a Medicaid coverage gap (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 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.)
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, Georgia will 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, but it’s future is uncertain in the both the legal system and the Biden administration’s CMS oversight.
Georgia’s reinsurance program will cover 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 that the state was now seeking federal approval for a reinsurance program that will take effect in 2022 (but with no changes to the other parameters of the program); this is what was approved by CMS in November 2020.
The reinsurance program will target 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.
Georgia Access Model (web brokers instead of HealthCare.gov)
Under the terms of the federal government’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 approval could also be rescinded or amended by the Biden administration. 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 public comments that were submitted regarding the Georgia Access Model were negative, and encouraged the state to keep the HealthCare.gov platform.
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.
2021 rates and plans
Georgia submitted its 1332 waiver proposal to CMS in late 2019, and CMS determined it complete in early February 2020. Around the same time, Governor Kemp sent CMS a letter asking them to pause their review of some aspects of the state’s proposal in order to focus on an expeditious review of the reinsurance portion of the proposal, as Georgia had been hoping to implement the reinsurance program as of 2021. But that was later delayed until the 2022 plan year, so rates for 2021 were based on the status quo; the reinsurance program won’t start to bring down rates until 2022.
Georgia’s six exchange insurers implemented the following average rate changes for 2021, some of which are quite a bit different from the rate changes the insurers initially proposed:
- Alliant: 4.87% decrease
- Ambetter from Peach State Health Plan (Centene): 9.76% increase
- Blue Cross Blue Shield Healthcare Plan of Georgia: 1.05% increase
- Kaiser: 19.02% decrease
- Oscar: 2.11% increase
- CareSource: 3.77% increase
Ambetter had the most significant rate increase, and also has the largest market share. At ACA Signups, Charles Gaba calculated an overall weighted average rate increase of 4.8%. As always, this applies to full-price plans; after-subsidy rates also depend on how the benchmark premium is changing in a given area. According to CMS, the average benchmark premium increased by just 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 (Centene/Ambetter, for example, is expanding into 27 additional Georgia counties for 2021).
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 percent. 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 percent. The increases ranged from 2.7 percent for Kaiser to 29 percent for Alliant.
- 2017: Average increase of 32.8 percent. The increases ranged from 13.7 percent for Ambetter to 67.5 percent for Humana.
- 2018: Average increase of 54.2 percent (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 percent. 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 percent higher for 2019 than it was for 2018.
- 2020: Average rate decrease of 0.9 percent 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.
Anthem is partnering 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 percent if CSR funding continued; 53 percent if it didn’t
- Ambetter from Peach State Health Plan (a Centene company): 23.8 percent if CSR funding continued; 51 percent 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 percent if CSR funding continued; 57.5 percent if it didn’t. BCBSGA had 79,366 members on ACA-compliant plans in 2017.
- Kaiser: 30.6 percent if CSR funding continued; 56.7 percent if it didn’t.
At that point, Charles Gaba of ACA Signups calculated a weighted average rate increase of 31.5 percent if CSR funding continued, and 54.2 percent 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 percent to make up for the lack of federal funding. But in Georgia, the impact was projected to be more significant, with a 23 percent 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 percent (cost of CSR was added to on-exchange silver plans)
- Ambetter: 50.8 percent (cost of CSR was spread across the premiums for all ACA-compliant Ambetter plans)
- Anthem: 57.5 percent (cost of CSR was added to silver plans)
- Kaiser: 30.8 percent (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 percent more expensive in 2018, the average bronze plan was 33 percent more expensive, and the average gold plan was 44 percent more expensive. For perspective, the national averages were 34 percent, 18 percent, and 16 percent, 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 percent and 250 percent of the poverty level.
The following year, for 2019 coverage, Kaiser’s rate increase (an average of 14.7 percent) 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 stopped offering coverage in the following counties after the end of 2018: Appling, Bacon, Ben Hill, Bibb, Bleckley, Brantley, Bryan, Bulloch, Camden, Candler, Coffee, Dodge, Dooly, Effingham, Evans, Glynn, Houston, Irwin, Jeff Davis, ones, Liberty, Long, McIntosh, Meriwether, Miller, Monroe, Montgomery, Peach, Pierce, Pulaski, Putnam, Screven, Tattnall, Telfair, Toombs, Treutlen, Troup, Twiggs, Wayne, Wheeler, and Wilcox.
But Anthem has rejoined the following counties for 2019, after exiting them at the end of 2017: Banks, Bartow, Chattooga, Cherokee, Cobb, COweta, Dawson, Dekalb, Douglas, Fannin, Fayette, Floyt, Forsyth, Franklin, Fulton, Gilmer, Gwinnett, Habersham, Hall, Hart, Henry, Lamar, Lumpkin, Pickens, Pike, Polk, Rabun, Stephens, Towns, Union, and White.
So in total, 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 Insitute 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 percent, versus a national average of 16.5 percent — and that was in addition to the normal rate increases we would have seen without those changes).
How the shifting plan options change your premium subsidy — some real-life examples
Sometimes the easiest way to understand the annual changes in premiums and plan options is to consider real-life examples. Let’s consider two counties in Georgia: Gordon, and Hancock. We’re going to look at example prices for a 45-year-old earning $35,000 (we’ll keep the person the same age in both 2018 and 2019, to compare apples to apples and avoid the inevitable premium increase that happens every time we get another year older). So all of the numbers in this example are specific to a 45-year-old who earns $35,000… if an applicant earns more or less than that, or if they’re older or younger than 45, the numbers will be different.
- In Gordon County, Ambetter and Alliant offered plans in 2019, whereas Alliant was the only exchange insurer in 2018.
- The subsidy amount in 2018 was $499/month.
- There were six plans available in 2018. After the subsidy was applied, their premiums ranged from $56/month to $315/month.
- The benchmark plan (Alliant SoloCare Silver PPO 40010) was about $769/month before the subsidy, and $271/month after the subsidy.
- The subsidy was much smaller in 2019, at just $141/month.
- There were 22 plans available for 2019. After the subsidy was applied, they ranged in price from $218/month to $630/month.
- The benchmark plan in 2019 (Ambetter Balanced Care 4) was about $419/month before the subsidy, and $277/month after the subsidy.
- ALL of the Ambetter plans available in 2019 were less expensive than any of the Alliant plans. There were eight Alliant plans for sale in 2019, and they were the eight most expensive options out of the 22 available plans.
- In Hancock County, only Blue Cross Blue Shield offered plans in 2019, as was the case in 2018.
- The subsidy amount in 2018 was $373/month.
- There were 13 plans available in 2018. After the subsidy was applied, their premiums ranged from $160/month to $726/month.
- The benchmark plan (BCBS’s Pathway X HMO 5300) was about $644/month before the subsidy, and $271/month after the subsidy.
- The subsidy amount in 2019 was $479/month.
- There were eight plans available in 2019, ranging in price from $0/month to $501/month. Three of the plans had $0 premiums, and one was just 77 cents/month.
- The benchmark plan (BCBS’s Pathway X HMO 2100 Online Plus) was $756/month before the subsidy, and $277/month after the subsidy.
These data include several key takeaway points:
- The after-subsidy price of the benchmark plan is the same for enrollees with equal incomes, regardless of where they live (and regardless of how old they are; a 60-year-old in Gordon County who earned $35,000 in 2019 received a subsidy of $509/month, but his after-subsidy cost for the benchmark plan was the same $277/month that our 45-year-old enrollees would pay).
- When an insurer is the only one participating in the exchange in a given area, they can design their plan offerings so that the second-lowest-cost silver plan (ie, the benchmark plan, on which subsidies are based) is priced much higher than the lowest-cost silver plan, the bronze plans, and even, in some cases, gold plans (as described above, this is a more recent phenomenon, triggered by the Trump Administration’s decision to eliminate funding for cost-sharing reductions, and the workaround that states and insurers implemented that involves adding the cost of CSR to silver plan rates). This was the case in Hancock County in 2019, and it’s why there were several free or very low-cost options available to some subsidized enrollees. Anthem adjusted their plan offerings so that their second-lowest-cost plan was a much more expensive option (it had a $2,100 deductible, instead of the $5,300 deductible policy that was the second-lowest-cost plan in 2018). So although Anthem’s average premiums decreased slightly for 2019, they picked a higher-priced plan and made it the second-lowest-cost silver plan, which resulted in larger subsidies for everyone in that area. This strategy doesn’t work as well in areas with multiple insurers, though, as they don’t know which insurer will have the benchmark plan until the rates are finalized.
- When an area gains a new insurer, enrollees will find that their premium subsidy drops sharply if the new insurer undercuts the existing market and offers lower-cost plans, including a new lower-cost benchmark plan (Phoenix, Arizona in 2019/2020 is another example of this). And if the new insurer doesn’t have a wide spread between their lowest-cost plans and the benchmark plan, people will end up paying more, after the subsidy, for the lowest-cost plans (but if they already had the benchmark plan and they switch to the new benchmark plan, their premiums will remain mostly unchanged, as long as their income doesn’t change). That’s what’s happened in Gordon County for 2019, with Ambetter’s entry into the market. Ambetter’s plans were less expensive than Alliant’s but they didn’t have as much of a price difference between their lowest-cost plan and the second-lowest-cost silver plan they offer (which became the new benchmark plan, since Alliant’s silver plans were much more expensive). That’s why our example person could get a plan in Gordon County for $56/month in 2018, but had to pay at least $218/month in 2019.
- But the entry of a new, lower-cost insurer is beneficial to those who don’t get premium subsidies. If our 45-year-old applicant in Gordon County earns $60,000 instead of $35,000, he’ll have to pay full price. In 2018, the full price options ranged from $555/month to $813/month. But in 2019, they ranged from $359/month to $771/month. So this particular applicant would have saved nearly $200/month if he switched from the lowest-cost 2018 option to the lowest-cost 2019 option.
Enrollment in Georgia’s exchange
As is the case in most states that use HealthCare.gov, enrollment peaked in Georgia’s exchange in 2016. But although it declined in 2017, 2018, and 2019, it grew slightly in 2020, and grew sharply in 2021. It’s still well below where is was in 2016, but significantly higher than it was over the last few years.
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):
- 2014: 316,543 people enrolled
- 2015: 541,080 people enrolled
- 2016: 587,845 people enrolled
- 2017: 493,880 people enrolled
- 2018: 480,912 people enrolled
- 2019: 458,437 people enrolled
- 2020: 463,910 people enrolled
- 2021: 517,113 people enrolled
Insurer participation in Georgia’s exchange
Georgia consumers shopping for health insurance on the marketplace had nearly double the number of insurers to choose from in 2015 as they did in 2014. In addition, three companies — as opposed to one in 2014 —offered policies statewide.
Nine insurers offered plans in the Georgia health insurance marketplace for 2015, including four that were new to the exchange for 2015. The returning companies from 2014 were: Alliant Health Plans, Blue Cross Blue Shield of Georgia, Humana, Kaiser Permanente, and Peach State Health Plans (Ambetter). The new entrants to the marketplace for 2015 were Cigna, Coventry/Aetna, UnitedHealthcare, and Time Insurance.
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.
However, all of those newcomers had left the exchange by the end of 2016:
- UnitedHealthcare: In April 2016, a Georgia state insurance office spokesperson confirmed that UnitedHealthcare would exit the exchange in Georgia at the end of 2016. This was not unexpected, given that United had hinted at the possibility of eventually pulling out of the exchanges in the fall of 2015, and had cut broker commissions in most states for 2016 in an effort to reduce sales. UnitedHealthcare’s market share in the Georgia exchange was relatively small in 2015, with 825 enrollees in plans through UnitedHealthcare Life Insurance, and 9,933 in plans from UnitedHealthcare of Georgia.
- Aetna: Aetna offered plans in 67 of Georgia’s 159 counties in 2016, but they exited the exchange at the end of 2016. They had somewhere between 70,000 and 90,000 on-exchange enrollees in Georgia.
- Cigna: Cigna also exited the exchange in Georgia at the end of 2016. Cigna had about 1,500 exchange enrollees in 14 counties in Georgia in 2016
- Harken Health: Harken Health joined the exchange in the Atlanta area for 2016, but exited at the end of the year and did not offer exchange plans in Georgia (or in Illinois, where they offered exchange plans in the Chicago area in 2016) in 2017. Harken continued to offer off-exchange plans in the Atlanta area, but only until mid-2017, when the insurer exited the market altogether.
So Georgia had five insurers participating in the exchange in 2017. As was the case in most states, however, insurer participation in localized: 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.
Humana exited Georgia’s market at the end of 2017, and is no longer offering individual health insurance anywhere in the nation. In Georgia’s exchange, Humana plans were only available in 2017 in Atlanta, Columbus, Macon, and Savannah. Humana had the largest percentage rate increase in the Georgia exchange for 2017, and their total exchange enrollment across 11 states was only about 150,000 people in 2017. So their exit at the end of 2017 was not unexpected, and did not have a dramatic impact.
In 2018, although there are four insurers offering plans in the Georgia exchange, only 14 of the state’s 159 counties have two insurers participating in the exchange; the rest of the counties have a single insurer offering coverage.
Blue Cross Blue Shield of Georgia (an Anthem company) was the only insurer offering coverage in 96 of Georgia’s 159 counties in 2017, and their continued participation in exchanges across the country was uncertain in the spring and summer of 2017. In May 2017, Blue Cross Blue Shield of Georgia filed plans to once again offer coverage statewide in 2018, but they indicated in June that they were planning to withdraw their filing and not offer 2018 coverage.
By early August, however, Anthem had reached an agreement with Georgia Insurance Commissioner Ralph Hudgens, in which they 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. The Georgia Office of the Insurance Commissioner confirmed that those 85 counties were specifically selected in the agreement between Hudgens and Anthem due to the fact that they would have been left with no insurer in 2018 if Anthem had proceeded with their initial plan to exit the Georgia exchange 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.
A full list of the counties where each insurer is offering plans in the Georgia exchange is available here. The counties shaded in yellow in the Ambetter column were new for Ambetter in 2018 (Ambetter’s 2017 service area included the 24 counties that aren’t shaded in yellow on the 2018 coverage area list). There were no counties without an insurer in the exchange in 2018, which would not have been the case if Anthem hadn’t agreed to remain in the exchange in 85 Georgia counties.
Earlier in 2017, Anthem had indicated that they were considering exiting a large number of the areas/states across the country where they currently offer coverage — a scenario that was obviously of great concern in a state like Georgia where there are no other options in much of the state. By late April, Anthem had said that they were planning to participate in the exchanges in 2018, assuming the Trump Administration continued to fund cost-sharing reductions (CSR). But by August, Anthem had announced that they would exit the exchanges in Indiana, Wisconsin, Ohio, and Nevada, and would scale back their participation in Georgia and California.
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 have balked at what they see 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.
Background on the marketplace in Georgia
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.
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.