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Idaho has a state-run health insurance exchange (Your Health Idaho) and eight carriers offer 2023 coverage through the marketplace, including two that are new for 2023 (Moda Health and St. Luke’s Health Plan). There are also four dental insurers that offer plans through the exchange, including one that’s new for 2023 (Guardian Life Insurance Company).
Idaho has a reinsurance program as of 2023, which kept overall average (pre-subsidy) premiums about 12% lower than they would otherwise have been. Average premiums would have increased without the reinsurance program, but instead, average premiums decreased by about 3.6% for 2023.
Idaho is the only state in the country where open enrollment ended in December, instead of extending into January (the deadline was December 15, 2022 in Idaho, but January 15 or later in the rest of the country). But open enrollment for 2023 coverage also began early in Idaho, starting October 15, instead of November 1, like the rest of the country.
Republican Gov. Butch Otter announced in December 2012 that Idaho would implement a state-run health insurance exchange, and HHS gave conditional approval of the state’s plan in early January 2013.
The state-run option was initially resisted by both the governor and many Republican legislators. Like those in other “red” states, Idaho leaders hoped the U.S. Supreme Court would find the Affordable Care Act (ACA) unconstitutional. However, after the Court upheld most elements of the ACA and a state task force in October 2012 strongly recommended a state-run exchange, Otter began leaning toward that option as preferable to a federally run exchange.
After Otter’s announcement in December 2012, lawmakers began considering legislation, and both chambers passed bills authorizing a state-run exchange in the first quarter of 2013. However, that left scant time to set up the exchange. So Idaho used the federal site (HealthCare.gov) for the first open enrollment period (for 2014 coverage), but transitioned to its state-run platform in time for the 2015 open enrollment period.
In December 2015, a Leavitt Partners study called Your Health Idaho a “model for state based adoption (of an exchange)” and noted that the exchange had a budget well below average, a “lean organizational structure” and “strong financial controls.” The Leavitt study also indicated that Your Health Idaho benefited from the fact that they used Healthcare.gov during the first open enrollment, and waited until the second open enrollment period to debut their own enrollment platform. That allowed them to obtain lower-cost, better-developed software solutions, with the benefit of hindsight in terms of seeing what worked and what didn’t for the other state-run exchanges during year one.
Idaho is the only state that initially opted to build its own marketplace but reject Medicaid expansion. But Idaho Medicaid was eventually expanded in 2020, thanks to a voter-backed ballot initiative that passed in 2018.
Idaho is unique in terms of its approach to open enrollment dates. It’s the only state in the country where open enrollment ends in December (instead of extending into January). But as of the open enrollment in the fall of 2022, Idaho has also opted to start the enrollment window early (in previous years, it began November 1, just like the rest of the country).
So open enrollment for 2023 coverage in Idaho ran from October 15 to December 15, 2022, with coverage effective January 1, 2023.
Outside of open enrollment, a qualifying event is necessary to enroll or make changes to your coverage.
For 2023 coverage, there are eight insurers that offer exchange plans in Idaho, which is a record high for the Idaho exchange. Molina joined the Idaho marketplace in 2022. And for 2023, St. Luke’s Health Plan and Moda Health joined.
The following insurers offer 2023 medical plans in the Idaho exchange, with plan availability varying from one location to another:
A new insurer was approved by the Idaho Department of Insurance for 2015: Mountain Health CO-OP, which is the Idaho branch of Montana Health CO-OP. The CO-OP joined Blue Cross of Idaho, BridgeSpan Health Company, PacificSource Health Plans, and SelectHealth, all of which returned to the exchange for 2015.
The same five carriers offered coverage in 2016 and 2017. But BridgeSpan exited the market at the end of 2017 (they initially planned to offer off-exchange plans in 2018, but ultimately left the individual market altogether), and SelectHealth reduced their coverage area for 2018.
Compared with the rest of the country, however, Idaho remained among the states with the most robust exchanges in terms of insurer participation for 2018. Most counties in the state had four insurers offering plans in the exchange, and 12 counties had three. There were only a handful of other states where most counties had four or more insurers offering exchange plans for 2018.
Your Health Idaho confirmed by email in December 2017 that while BridgeSpan enrollees and eastern Idaho enrollees with select Select Health plans were being mapped to comparable plans (assuming they didn’t pick their own new plan by December 15), there was no special enrollment period for BridgeSpan or SelectHealth members who had coverage through Your Health Idaho.
The exchange noted that the comparable plans selected on behalf of these enrollees were the least expensive plan at the same metal level as the consumer’s 2017 plan, and that this was based on guidance from the Idaho Department of Insurance. Enrollees with terminating BridgeSpan and Select Health coverage were notified of the impending plan cancellation and the plan that the exchange intended to map them to, and they were able to pick their own plan instead between November 1 and December 15. But there was not a special enrollment period for people who were mapped to a new plan by the exchange (this is in contrast to people in similar situations in states that use HealthCare.gov, where the special enrollment period is available, even after the exchange picks a replacement plan).
Other than BridgeSpan’s exit, Idaho’s exchange had very consistent insurer participation over its first several years. Blue Cross of Idaho, Mountain Health CO-OP, SelectHealth, and PacificSource all continued to offer plans in the exchange.
Starting in 2016, there were not any Platinum plans available in the Idaho exchange (that’s still the case as of 2023). Only about 2% of Idaho exchange enrollees selected platinum plans in 2015, and the carriers opted not to offer those plans starting in 2016, as they aren’t required by the ACA and clearly were not a popular choice among enrollees.
For 2021, Regence BlueShield of Idaho joined the exchange, after previously offering off-exchange plans. So there were five on-exchange insurers as of 2021: Regence, Blue Cross of Idaho, Mountain Health CO-OP, PacificSource, and SelectHealth. All five continued to offer coverage for 2022 as well, and were joined by Molina.
Idaho’s reinsurance program took effect in 2023, resulting in lower overall average premiums. Across the existing six insurers, the overall average rate change for 2023 was a 3.6% decrease. The insurers implemented the following average rate changes:
But weighted average rate changes aren’t always useful in terms of understanding how a given enrollee’s rate will change:
The Idaho Department of Insurance does not have the authority to prevent health insurers from implementing rates that are deemed unjustified. But they do have a review and negotiation process during which they analyze the rates that have been filed for the coming year and work with carriers to ensure that proposed rates are actuarially justified, and it’s common for final rates in Idaho to be considerably different from what the insurers initially propose.
Here’s a look at how premiums have changed in Idaho over the years. Note that these rate changes are calculated before subsidies are applied; for people who receive premium subsidies, the subsidies grow to keep pace with the benchmark plan in each area, largely offsetting changes in premiums.
2016: An estimated average rate increase of 20 percent, ranging from an 8 percent decrease for PacificSource, to a 26 percent increase for Montana Health CO-OP.
Kaiser Family Foundation analyzed data on benchmark plan (second-lowest-cost Silver plan) premium changes from 2015 to 2016 in metropolitan areas across the country. In Boise, they found that the average benchmark plan for a 40-year-old non-smoker would be increasing from $210/month to $273/month – a 30 percent increase, which is three times the average they found nationwide. But that’s before premium subsidies were applied; most enrollees receive subsidies, and the subsidies change to keep pace with the cost of the benchmark plan.
2017: Average increase of 24%, ranging from 15% for PacificSource, to 29% for SelectHealth.
2018: Average rate increase of 27 percent, but much of that was due to the termination of federal funding for cost-sharing reductions (CSR). The average approved rate increases for silver plans in Idaho (for on-exchange insurers) were much higher than the overall averages, at 44 percent (the average rate increase for bronze and gold plans was 11 percent and 9 percent, respectively).
2019: Average increase of 5%, ranging from a 1% decrease for SelectHealth, to a 10% increase for Blue Cross of Idaho and PacificSource. The cost of cost-sharing reductions continued to be added to silver plan rates in 2019.
2020: Overall, the average rate increase for 2020 was about 6%, versus the proposed overall average increase of 7% that insurers had initially proposed. Average rate changes ranged from a 1% increase for Regence (off-exchange only in 2020) to an 8% increase for SelectHealth.
2021: Overall, the average rate increase for 2021 was about 1%, although three of the state’s insurers reduced their average premiums for 2021.
2022: The Idaho Department of Insurance announced approved average rate changes in early October 2021, for coverage effective in 2022. The approved rates amounted to an overall average rate decrease of about 2%.
Here’s a look at how enrollment in private individual market plans (during open enrollment) through Your Health Idaho has changed each year:
Your Health Idaho’s enrollment reports (examples here and here) tend to have higher numbers than the CMS reports, because they include people who enrolled only in dental coverage, as well as those who signed up for medical plans (the CMS reports only count medical plans).
Nationwide, enrollment in the exchanges peaked in 2016 and has declined since then, for a variety of reasons. Some—like the Trump administration’s budget cuts for HealthCare.gov—don’t affect state-run exchanges like Your Health Idaho. But others, such as the elimination of the individual mandate penalty and the new federal rules that expand access to short-term health plans, have affected enrollment in Idaho. Premium increases have also played a role; although they’re mitigated by larger subsidies for people who are subsidy-eligible, people who don’t get premium subsidies must shoulder the full burden of rate hikes, and coverage has become unaffordable for some.
And for 2020, it was expected that enrollment in private plans through the exchange would decline significantly as a result of Medicaid expansion. People with income between 100 and 138% of the poverty level are now eligible for Medicaid in Utah instead of premium subsidies in the exchange. The “enhanced” short-term health plans that became available in Idaho as of 2020 may have also contributed to the decline in exchange enrollment.
For 2021, part of the decline in enrollment is related to the fact that people transitioned to Medicaid if their income dropped below 138% of the poverty level (even if only for a short time; Medicaid eligibility is based on current monthly income as opposed to annual income). And during the COVID public health emergency, states are not allowed to disenroll people from Medicaid unless the person requests it or moves out of state; eligibility redeterminations are not allowed (this is for states that are receiving the increased federal Medicaid funding during the pandemic; all states opted into this). But the drop in enrollment in Idaho was substantial, and far more than most other Medicaid expansion states experienced in 2021.
Enrollment rebounded in 2022, however, likely driven in large part by the enhanced affordability created by the American Rescue Plan.
Five insurers currently offer dental plans through the Idaho marketplace. Learn about dental coverage options in Idaho.
The Idaho Department of Insurance clarified that for 2018, “the proposed rate increases for silver-level plans on the exchange are significantly higher this year because cost-sharing reduction subsidies are assumed to not be funded by the federal government.” This assumption was correct, as the Trump Administration cut off CSR funding in October 2017, just before the start of open enrollment for 2018 coverage.
According to the Idaho Department of Insurance, insurers didn’t have leeway to create new, similar-but-not-identical off-exchange plans at the silver level for 2018 (that’s the approach that California and several other states used). Since on-exchange carriers that offer the same plan off-exchange are required to charge the same price on and off-exchange, the additional premium to cover the cost of CSRs was spread across the on and off-exchange silver plans in Idaho, unless the plan is offered only outside the exchange (this would be the case with all of Regence Blue Shield’s silver plans, since Regence doesn’t offer plans in the exchange).
Instead, insurers in Idaho created new “expanded bronze” plans, using the new de minimum range (-4/+5) that applies to bronze plan actuarial value starting in 2018 (this extended actuarial value range was part of the market stabilization rule that HHS finalized in April 2017). So insurers in Idaho began offering bronze plans with 65% actuarial value as of 2018. Compared with prior years’ actuarial value rules, this is in between a silver and a bronze plan, which have typically had actuarial values of roughly 70% and 60%, respectively.
For silver plan enrollees in the exchange who receive premium subsidies, the additional CSR-related premium load on silver plans is covered or mostly covered by commensurately larger premiums subsidies. And for enrollees in other metal levels who are receiving premium subsidies, net premiums are more affordable than they were in 2017, as the larger premium subsidies (to account for the CSR load on silver plans) can be applied to plans at other metal levels that don’t have the CSR load added to their pre-subsidy premiums.
For non-silver plan enrollees who aren’t receiving premium subsidies, the cost of coverage has increased in line with normal annual rate increases, but the CSR load isn’t a factor, since it’s only being added to silver plans.
For silver plan enrollees who aren’t receiving premiums subsidies, however, the full weight of the higher rates (driven in large part by the cost of CSR) began to apply in 2018. These enrollees could keep their silver plans, but many have found the new “expanded bronze” plans, on or off-exchange, to be a better — and much less expensive — fit. Expanded bronze plans continue to be an option in Idaho.
Premium subsidies (which are different from cost-sharing reduction subsidies) are based on the cost of silver plans in the exchange. So an approach like Idaho is taking (ie, applying the higher rates that come with a lack of CSR funding to silver on-exchange plans and the same silver plans offered off-exchange, rather than spreading them out across all plans) results in larger premium subsidies, as the subsidies grow to keep pace with the increasing silver plan premiums. Bronze and gold plans become an even better value for people who receive subsidies, as the larger subsidies are applicable to those plans too, despite the fact that the additional premiums to account for the lack of CSR funding is only added to silver plans.
The subsidies are actually just tax credits, which means the Trump administration really just took one hand to give to the other (ie, not funding CSRs, but having to pay out more in premium subsidies). The people who end up bearing the brunt of the rate increases are those who don’t qualify for premium subsidies.
And as noted above, the people who bear the brunt of the additional premiums are only those who purchase silver plans (on-exchange, or the same qualified health plan sold off-exchange) and don’t receive premium subsidies. Fortunately, as a result of the American Rescue Plan (extended by the Inflation Reduction Act) and the proposed family glitch fix, fewer people now find themselves ineligible for subsidies.
During President Trump’s time in office, there was considerable discussion about legislative and regulatory changes at the federal level that would allow individual and small group plans to be sold without complying with the full suite of ACA regulations. None of the legislative changes were enacted, although some of the regulatory changes were implemented (for example, the relaxed rules for short-term health plans).
States also have the option to submit 1332 waivers that (if approved) would allow them to get around some of the ACA’s requirements. But Idaho’s Department of Insurance opted to simply take the bull by the horns and issue a regulatory bulletin in 2018, outlining a new protocol for allowing insurers in Idaho to sell “state-based health benefit plans” that would avoid many of the ACA’s regulations. The bulletin came three weeks after Governor Butch Otter issued an executive order calling on regulators to devise methods for “restoring choice in health insurance for Idahoans.
University of Michigan law professor, Nicholas Bagley, called Idaho’s bulletin “crazypants illegal” and health policy experts expressed varying degrees of skepticism over the chances that the state’s new regulations would stand up to legal scrutiny. In March, after weeks of speculation over whether the federal government would step in to uphold federal law in Idaho, CMS sent a letter to Governor Otter and Idaho Insurance Commissioner, Dean Cameron, explaining that the “state-based” plans would run afoul of the ACA, and if Idaho were to proceed with implementing them, CMS would have to step in and enforce the ACA on behalf of the state. But CMS went out of their way to clarify that they don’t think the ACA is serving the people of Idaho well, and that they appreciate the state’s efforts to essentially circumvent the law. Idaho’s “state-based” plans were simply too much a stretch.
CMS clarified that if Idaho failed to enforce the ACA and CMS had to begin enforcing the law instead, the agency would issue cease and desist letters to any insurer offering “state-based” plans in Idaho (Blue Cross of Idaho had previously stated their intent to begin offering “state-based” plans under the terms of Idaho’s regulatory bulletin). If the insurer continued to offer the plans, it would be subject to financial penalties of up to $100 per day, per individual enrolled in the non-compliant plans.
But CMS went on to state that the agency believes that “with certain modifications,” Idaho’s “state-based” plans could instead be offered as short-term plans, which are exempt from the ACA’s regulations.
The federal government subsequently finalized new regulations that allow for much longer short-term plans, unless a state imposes its own restrictions. Although Idaho previously banned the renewal of short-term plans, legislation was enacted in Idaho in 2019 to allow for “enhanced” short-term plans, which are renewable if the policyholder chooses that option.
Blue Cross of Idaho was the first insurer to create “enhanced” short-term plans (labeled “Access” plans), and SelectHealth followed soon thereafter. The policies are guaranteed-issue, but with premiums based on medical history. They’re renewable for up to 36 months of coverage, and although they have a 12-month waiting period for pre-existing condition coverage, the waiting period can be reduced or eliminated if you had creditable prior coverage (this is how pre-existing condition waiting periods worked on employer-sponsored plans before the ACA eliminated them altogether).
The enhanced short-term plans have some features that resemble ACA-compliant plans, such as free preventive care and coverage for maternity care, mental health care, and prescription drugs, all of which are benefits that are often excluded on traditional short-term plans. But enhanced short-term plans have benefit caps, out-of-pocket caps that exceed the allowable limits under the ACA, and they base premiums on medical history, which isn’t allowed on ACA-compliant plans.
At Health Affairs, Katie Keith has an excellent overview of what Idaho’s bulletin would have allowed and the implications of what would have happened if insurers had started offering these “state-based” plans. In summary, the bulletin includes the following regulations:
Clearly, some of those provisions would align well with the concept of short-term plans, which is the option CMS encouraged Idaho to pursue in order to implement their proposal within the parameters of the ACA (since the ACA doesn’t apply to short-term plans).
In February, before CMS rejected Idaho’s proposal, Blue Cross of Idaho submitted five state-based plans to the Department of Insurance for review. The proposed BC of Idaho plans would have had $1 million annual benefit caps, would not have covered pediatric dental or vision, and one of the plans would not have included maternity coverage.
The plans would have had premiums that would have varied considerably depending on medical history: The Wall Street Journal reported that a healthy 45-year-old would pay about $194.67 a month in premiums, but a 45-year-old with a poorer medical history might be charged as much as $525.69/month in premiums (no premium subsidies would be available). For comparison, an ACA-compliant bronze plan from Blue Cross of Idaho would have pre-subsidy premiums of about $343.09/month for a 45-year-old, and those premiums don’t vary based on medical history (under the ACA, healthy people pay the same rates as sick people). For people who buy the ACA-compliant plans via Your Health Idaho, and who are eligible for premium subsidies, the subsidies offset a significant portion of the premium costs.
The state-based plans would no doubt have appealed to younger, healthier applicants, particularly those who don’t qualify for premium subsidies in the exchange (most exchange enrollees do qualify for premium subsidies, but everyone who buys individual market coverage off-exchange is paying full price, with no available subsidies). A healthy person would be drawn to the cheaper premiums, while a person with medical conditions will be better off keeping their ACA-compliant plan. This, in turn, would leave the ACA-compliant market with sicker, older enrollees, and higher premiums.
Under Idaho’s new rules, an insurer’s state-based and ACA-compliant risk pools would have to have been merged, but it’s unclear how well that provision would have been enforced. But since the state would have required insurers to offer ACA-compliant plans in order to offer state-based plans, and since premium subsidies via Your Health Idaho continue to be available (and grow to keep pace with premiums), the ACA-compliant market would have continued to exist alongside the “state-based” plans, albeit likely with fewer enrollees than it has to today. Assuming the people who would have remained in the ACA-compliant market are primarily those who are older, sicker, and/or receiving premium subsidies, the total federal outlay for premium subsidies would likely have grown, placing an additional burden on taxpayers.
Consumers who purchase state-based plans would ostensibly have been somewhat protected by the provision that requires insurers to transfer members to one of the insurer’s ACA-compliant plans if the member hits the state-based plan’s benefit cap. But rescission could have become a major issue in scenarios in which members do hit the benefit cap. Since these plans would have been medically underwritten, a person who ended up hitting the benefit cap (ie, a million dollars worth of claims during the year) could have been subject to significant post-claims underwriting.
Basically, the insurer would have been able to go back through the person’s medical records with a fine-toothed comb, checking to make sure that the person had been 100 percent honest when completing the initial medical underwriting questions. If the insurer found anything that the person hadn’t disclosed on the application, they would have potentially been able to rescind the policy for fraud or misrepresentation (this is still allowed under the ACA, but is much less of an issue on plans that don’t ask enrollees about their medical history). At that point, not only would the person retroactively lose their coverage, they also wouldn’t be eligible to switch to an ACA-compliant plan until the next open enrollment period.
It’s also unclear whether the out-of-pocket costs that the consumer had already paid would have been counted towards the ACA-compliant plan’s out-of-pocket exposure, or if the consumer would have been starting from zero mid-year in that scenario, assuming they were indeed able to transition to an ACA-compliant plan.
And it’s also important to note that consumers who select a state-based plan and then find out that it doesn’t cover as much as they thought it did would not have been able to switch to an ACA-compliant plan until open enrollment, unless they have a qualifying event. For example, the consumer might not notice that a particular state-based plan doesn’t cover maternity, especially since people have become accustomed to the concept of all plans covering maternity. In that case, she might only find out about the lack of maternity coverage if and when she becomes pregnant, and she would not be able to switch to an ACA-compliant plan until open enrollment.
This is an issue with short-term plans as well. A person who enrolls in a short-term plan and subsequently finds out that it doesn’t cover his or her medical needs cannot switch to an ACA-compliant plan until the next open enrollment. And since short-term plans are not considered minimum essential coverage, the termination of a short-term plan does not count as a qualifying event to trigger a special enrollment period for ACA-compliant plans.
Cameron and Otter expressed optimism in the face of the letter from CMS, noting that “we consider the letter an invitation from CMS to continue discussing the specifics of what can and cannot be included in state-based plans. We will consider all possible options and then continue discussions with CMS and HHS on how best to achieve our shared goals of reducing the costs of coverage and stabilizing our health insurance market.” As noted above, the state has largely shifted focus to enhanced short-term plans, but Cameron noted in late 2019 that Idaho “still may pursue the state-based plans.”
As part of their cost-saving plan, Your Health Idaho opted not to build a SHOP (small business) exchange enrollment platform, and instead relies on direct enrollment through health insurance carriers (with agents and brokers providing enrollment assistance) when businesses want to enroll in SHOP plans.
Your Health Idaho has a paper application that small businesses can complete, with contact information that the exchange can use to get in touch with the business and help them move forward with the enrollment process. But in general, Your Health Idaho recommends that small businesses reach out to a broker or agent for assistance with SHOP enrollment.
This approach saves the exchange from having to administer and fund a SHOP platform, and in hindsight, is probably a wise decision—SHOP enrollments nationwide have been relatively lackluster, and Idaho’s decision means that the exchange is not having to fund and maintain a low-use enrollment platform.
Your Health Idaho
State Exchange Profile: Idaho
The Henry J. Kaiser Family Foundation overview of Idaho’s progress toward creating a state health insurance exchange.
Idaho Department of Insurance
Answers questions about insurance bought on the individual market and insurance provided by an employer who only does business in Idaho.
(208) 334-4250 / toll-free (800) 721-3272
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.
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