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

COVID-related enrollment window continues through August 15, 2021; US Health & Life joining marketplace for 2022

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Key takeaways

Indiana exchange overview

Indiana relies on the federally facilitated exchange/marketplace, so residents enroll through HealthCare.gov. Three insurers offer plans in the exchange as of 2021, including Celtic/Ambetter and CareSource, as well as Anthem, which rejoined the exchange for 2021 after previously exiting at the end of 2017. For 2022, US Health and Life is joining the exchange, bringing the total number of participating insurers to four.

Indiana is one of just three states where insurers must add the cost of cost-sharing reductions (CSR) to plans at all metal levels as of 2021 (Mississippi and West Virginia also require this). In most states, the cost of CSR is added only to Silver plan rates, which results in larger premium subsidies and more affordable coverage for most enrollees. West Virginia will switch to this “silver loading” approach for 2022, but Indiana will continue to require the cost of CSR to be spread across all plans.

136,593 people enrolled in private individual market plans through the Indiana exchange during the open enrollment period for 2021 coverage, and more than 16,000 enrolled in the first three-and-a-half months of the COVID-related special enrollment period in 2021 (more than double the normal enrollment volume during that time frame).

Indiana is one of the states where enrollment declined from 2020 to 2021 (as opposed to a nationwide increase), with about 3.7% fewer enrollees in 2021. And the 2021 enrollment is down nearly 38% from the exchange’s peak enrollment in 2015, when more than 218,000 people enrolled. But that decline has to be considered in conjunction with the fact that Medicaid expansion in Indiana didn’t take effect until 2015 (February 2015 was the earliest available effective date), so people who have since enrolled in Medicaid were instead enrolled in heavily subsidized QHPs through the exchange in early 2015, and subsequently transitioned to Medicaid. As of January 2021, Medicaid enrollment was 59% higher in Indiana than it was at the end of 2013 (that’s up from about 30% as of early summer 2020; the COVID pandemic has driven up Medicaid enrollment nationwide, and particularly in states where Medicaid has been expanded under the ACA).

The expansion of short-term health plans is among the factors related to lower marketplace enrollment in Indiana. The state used to limit short-term health plans to six months, but enacted new legislation in 2019 to allow short-term plans to have initial terms of up to 364 days, and to be renewable (if an insurer chooses to offer that option) for a total duration of up to three years. This allows some healthy people to use short-term plans as de facto substitutes for ACA-compliant plans, despite the fact that they do not provide the same level of coverage.

And as described in more detail below, Indiana enacted legislation that allowed medically-underwritten Farm Bureau health plans to be sold in the state as of 2021. These plans can also function as a substitute for real health insurance, if the applicant is healthy enough to meet the medical underwriting standards.


When can I enroll in health insurance in Indiana?

Although open enrollment for 2021 coverage ended in December 2020 in Indiana, there’s a one-time enrollment window, which runs from February 15 to August 15, 2021, designed to address the ongoing COVID pandemic. A qualifying event is not necessary in order to enroll or make a plan change during this window, and plan selections made during the COVID-related enrollment window will take effect the first of the following month.

The enrollment window can be used by people who are uninsured or under-insured (maybe because they’re enrolled in something like a short-term health insurance plan or a health care sharing ministry plan). But it’s also an opportunity to make a plan change, if you already have coverage through the exchange in Indiana and would prefer a different plan for the remainder of 2021. This gives people — including anyone who has received unemployment compensation in 2021 — an opportunity to take advantage of the enhanced premium subsidies that are available as a result of the American Rescue Plan.

After August 15, 2021, Indiana residents will need a qualifying event to enroll or make a plan change for 2021. The next open enrollment period, for 2022 coverage, begins November 1, 2021.

But Indiana has expanded Medicaid, which means that in most cases, people whose monthly household income drops below 138% of the poverty level are eligible for Medicaid (this translates to about $1,482/month for a single individual). And enrollment in Medicaid continues year-round, without a need for a qualifying event.


Average proposed rate decrease of 1.65% for 2022; US Health and Life joining the marketplace; Anthem expanding coverage area

Four insurers will offer coverage in Indiana’s exchange for 2022. US Health and Life is joining the exchange, and the three existing insurers will all continue to offer coverage. The following average rate changes have been proposed, amounting to an average rate decrease of 1.65%:

  • Anthem: 2.8% increase
  • Caresource: 0.1% decrease
  • Celtic/MHS/Ambetter: 3.5% decrease
  • US Health and Life: New to the marketplace

Anthem is expanding its coverage area dramatically, to cover 45 counties in 2022 (up from just three counties in 2021). US Health and Life will offer plans in 30 counties. The other two insurers will both continue to offer plans statewide.


According to the rate filings for 2022, the Indiana Department of Insurance is still instructing insurers to spread the cost of cost-sharing reductions across all plans (broad loading) as opposed to adding the cost only to silver plans (silver loading).

Nearly all states allow or instruct insurers to silver load, as that has the effect of increasing premium subsidies for everyone in the market, and making bronze and gold plans particularly affordable. But Indiana has continued to broad load ever since the Trump administration cut off federal funding for cost-sharing reductions at the end of 2017. West Virginia and Mississippi were also still requiring this as of 2021, but West Virginia is allowing silver loading as of 2022 (Delaware and Colorado had also required broad loading in 2018, but subsequently shifting to silver loading).

rate changes in previous years

Here’s a look at how average premiums have changed in Indiana’s individual market since ACA-compliant plans debuted in 2014:

2015: Average increase of 5%

Premiums increased by an average of about five percent in 2015, according to an Indiana Department of Insurance representative. A study by The Commonwealth Fund matched that estimate. The 2015 increase was much more modest than in the years leading up to the passage of the Affordable Care Act.

2016: Average increase of just 0.7%

Across the 8 carriers that continued to offer plans in the exchange in Indiana, the Department of Insurance calculated an approved weighted average rate increase of 0.7% for 2016 (they also posted a complete list of their individual and small group market carriers and their approved rate changes for 2016). Although Indiana’s average rate increase for 2016 was considerably lower than the national average, that also has to be viewed in light of the fact that premiums in Indiana were higher than the national average in 2014 and 2015.

Indiana was one of just four states using Healthcare.gov where the average benchmark premium was lower in 2016 than it was in 2015. And the drop was more significant in Indiana than any of the other states, at 12.6%. But benchmark premiums only tell part of the story, since the benchmark plan can change from one year to another, and it’s just one plan out of many that are offered in the exchange.

2017: Average increase of almost 19%

Indiana’s marketplace lost several insurers at the end of 2016. For the four remaining carriers that offered plans in the Indiana exchange in 2017, the approved average rate increase ended up being 18.9%, ranging from a 5.3% decrease for Celtic/Ambetter, to a 29% increase for Anthem BCBS.

Indiana was again notable in that it was one of only two HealthCare.gov states where the average benchmark (second-lowest-cost silver) plan premium was lower in 2017 than it was in 2016. Average benchmark rates in Indiana were 3% lower in 2017, while the average across all HealthCare.gov states was a 22% increase. For a 27-year-old, the average benchmark plan in Indiana was just $229/month (before subsidies) in 2017, versus $296/month across all HealthCare.gov states.

But in order to get the lower rates, or even to avoid a significant rate increase, many enrollees had to pick a different plan for 2017. The plans available in 2017 were all HMOs with narrower networks than some enrollees were used to having. And Anthem, which had the most name-brand recognition, had the highest premiums.

2018: Average increase of 24%, due in large part to CSR defunding (cost of CSR spread across premiums for all plans)

Indiana’s exchange dropped to just two participating insurers as of 2018: CareSource and Ambetter/Celtic. In early October, the Indiana Department of Insurance published the approved average rate changes, which were unchanged from the revised rate proposals that insurers filed in August, and amounted to an average increase of nearly 24% (about 20% for CareSource and 35.7% for Ambetter/Celtic). The weighted average rate increase didn’t account for the fact that the majority of the exchange enrollees in Indiana had to switch to a different plan for 2018, due to the departure of Anthem and MDwise from the exchange.

Notably, the approved rate changes were based on the assumption that funding for cost-sharing reductions (CSR) would not continue in 2018. The filings that the insurers had submitted earlier in the year (with an average increase of just 7.7%) were based on the assumption that CSR funding would continue, so the revised rate changes were significantly larger. And soon after Indiana approved the revised filings, the Trump administration announced that federal funding for CSR would end immediately.

As noted above, Indiana directs insurers to spread the cost of CSR across premiums for all ACA-compliant plans, on and off-exchange, instead of adding it only to silver-plan rates (as most states do). The Indiana Department of Insurance noted that their decision to spread the load across all plans was an effort to keep the price variations between each metal level somewhat consistent, so that silver plans would still be less expensive than gold plans, for example. But the result is that there is no way for people who don’t get premium subsidies to escape the additional cost, as it is built into all plans, both on and off-exchange.

2019: Average increase of 2.6%

Both exchange insurers in Indiana expanded their coverage areas for 2019, giving people in most counties the option to pick from either insurer. The average approved rate increase in Indiana’s individual market was 2.6% for 2019: An average increase of 5.4% for CareSource, and an average decrease of 0.5% for Celtic/Ambetter.

In areas where Ambetter/Celtic entered the market, they generally priced their plans below the prices of the existing plans, which means the benchmark rates decreased for 2019. That resulted in lower subsidies, because the subsidies don’t need to be as large in order to get the after-subsidy premium for the benchmark plan down to an affordable level. But it also means that people in some parts of Indiana needed to be particularly careful when renewing their coverage for 2019, as their subsidy might have been a lot smaller than what they were getting in 2018.

2020: Average increase of 13.5%

Two insurers offered plans in Indiana’s exchange in 2020, with plans available statewide from both insurers (Celtic already offered plans statewide in 2019, but CareSource expanded from 79 counties to 92 counties as of 2020).

In July 2019, the Indiana Department of Insurance published proposed average rate changes for CareSource and Celtic. Rates were adjusted during the summer, and the following average rate increases were eventually approved by state regulators:

  • CareSource (83,242 members): 4.9% average increase
  • Celtic (MHS/Ambetter): 18.9% average increase

Anthem, which only offered an off-exchange catastrophic plan in Benton, Jasper, Newton, Warren, and White counties as of 2020, increased their average rates by about 3% for 2020. But the filing noted that they only had 28 enrollees in 2019, so they were essentially a non-entity in Indiana’s ACA-compliant individual market at that point (Anthem rejoined the exchange in three counties in northwestern Indiana for 2021).

Across all three insurers, Indiana’s Department of Insurance said that the average rate increase was just under 10% for 2020, but at ACA Signups, Charles Gaba calculated a weighted average increase of 13.5%.

2021: Average increase of 10.5%

Anthem rejoined the exchange in Indiana for 2021, with plans that available in the northwestern part of the state, in Lake, LaPorte, and Porter counties. Anthem previously offered on-exchange plans in Indiana, but left the exchange after the end of 2017 and only offered an off-exchange catastrophic plan from 2018 through 2020, in five counties (the off-exchange catastrophic plan continues to be offered in those five counties in 2021).

Anthem joined the exchange’s two existing insurers — CareSource and Ambetter — so there are three participating insurers in the Indiana exchange in 2021. Anthem’s plans are available in three counties, while CareSource and Ambetter both continue to offer coverage statewide. The following average rate changes were filed by the insurers, and approved by regulators:

  • CareSource: 4.28% average increase (48,660 members as of 2020)
  • Celtic: (MHS/Ambetter): 14.32% average increase (71,110 members as of 2020)
  • Anthem: 0.26% average decrease (Anthem’s filing indicated that they only had four members enrolled in their existing off-exchange catastrophic plan as of 2020; all of their on-exchange products were new for 2021)

According to the Indiana Department of Insurance, the overall average proposed rate increase for 2021 was 10.5% (10.2 percent by our calculations), and the rates were approved as-filed. Indiana’s average percentage rate increase was among the most substantial in the nation for 2021, but average premiums in the state are still only slightly above average as of 2021.

Indiana enacted legislation to allow Farm Bureau to sell medically underwritten plans in 2021

In March 2020, Indiana Governor Eric Holcomb signed SB184 into law, allowing the Indiana Farm Bureau to sell medically underwritten health plans. The approach is similar to the Farm Bureau plans that have long been sold in Tennessee. The plans became available for purchase starting in October 2020, with coverage effective in 2021. As of late January 2021, Indiana Farm Bureau reported that they had received 1,718 applications for coverage.

Medically underwritten Farm Bureau plans are also allowed to be sold in Iowa and Kansas, and South Dakota will soon follow suit. Because they’re medically underwritten and not required to provide the same level of coverage as ACA-compliant plans, they tend to be less expensive than ACA-compliant health plans. The laws in the states that allow these plans are specific in exempting them from state insurance regulation, which is exactly what Indiana’s new law specifies: Under the terms of SB184, the Farm Bureau coverage “is not insurance” and “is not subject to the regulatory authority of the department of insurance under this titel or any other provision of Indiana law.”

Because medically underwritten plans tend to appeal to healthy applicants, there are concerns that they can weaken the ACA-compliant risk pool by attracting healthy people who would otherwise have ACA-compliant coverage.

Enrollment in Indiana’s exchange: 2014-2021

Exchange enrollment peaked in Indiana in 2015, and has steadily declined since then, dropping by almost 38 percent as of 2021:

Some of the enrollment decrease in 2016 was likely due to the fact that Medicaid expansion in Indiana didn’t take effect until February 2015; low-income residents who were enrolled in heavily subsidized exchange plans in 2015 had transitioned to Medicaid by 2016.

Enrollment decreases in subsequent years are due to a variety of factors, including higher premiums for people who don’t get premium subsidies, a shorter enrollment window (just over six weeks, instead of the three-month+ window that was available in earlier years), the expansion of short-term health plans (Indiana has agreed to go along with those rules as of mid-2019), the Trump administration’s decision to sharply reduce funding for HealthCare.gov’s outreach and enrollment assistance, and the elimination of the individual mandate penalty at the end of 2018.

Insurer participation in Indiana’s exchange: Nine insurers by 2015, only two from 2018 – 2020, but three again in 2021 and four in 2022

Indiana residents had many more choices on the federal marketplace for 2015 that they did in 2014. The number of insurers more than doubled, going from four to nine. And, the number of available plans jumped from 278 to 975.

According to the Indiana Department of Insurance, rughly 85 percent of Indiana’s ACA-compliant individual plans had been sold through the exchange in 2015, and Anthem Blue Cross Blue Shield had about 65 percent of the on-exchange market share in 2015.

Humana exited the individual market in Indiana at the end of 2015, but Humana didn’t participate in the exchange previously, so it was only the off-exchange market that they exited.

In addition to Humana, Time/Assurance exited the market (nationwide) at the end of 2015. Unlike Humana, Time did offer plans in the exchange in 2015.

Coordinated Care appeared on Indiana’s list of carriers as a new off-exchange carrier for 2016. Coordinated Care offered on-exchange plans in 2015, but they cross-walked all of their exchange business to Celtic Insurance for 2016. They came to an agreement with CMS that called for them to maintain one ACA-compliant Coordinated Care plan, available outside the exchange. It’s a platinum plan, and they did not actively market it.

UnitedHealthcare offered plans only outside the exchange in 2016 (United’s subsidiary, All Savers, did offer on-exchange plans), but exited the individual market entirely in Indiana at the end of 2016. And four on-exchange insurers — All Savers (UnitedHealthcare), Southeastern Indiana Health Organization, Physicians Health Plan, and Indiana University Health Plans — exited the market in Indiana at the end of 2016. As a result of insurer exits and plan redesigns, there were no PPO options available in the individual market in Indiana by 2017.

The Indiana Department of Insurance confirmed that Aetna filed rate proposals to join the Indiana exchange for 2017, and was planning to have coverage options available both on and off-exchange when open enrollment began on November 1, 2016. But that plan was scuttled in early August, when Aetna announced that they were not going to expand into any new exchanges for 2017.

When rates and plans were initially filed for 2018, there were four counties in Indiana where no insurers were planning to offer coverage in the exchange: Decatur, Jackson, Wayne, Grant. But in early August, CareSource agreed to remain in Grant, Decatur, and Jackson counties. Wayne County did not have any insurers slated to offer coverage at that point, but by mid-August, Celtic/Ambetter had agreed to offer coverage in Wayne County (Wayne County has 67,000 residents, and 1,166 of them enrolled in exchange plans for 2017).

Celtic/Ambetter’s revised filing also included coverage for Decatur and Jackson counties, although CareSource was the only insurer that filed to offer coverage in Grant County. CareSource later submitted a revised filing that included Wayne County — so although Wayne County residents were initially facing the prospect of having no insurers in the exchange in 2018, they ended up having two (CareSource and Celtic/Ambetter).

Anthem and MDwise, both of which offered plans statewide in the exchange in 2017, opted to leave the exchange at the end of 2017. According to the Indy Star, 46,000 Indiana residents had exchange plans from Anthem in 2017, and 30,800 had exchange plans from MDwise.

MDwise exited the individual market altogether. But Anthem has continued to offer just one off-exchange catastrophic plan in five counties (Benton, Newton, White, Jasper, and Warren). This is the same strategy that Anthem used in Virginia, Ohio, Wisconsin, and Nevada; by keeping one off-exchange plan, the insurer prevented a statewide market exit, which would preclude a return to the state’s individual market for five years under federal rules that predate the ACA. With the off-exchange plan still available in a small portion of the state, Anthem maintains the option to return to the Indiana market at any time in the future, should they choose to do so.

So all of MDwise’s individual market enrollees and virtually all of Anthem’s individual market enrollees lost their coverage at the end of 2017. Between the two insurers, more than 100,000 people in Indiana saw their plans terminated at the end of 2017.

From 2018 through 2020, Celtic/Ambetter and CareSource were the only insurers offering plans in the Indiana exchange. But their coverage areas grew during that time, and both were offering coverage statewide as of 2020 (in 2018, CareSource offered plans in 75 counties and Celtic offered plans in 43 counties; those grew to 79 and 92 counties, respectively, by 2019, and both insurers will offer plans in all 92 counties in 2020).

As of 2021, Anthem has rejoined the exchange, offering plans in Lake, LaPorte, and Porter counties. Anthem’s coverage area will grow to 45 counties as of 2022, and US Health and Life is also joining the exchange for 2022, bringing total insurer participation up to four.

How Indiana approached exchange implementation

Indiana is among the majority of states that opted to use the federal health insurance marketplace, HealthCare.gov. While former Gov. Mitch Daniels was a critic of the Affordable Care Act, he refrained from making a final decision about the state’s marketplace and asked the three gubernatorial candidates for their opinions. Following the election, then Gov.-elect Mike Pence weighed in and rejected both the state-run and partnership models.

In 2014, Indiana Attorney General Greg Zoeller and 39 school districts filed a suit challenging premium subsidies in the state as it did not operate its own health insurance exchange. A U.S. District Court judge delayed ruling on the suit, given that the U.S. Supreme Court was taking up the issue in King v. Burwell (ultimately, the Supreme Court ruled that subsidies are legal in states that use Healthcare.gov)

In January 2015, several state representatives introduced HB1479 to “prohibit any agency of the state from assisting in the enforcement of the Patient Protection and Affordable Care Act.” The bill would have prohibited Indiana insurance officials from enforcing violations of the Affordable Care Act and would have allowed state residents subject to the federal penalty for not having health insurance to deduct the penalty amount on their state taxes. The bill did not pass the House Ways and Means Committee however, so it was not taken up in the full House.

Medicaid expansion began in 2015

In January 2015, Indiana received federal approval of its waiver for Medicaid expansion. The Healthy Indiana Plan, or HIP 2.0, requires most newly eligible beneficiaries to contribute to a health savings account (HSA) and to pay co-payments for emergency room visits for non-emergency care. HIP 2.0 is fairly complicated, with various contribution and benefit levels based on income and whether or not a beneficiary makes the required HSA contribution.

Indiana began accepting HIP 2.0 applications immediately after receiving approval, with coverage effective February 2015. Indiana officials estimated that 350,000 residents would be eligible for the program. According to a state press release, the approval of HIP 2.0 replaces traditional Medicaid coverage for Indiana’s non-disabled, non-elderly adults.

More than 235,000 previously uninsured residents had enrolled in HIP 2.0 in its first year, and by mid-2019, total Medicaid/CHIP enrollment in Indiana was 30 percent higher than it had been at the end of 2013.

Indiana health insurance exchange links

HealthCare.gov
800-318-2596

Affordable Care Act Resources on IN.gov

State Exchange Profile: Indiana
The Henry J. Kaiser Family Foundation overview of Indiana’s progress toward creating a state health insurance exchange.

Indiana Department of Insurance
Assists consumers who have purchased insurance on the individual market or who have insurance through an employer who only does business in Indiana.
(800) 622-4461 / idoi@idoi.in.gov


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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