Iowa health insurance marketplace guide 2023

Iowa operates a partnership exchange with the federal government. Iowa residents use the federal marketplace, HealthCare.gov, to compare and purchase coverage. The state is responsible for plan management, consumer assistance, and Medicaid eligibility determination. 72,240 people enrolled in health plans through the Iowa exchange during the open enrollment period for 2022 coverage.

Iowa’s plan management functions include selecting and monitoring the qualified health plans (QHP) that offer policies on the exchange. Iowa’s role in consumer assistance is education and outreach, coordinating the in-person consumer assisters, and overseeing the Navigator program. The federal government manages the exchange website and call center, and funds the Navigator program.

Federal Navigator funding was cut significantly for the fall 2017 open enrollment period (for 2018 coverage), as was funding for outreach and advertising for HealthCare.gov. In 2018, Iowa did not receive any navigator grants at all. But one Iowa organization, First Choice Services, received $100,000 in navigator funding in 2019, and another $100,000 in 2020. And in 2021, when Navigator funding was increased to a record high by the Biden administration, two agencies in Iowa received a total of more than $462,000 (First Choice Services, as well as Planned Parenthood of the Heartland). In 2022, during another round of record-high Navigator funding, those same two organizations received a total of more than $512,000.

The open enrollment period for individual/family health coverage runs from November 1 to January 15 in Iowa. Outside of open enrollment, a qualifying event is necessary to enroll or make changes to your coverage.

Our comprehensive guide to open enrollment explains what you need to know about open enrollment.

We also have a comprehensive guide to qualifying events and special enrollment periods. 

There are three insurers that offer exchange plans in Iowa, with plan availability varying from one location to another:

• Oscar
• Medica
• Wellmark

In 2014, plans were available in Iowa’s exchange from Aetna (Coventry), Avera, CoOpportunity, and Gunderson. Coventry and CoOpportunity offered plans statewide, while Gunderson’s plans were only available in five northeastern counties and Avera’s plans were only available in nine northwestern counties.

Early in the open enrollment period for 2015 plans, Coventry and CoOpportunity Health both offered plans statewide in the Iowa exchange, and Avera and Gunderson continued to offer plans in the northern corners of the state. But CoOportunity stopped offering policies in late December 2014 (CoOpportunity had stopped offering private plans to Medicaid expansion enrollees as of November, and their 9,700 members in that program had transitioned to Iowa’s fee-for-service Medicaid program instead). CoOportunity was a CO-OP health insurer formed with funding through the Affordable Care Act. CoOpportunity got into financial difficulty after higher than expected enrollment and claim costs in 2014, and was subsequently liquidated, leaving Coventry as the only marketplace insurer available in most of Iowa.

Avera did not offer health insurance in the Iowa exchange in 2016 (their plans were all off-exchange). But Medica joined the exchange state-wide (Aetna/Coventry continued to offer plans statewide), and UnitedHealthcare began offering exchange plans in most of the state. Gunderson continued to offer plans in just the northeast corner of the state.

UnitedHealthcare’s participation in Iowa’s exchange was short-lived however, as they exited at the end of 2016 (as was the case in most states where they offered exchange plans). In 2016, United had offered plans in 76 of Iowa’s 99 counties, and in 71 of those counties, United offered at least one of the two lowest-cost silver plans in the exchange. In 66 counties, the benchmark plan for a 40-year-old would have been between $25 and $100/month more expensive in 2016 if United hadn’t participated. However, the impact of United’s was buffered by the fact that Wellmark joined the exchange in 2017.

Avera’s initial rate filing for 2017 indicated that they would return to the exchange for 2017. They ultimately reversed course, however, and did not return to the Iowa exchange (as of 2019, their individual market plans are still only available in South Dakota). But Iowa’s exchange still had four insurers participating in 2017, as that was the year that Wellmark finally joined the Iowa exchange (Wellmark had long been the dominant insurer in Iowa’s individual market, but had avoided the exchange for the first three years). Medica was the only carrier offering exchange plans in all 99 counties in Iowa, and in 13 of the state’s counties, Medica was the only carrier offering plans in the exchange. Aetna, Wellmark, and Gunderson all offered plans in select areas of the state. [Aetna had stopped offering exchange coverage in 2017 in most of the states where they participated in 2016. They continued to offer coverage in the exchanges in four states, including Iowa (the others were Delaware, Nebraska, and Virginia). But at the end of 2017, they exited the individual market in all four of those states.]

For 2018, Medica continued to offer plans statewide in Iowa’s exchange, but Wellmark, Gunderson, and Aetna all left the exchange at the end of 2017. So Medica was the only option for Iowa residents who wanted on-exchange plans in 2018.

For 2019, Wellmark rejoined the exchange and began offering plans statewide (in part because they were allowed to partner with Farm Bureau to sell medically underwritten plans outside the exchange; details below). So all exchange enrollees in Iowa had a choice between Medica and Wellmark for 2019 coverage.

This continued to be the case in 2020. And Wellmark also began offering a “Value” plan with a smaller network (“community-based” as opposed to statewide), in addition to their Wellmark Health Plan, although this option was no longer available by 2021.

For 2021, Oscar joined the Iowa exchange with plans available in Des Moines, Dubuque, Sioux City, and Waterloo. All three insurers have continued to participate for 2022 and 2023.

The following average rate changes apply to full-price premiums in Iowa for 2023:

• Medica: Overall average rate increase of 9.7%.
• Wellmark: Overall average rate decrease of 0.9%
• Oscar: Overall average rate increase of 5%

The Iowa Division of Insurance approved all three insurers’ rates as-proposed (details here for Medica and Oscar, and in SERFF filing number WMIA-133287853 for Wellmark).

Iowa’s insurance division held public hearings regarding the proposed rate changes for Medica and Oscar. A public hearing was not necessary for Wellmark’s plans, since the proposed rate change was below the state’s threshold (Wellmark’s rates for grandmothered and grandfathered plans were subject to public hearings, however). 

Across all three insurers, the overall average rate increase was very modest, thanks to Wellmark’s slight rate decrease.

But average rate changes only tell part of the story. They only apply to full-price premiums, whereas most people get subsidies and their net rate changes also depend on how much the subsidy amount changes from one year to the next. The American Rescue Plan’s subsidy enhancements will remain in place through 2025 (thanks to the Inflation Reduction Act), making coverage more affordable than it used to be.

Overall average rate changes also don’t account for the fact that premiums increase with age. So even if a person’s insurance company doesn’t change its rates at all, the person’s premium will grow each year just because they’re getting older (subsidies also grow to keep pace with the age-related premium increases; subsidies for older enrollees are much larger than subsidies for younger enrollees).

For perspective, here’s a look back at average rate changes in Iowa’s exchange over the years:

• For 2015, average rates increased by 11%. A study by The Commonwealth Fund found that marketplace premiums in Iowa increased by 11% on average compared to 2014. The Commonwealth Fund’s study was weighted for differences in premiums between urban/suburban/ rural areas and insurer participation.
• For 2016, average rates increased by 22%. At ACAsignups, Charles Gaba put the weighted average rate increase market-wide at a little over 22%. But for people who already had a plan through the exchange, it was 19.8%, since those plans were all from Coventry. However, the average benchmark premium increased by 12.8% in Iowa, which was less than the overall average rate increase for on-exchange plans. The benchmark plan is just the second-lowest-cost Silver plan in each area — it’s not necessarily the same plan from one year to the next, or even from the same carrier. Iowa was a good example of a new carrier taking over the benchmark position in at least some areas of the state.
• For 2017, average rates increased by 29%. Four insurers offered plans in Iowa’s exchange for 2017, with average rate increases that ranged from 19% to 42%. Across the whole market, the average rate increase was almost 29%.
• For 2018, average rates increased by nearly 57%. In the spring of 2017, Iowa was one of just a few states facing the most uncertain market conditions for 2018. Initially, it wasn’t clear that there would be any filers, but ultimately, Medica did file plans for statewide coverage in Iowa in 2018.
  Medica’s 56.7% average rate increase was larger than they had initially filed, and was based on the assumption that cost-sharing reductions (CSRs) would not be funded by the federal government in 2018; higher rates for silver plans to account for the lack of funding were incorporated in the proposed rates. CSR funding was eliminated by the Trump administration in October 2018, but Medica had already planned for that contingency with their proposed rates, so no additional changes were necessary once CSR funding was eliminated.
  Subsidies in Iowa grew significantly in 2018, offsetting much of the rate hikes that people would have otherwise experienced. But that help was only available for people whose income didn’t exceed 400% of the poverty level. For those who weren’t eligible for premium subsidies, there’s was no avenue for relief from the 2018 rate hikes, which made coverage unaffordable for many. The Iowa Division of insurance reported in early 2018 that nearly everyone who wasn’t subsidy-eligible had left the individual market (as of 2021, the income cap for subsidy eligibility has been temporarily eliminated, nationwide).
• For 2019, overall average rates decreased by 9%. Wellmark rejoined Iowa’s exchange, so plans were available statewide from both Wellmark and Medica. Medica’s average premiums decreased by 9% for 2019, although it varied by plan. Wellmark had no applicable rate change, since they were new to the market for 2019. Wellmark had previously participated in the exchange for one year, in 2017, but had only offered plans in 40 of the state’s 99 counties. So their statewide coverage offerings in 2019 were an expansion over what they were offering prior to their exit from the ACA-compliant market at the end of 2017.
  (Under HIPAA [see 42 USC 300-gg-42(b)(2)], an insurer that entirely exits the individual market in a particular state cannot re-enter that state’s individual market for five years. But Wellmark did not discontinue their grandfathered and grandmothered individual market plans in Iowa in 2018, so their exit from the ACA-compliant individual market did not constitute a full exit from the individual market in the state. As such, there was nothing preventing them from re-entering that segment of the market in 2019.)
• For 2020, overall average premiums decreased by 11%. Wellmark’s average premiums increased by a little under 5%, with slight variation depending on whether the plan has a statewide network (Wellmark Health) or a community-based network (Wellmark Value Health). But Medica’s average premiums decreased 11.3% for 2020. And because Medica had nearly all of the market share, overall average premiums were nearly 11% lower in 2020 than they were in 2019.
  Iowa law requires the state to hold a public hearing for proposed rate increases that exceed the average annual health spending growth rate, which was 5.5% in 2020. Wellmark’s proposed average rate increase was less than 5% and Medica proposed a rate decrease, so no public hearings were held.
  A public hearing was held, however, for Wellmark’s proposed 12.4% increase for grandfathered and grandmothered health plans. Public comments on the proposed increase were uniformly negative, but the state determined that the rate increase was actuarially sound, so it was approved for 2020. It’s noteworthy that the number of people with grandfathered and grandmothered individual market plans from Wellmark stood at 54,500 as of 2019, which was down from 63,500 the year before, but still well above the total number of residents with ACA-compliant health plans in the individual market. Iowa is fairly unique in terms of having more people enrolled in pre-ACA plans (which can no longer be sold to any new enrollees) than in ACA-compliant plans. And although the number of people with non-ACA-compliant Wellmarket plans dropped by 9,000 people from 2018 to 2019, it’s still a substantial pool of insureds.
• For 2021, average rates decreased by 4.5%. Both of the existing insurers decreased their average premiums for 2021 (Medica by 2.3%, and Wellmark by 42%; Medica had the bulk of the market share, however). The steep reduction in premiums for Wellmark appears to have sharply reduced the benchmark premiums in the state, which leads to lower premium subsidies even for people who didn’t have Wellmark coverage. CMS reported that the average benchmark premium in Iowa would be 29% lower in 2021 than it was in 2020. This was by far the largest reduction in benchmark premiums in the country (the average was a 2% reduction across all the states that use HealthCare.gov). But the American Rescue Plan subsequently increased the size of premium subsidies for 2021, and made them more widely available. The subsidy improvements were retroactive to January 2021 for people who had been enrolled in a marketplace plan since the beginning of the year.
• For 2022, average rates increased by about 6.7%. Across all three insurers, there was an overall weighted average rate increase of 6.64% for 2022. That was a larger percentage rate increase than the overall US average for 2022, but it came on the heels of three consecutive years of rate decreases in Iowa.

82,704 people enrolled in private individual market plans through Iowa’s exchange during the open enrollment period for 2023 coverage, which was a new record high for Iowa’s exchange (the previous record high had come the year before, when 72,240 people enrolled). 

Here’s a summary of how enrollment (during each annual open enrollment period) has changed over the years in Iowa’s exchange:

• 2014: 29,163 people enrolled. This was lower than expected, and a Kaiser Health News article attributed the low enrollment to Wellmark Blue Cross & Blue Shield’s decision against participating in the Iowa marketplace. In addition, the fact that transitional (pre-2014) plans were allowed to renew meant that overall enrollment in ACA-compliant plans was lower than expected.
• 2015: 45,162 people enrolled
• 2016: 55,089 people enrolled
• 2017: 51,573 people enrolled (Across all the states that use HealthCare.gov, enrollment dropped by about 5% in 2017.)
• 2018: 53,217 people enrolled 
• 2019: 49,210 people enrolled
• 2020: 54,586 people enrolled
• 2021: 59,228 people enrolled
• 2022: 72,240 people enrolled 
• 2023: 82,704 people enrolled

A note about 2018 enrollment: As of February 2018, the Iowa Insurance Division reported that 46,563 people had in-force ACA-compliant individual market coverage in the state, and nearly 90% of them were receiving premium subsidies. Most of the people who weren’t eligible for premium subsidies had left Iowa’s ACA-compliant individual market for 2018. Although the ACA’s individual mandate penalty was still in effect for 2018, an exemption was available to anyone for whom the lowest-cost bronze plan would cost more than 8.05% of household income; this likely applied to many of the people who left the unsubsidized market in 2018. By November 2018, total enrollment in ACA-compliant individual market plans (including on- and off-exchange plans) in Iowa had dropped to 39,000 people. Virtually all of those individuals had on-exchange coverage, as the off-exchange ACA-compliant market in Iowa appeared to have dwindled to almost no enrollees (due in large part to the fact that pre-subsidy premiums in Iowa were the highest in the country as of 2018, making unsubsidized coverage largely unaffordable for most people). Notably, Iowa still had 68,000 people enrolled in individual market grandmothered and grandfathered plans at that point. Those pre-ACA plans still exist in other states as well, but they don’t comprise the bulk of any other state’s entire individual insurance market. 

Kaiser Family Foundation data indicated that as of 2018, just 17% of eligible Iowa residents had enrolled in coverage through the exchange, the lowest percentage in the country (nationwide, the average was 34% at that point). The lower-than-expected enrollment may have been due in part to the lack of marketing for the exchange in the state, or the fact that Wellmark sat out the first three years of exchange operation (they began offering exchange plans in 2017, exited for 2018, but then returned in 2019) while continuing to renew grandmothered and grandfathered health plans for tens of thousands of residents (Wellmark still had 54,500 people enrolled in grandfathered and grandmothered plans as of 2019, which is more than the total number of people enrolled in ACA-compliant plans. By 2022, Wellmark’s grandmothered/grandfathered enrollment had dropped to around 34,000).

Three insurers currently offer dental plans through the Iowa marketplace. Learn about dental coverage options in Iowa.