- Open enrollment for 2021 health plans ended on December 15, 2020, but a COVID-related enrollment window runs from February 15 to August 15, 2021 (qualifying events are not necessary to use this window).
- Kentucky planning to transition back to Kynect, with a fully state-run exchange operational by the fall of 2021.
- Number of counties with two participating insurers grew again for 2021 (most of the state now has two participating insurers).
- Short-term health plans can be sold in Kentucky with initial plan terms up to 364 days.
- 2021 enrollment down about 7% from 2020, and down nearly 27% from Kynect’s peak enrollment in 2015.
- Work requirement for Medicaid was scheduled to take effect in 2019 but a judge blocked it and Gov. Beshear rescinded it when he took office.
Kentucky exchange overview
Open enrollment for 2021 health plans ran from November 1 through December 15, 2020. But a COVID-related enrollment window has been opened by the Biden administration, giving people an additional six months to secure coverage for 2021. This window is scheduled to end on August 15, 2021.
In states that use HealthCare.gov, including Kentucky, this window can be used by people who are uninsured, as well as those who already have coverage and would like to choose a different plan for the remainder of the year. A qualifying event is not necessary in order to use this COVID-related enrollment window, although qualifying events will once again be necessary after August 15, for people who want to enroll or make a plan change outside of the annual open enrollment period.
Two insurers offer coverage in Kentucky’s exchange: Anthem and CareSource. And both expanded their coverage areas for 2021, giving residents in 94 counties (up from 56 in 2020) a choice of plans from both insurers. Residents in the other 26 counties can only select a plan from Anthem, although Anthem offers numerous plans. Although Humana exited the individual market at the end of 2017, their plans were only available in 2017 in a single county in Kentucky, so the impact of their exit was fairly minor.
Enrollment peaked in Kentucky’s exchange in 2015, when more than 106,000 people signed up for individual market coverage through Kynect. Enrollment began to drop once former Governor Matt Bevin transitioned away from Kynect and had the state use HealthCare.gov instead. It’s fluctuated up and down since then, but hit a record low in 2021, with fewer than 78,000 people signing up during open enrollment. but the additional COVID-related enrollment window (February 15 to May 15, 2021) is likely to result in increased enrollment.
Kentucky had a gubernatorial election in November 2019 – just days after the start of open enrollment for 2020 health plans – in which Governor Matt Bevin, who was a strong opponent of the ACA, was defeated by Kentucky’s Democratic Attorney General, Andy Beshear, who supports the ACA. One of Beshear’s first acts as governor was to rescind the Medicaid work requirement that the Bevin administration had created. Beshear has also begun the process of transitioning Kentucky back to a fully state-run exchange, after Bevin switched from the state’s successful state-run platform to the HealthCare.gov platform as of 2017.
Kentucky’s uninsured rate has dropped substantially under the ACA, thanks in large part to the state’s expansion of Medicaid, although it increased under the Trump administration. According to official US census data, Kentucky’s uninsured rate was 14.3 percent in 2013. It had dropped to a low of 5.4 percent in 2017, but had grown to 6.4 percent by 2019. (nationwide, the uninsured rate trended upward under the Trump administration).
Approved average rate increase of 5% in Kentucky for 2021 (down from the 11% average increase insurers proposed)
Anthem and CareSource filed average rate changes for 2021 individual market plans that amounted to a proposed average increase of 11 percent. But the Kentucky Department of Insurance approved a much smaller increase than Anthem had proposed, bringing the final approved overall average increase down to 5 percent for 2021 (in the small group market, most insurers’ rates were approved as filed, amounting to an average increase of 8.8 percent).
The following average rate changes were implemented for 2021 by Kentucky’s individual market insurers:
- Anthem: 5.7 percent increase. Anthem had 39,165 members in these plans in 2020 (another area of the filing says 45,000). Anthem’s initial filing called for a 16.6 percent increase. It noted that part of the rate increase was due to an assumption that morbidity will increase in the individual market in 2021 due to “selective shifting into and out of the individual market,” which was expected to be “more pronounced in 2021 due to uncertain economic conditions, loss of group coverage and income loss [driven by the COVID-19 pandemic.]” The proposed rates also included a 4.5 percent increase in expected morbidity as a result of elective procedures being completed in 2021 after being delayed in 2020 due to the pandemic. But the final approved rate increase was far smaller than Anthem had proposed.
- CareSource: 4.0 percent increase. CareSource had 35,697 members in these plans in 2020. CareSource initially proposed a 5.3 percent average rate increase. But they did not include a COVID-19 factor in their proposed rates for 2021, noting that there was too much uncertainty to determine whether costs would be higher, lower, or unchanged as a result of the virus.
For perspective, here’s a look at how premiums have changed in prior years in Kentucky’s exchange:
- 2015: Average increase of 10.5 percent. Three-quarters of Kynect’s enrollees had coverage under Kentucky’s CO-OP in 2014, and their rates increased by an average of 12.5 percent for 2015. The remaining quarter of the enrollees were split between Anthem (which reduced premiums by 4.3 percent) and CareSource (which increased premiums by 12.8 percent).
- 2016: Average increase of 14-15 percent. The Kentucky Department of Insurance initially finalized rates for eight individual market carriers for 2016, but that dropped to seven once the CO-OP dropped out. Despite the loss of Kentucky Health CO-OP, seven carriers in the individual market was more than Kentucky had had since the late 1990s, and it was an increase from just three carriers offering plans through Kynect in 2014. In addition to the carriers that were already offering individual plans through Kynect, the exchange added three more carriers for 2016: UnitedHealthcare offered plans statewide, Aetna offered plans in 10 counties, and Baptist Health (Bluegrass Family Health) offered plans in 79 counties.
- 2017: Average increase of 24.5 percent. Four carriers that offered plans in the Kentucky exchange in 2016 — Aetna, WellCare, Baptist Health (Bluegrass Family Health), and UnitedHealthcare — did not offer plans in 2017. Three insurers continued to offer coverage: Anthem, CareSource, and Humana. Anthem (available statewide in 2017), increased premiums by about 23 percent; CareSource offered plans in 61 counties and increased premiums by about 23 percent; Humana was only available in Jefferson county, and increased premiums by an average of 31 percent.
- 2018: Average increase of 45 percent: Anthem and CareSource both initially filed 2018 rates based on the assumption that cost-sharing reduction (CSR) funding would continue. But they both later filed revised rates with the cost of CSR added to silver plan premiums, which accounted for about a third of the total rate increase of 2018 (the Trump administration terminated CSR funding in October 2017, just before enrollment in 2018 plans began; insurers in Kentucky have continued to add the cost of CSR to silver plan rates in subsequent years).
Everyone eligible for CSR benefits continued to receive them (and that is still the case) as long as they selected silver plans; nothing changed about eligibility for CSR benefits or the benefits themselves. But instead of federal funding to cover their cost, the cost is now added to premiums. But adding the cost of CSR to silver plan premiums results in larger premium subsidies for all enrollees who are eligible for premium subsidies. That’s because premium subsidies are based on the cost of the second-lowest-cost silver plan, so the subsidies grow to keep pace with silver plan premiums. For people who receive premium subsidies, this change meant that bronze and gold plans became particularly affordable starting in 2018.
- 2019: Average increase of 12.5 percent. Much of the rate increase was likely due to the elimination of the individual mandate penalty after the end of 2018, and the Trump administration’s efforts to expand access to short-term plans and association health plans. Consumers in 34 counties could choose from both CareSource and Anthem, while the rest of the state had just one or the other.
- 2020: Average increase of 3.7 percent. Anthem’s rates increased by an average of 9.7 percent, and CareSource’s increased by an average of 4.5 percent. As of 2020, there were plans available from both insurers in 56 counties; in 37 counties there were only plans from Anthem, and in 27 counties there were only plans from CareSource.
(Note that when we talk about rate changes, we’re referring to pre-subsidy premiums. Premium subsidies fluctuate from one year to the next based on changes in the benchmark plan premium. People who receive premium subsidies can still see changes in their after-subsidy premiums from one year to the next (especially if a new plan takes over the benchmark spot and the enrollee keeps their existing coverage for the coming year), but the changes won’t necessarily mirror the percentage by which the full-price premiums change.)
Transitioning back to Kynect
For the first three years of ACA implementation, Kentucky operated its own exchange and enrollment website. Kynect, the state-run exchange, was widely considered one of the most successful state-run exchanges in the country.
But former Governor Matt Bevin, who took office in late 2015, campaigned on an anti-Obamacare platform, and spent much of 2016 transitioning the Kentucky exchange to the Healthcare.gov platform. Bevin was able to shut down Kynect via executive order, as the exchange was created with an executive order from former Governor Steve Beshear (as opposed to some state-run exchanges that were created via state legislation).
The enrollment platform switch took effect in November 2016, for enrollment in 2017 coverage. It got off to a rocky start, with brokers and enrollees finding the process more cumbersome and time-consuming than what they were accustomed to with Kynect. Enrollment, not surprisingly, was considerably lower in 2017. And although it rebounded somewhat in 2018, it has not yet reached the levels it was at in 2015 and 2016.
In June 2020, however, Governor Andy Beshear notified CMS that Kentucky plans to transition back to the Kynect system, with a fully state-run exchange operational by the fall of 2021. So for 2021 coverage, residents are still enrolling via HealthCare.gov. But for 2022 coverage and beyond, Kentucky residents will once again use Kynect.
Beshear’s office notes that the state will save at least $2.8 million in the first year of using Kynect, with additional savings after that. The 3 percent user fee that HealthCare.gov charged in 2018 amounted to $9.8 million in 2018 in Kentucky. The user fee has since dropped to 2.5 percent for state-based exchanges that use HealthCare.gov (Bevin had opted to keep Kentucky’s state-run exchange, but switch to the federal enrollment platform; this is still the approach that the state uses as of 2020).
Under the federally-supported model, Kentucky still technically runs its own exchange, but it uses Healthcare.gov as the enrollment platform (Arkansas, New Jersey, Oregon, Pennsylvania, and New Mexico are also state-based exchanges that use Healthcare.gov; Nevada also used HealthCare.gov through 2019, but switched back to a fully state-run exchange as of the fall of 2019; New Mexico plans to do the same thing in the fall of 2021, and Kentucky is also planning to make the same switch in the fall of 2021).
By transitioning back to a fully state-run exchange, Kentucky will gain much more control over exchange operations, including outreach and enrollment. For example, exchanges that use their own enrollment platform are able to extend open enrollment and add special enrollment periods as they see fit, whereas states that rely on HealthCare.gov cannot. Most of the fully state-run exchanges have issued open enrollment extensions most years, and all but one of them issued a special enrollment period for uninsured residents in response to the COVID-19 pandemic. Once Kynect is back up and running as the state’s exchange platform, Kentucky will once again have this sort of flexibility.
2021 enrollment down about 27 percent from peak enrollment in 2015
77,821 people enrolled in individual plans through Kentucky’s exchange during the open enrollment period. This was down almost 7 percent from the year before, when 83,139 people enrolled during the open enrollment period for 2020 coverage (nationwide, enrollment was up 2.2 percent). Here’s a summary of how enrollment in Kentucky’s exchange has fluctuated over the years:
- 2014: 82,747 people enrolled
- 2015: 106,330 people enrolled
- 2016: 93,687 people enrolled (Kynect was one of just a handful of states with lower enrollment in 2016 than in 2015, and most of the others had special circumstances, such as newly-expanded Medicaid or Basic Health Programs. But on December 18, 2015, Kynect’s successful advertising campaign was shut down after a contract extension was rejected by the state Finance and Administration Cabinet and the prior contract expired November 30. The advertising campaign was funded with $5 million in federal funding, and any unused portion was to be returned to the federal government. State outreach directors expressed dismay that the advertising campaign was shuttered mid-way through the open enrollment period. But it was not unexpected, as newly-elected Governor Matt Bevin had promised to shutter Kynect and switch to Healthcare.gov as one of his first priorities upon taking office.)
- 2017: 81,155 people enrolled (The transition to HealthCare.gov resulted in further declines for 2017, compounded by the Trump administration’s decision to cut advertising and outreach for HealthCare.gov in the final week of 2017 open enrollment (Trump took office on January 20, 2017; open enrollment for 2017 coverage ended January 31).
- 2018: 89,569 people enrolled
- 2019: 84,620 people enrolled
- 2020: 83,139 people enrolled
- 2021: 77,821 people enrolled
Individual market insurer participation in Kentucky’s exchange: 2014-2021
2014: Plans were available in Kentucky’s exchange from Anthem, Humana, and Kentucky Health Cooperative (an ACA-created CO-OP). Kentucky Health Cooperative garnered significant market share in 2014, enrolling 75 percent of Kynect’s private plan customers. The other 25 percent was split evenly between Humana and Anthem.
2015: CareSource and Wellcare joined the exchange for 2015, bringing the total number of participating insurers to five, although Anthem and the CO-OP were the only insurers offering plans statewide; the other three insurers each had much more limited coverage areas.
In October 2015, Kentucky Health Cooperative announced that they would cease operations by the end of 2015. At that point, the CO-OP had about 51,000 members, all of whom had to secure coverage with another carrier for 2016.
Kentucky Health CO-OP’s demise was cemented when the federal government announced on October 1 that risk corridor payments nationwide would be just 12.6 percent of the expected amount. Risk corridors were one of the ACA’s mechanisms for ensuring that carriers were on a somewhat level playing field in the first few years of ACA implementation. In 2014, 2015, and 2016, carriers that experienced lower-than-expected claims paid into the risk corridors fund, while carriers that experienced higher-than-expected claims were supposed to payouts from the fund. If the latter exceeded the former, the idea was that the government would make up the shortfall. And in the opposite scenario, the government would get to keep the overage.
But in late 2014 — after a full year of ACA claims and after 2105 rates had already been set — lawmakers retroactively made the risk corridors program budget neutral, which meant it could only pay out as much as it took in. For 2014, the risk corridors program ended up about $2.5 billion in the red, which meant that carriers got just a fraction of what they are owed. In the case of Kentucky Health CO-OP, that was $9.7 million, out of $77 million they were supposed to receive. Funds were to be paid in December 2015, but once it was determined that they would not be coming, the CO-OP had no choice but to close.
2016: Anthem offered exchange plans statewide, while CareSource offered plans in 46 counties. Plans were also available from Humana, Baptist Health, UnitedHealthcare, Wellcare, and Aetna, but four of those insurers exited the exchange at the end of 2016.
- Baptist Health stopped offering plans in the exchange at the end of 2016, although their off-exchange enrollees could keep their coverage through March 2017 (Baptist Health has subsequently dissolved altogether).
- UnitedHealthcare exited the Kentucky exchange and also exited the individual market in Kentucky outside the exchange. 2016 was the first year that United had offered plans in the Kentucky exchange, although they exited the exchanges in most states at the end of 2016.
- In late 2016, Wellcare’s website had a notice for marketplace plan members, letting them know that their coverage would end December 31, 2016, and that they would need to enroll in a new plan during open enrollment.
- Aetna had offered on-exchange plans in 10 Kentucky counties in 2016, but they stopped doing so at the end of that year.
2017: Anthem continued to offer coverage in all 120 counties in Kentucky in 2017 (and was the only carrier doing so), but in 74 of those counties, they only offered HMO plans for 2017. Anthem continued to offer PPO plans in 46 counties in Kentucky. CareSource added 15 more counties to their coverage area for 2017, offering plans in just over half the state’s counties. Humana also continued to offer coverage in Kentucky’s exchange, but reduced their coverage area to only Jefferson County. And Humana announced in February 2017 that they would exit the individual market nationwide at the end of 2017.
2018: CareSource continued to offer plans in 61 counties in 2018, but Anthem’s revised rate filing for 2018 reduced their coverage area to include only the 59 counties where CareSource did not offer coverage. So all counties in Kentucky had just a single insurer offering exchange plans for 2018. Residents who had Humana coverage in Jefferson County, as well as those who had Anthem coverage in the 61 counties where CareSource also offered plans, needed to select new plans for 2018.
2019: Anthem expanded its coverage area to include 93 counties, giving residents in 34 counties the opportunity to select a plan from either insurer (in the other 86 counties, just one insurer offers plans for 2019).
2020: CareSource expanded its coverage area to a total of 83 counties, overlapping with Anthem in 56 of those counties. So for 2020, there are 56 counties where Anthem and CareSource plans are available, 27 counties where only CareSource is available, and 37 counties where only Anthem is available.
2021: Both insurers expanded their coverage area, giving residents in 94 counties a choice between Anthem and CareSource.
Grandmothered plans allowed in Kentucky
Transitional, or grandmothered, health plans are allowed to continue to renew in Kentucky. The state has thus far gone along with all of the annual extensions permitted by the federal government; they have not yet announced an extension in line with the latest issued by the federal government in January 2021, but it’s likely that they will do so, allowing grandmothered plans to remain in force throughout 2022.
Renewal is at carrier discretion however, and transitional plans are not required to renew — carriers can choose instead to replace them with ACA-compliant plans. About 14,000 people in Kentucky were on plans — mostly from Humana — that were terminated at the end of 2014 because the carrier opted to switch to only ACA-compliant plans.
The extension of grandmothered plans has contributed to higher-than-expected claims costs for ACA-compliant plans across the country, since the people who remained on grandmothered plans were healthy enough to get those plans — despite medical underwriting — between 2010 and 2013. Since those individuals did not transition to ACA-compliant plans, the overall risk pool for the ACA-compliant plans ended up being sicker than expected.
According to the Kentucky Department of Insurance, there were still more than 38,000 people with individual market transitional (grandmothered) plans as of April 2016, and more than 86,000 with transitional small group coverage.
That’s in addition to grandfathered plans. As of March 2105, there were 25,491 people in Kentucky who still had coverage under grandfathered plans in the individual market, and 19,595 with grandfathered group coverage (this included 4,571 people on grandfathered small group plans, and the rest on large group plans).
History of Kentucky’s exchange
Kynect was considered one of the nation’s best marketplaces. More than 521,000 people obtained health insurance coverage through Kynect in 2014 — either private health insurance or Medicaid. During the open enrollment period for 2015 coverage, another 152,529 people enrolled in Medicaid through Kynect (Medicaid enrollment continues year-round), and 106,330 people enrolled in private plans through Kynect, 26 percent of whom were new to the exchange for 2015.
One sign of Kynect’s success was widespread awareness: a poll from late 2014 showed that nearly 80 percent of Kentucky residents had heard of the exchange and nearly 52 percent of Kentuckians between the ages of 30 and 64 said they knew “a lot” about it.
Another sign was the Beshear administration’s inclusion of Knyect in its list of top accomplishments of 2014. The state’s uninsured rate dropped nearly 8 points, and the newly insured were taking advantage of their coverage. The state reported that in 2014, 26,000 more people would have cholesterol screenings, 7,000 more women would have mammograms, 10,000 more women would have pap smears, and 14,000 more people with depression would be treated.
Kynect was one of the few marketplaces established through an executive order. Beshear’s order to establish the exchange in July 2012 followed months of seeming inaction on the exchange by the executive and legislative branches in the state (this also made it highly susceptible to being dismantled via executive order, which is what Governor Bevin did when he took office). Kynect was part of the state’s Cabinet for Health and Family Services, and it was overseen by 19-member board appointed by Beshear.
Then-Governor Steve Beshear went against public sentiment in deciding the state would run its own marketplace. In an article in The New York Times, Beshear urged state residents to set aside politics and use the marketplace to get insured. “You don’t have to like the president; you don’t have to like me. Because this isn’t about him, and it’s not about me. It’s about you, your family and your children.”
Kentucky spent about $11 million on outreach and marketing for 2014 open enrollment, and it trained 5,000 people to support enrollment — including state employees, insurance agents, volunteers and representatives of various community groups and social service organizations. These outreach efforts drove Kentucky’s enrollment totals.
While the federal marketplace, HealthCare.gov, and multiple state-run marketplaces had significant technical problems in 2014, Kynect ran well from the start. Experts say those in charge of implementing Kynect made good choices. They kept the design simple and worked with well-qualified and experienced vendors.
Ultimately, however, a new governor with an anti-Obamacare approach was able to unravel Kynect and switch Kentucky to HealthCare.gov. That change was temporary though, as the next governor opted to switch Kentucky back to the Kynect platform as of November 2021.
Kentucky health insurance exchange links
Kynect – Kentucky’s Healthcare Connection
Consumer site for Kentucky’s marketplace
Kentucky Health Benefit Exchange
Administrative site for Kentucky’s marketplace
Kentucky Health Insurance Advocate, Kentucky Department of Insurance
Assists people insured by private health plans, Medicaid, or other plans in resolving problems pertaining to their health coverage; assists uninsured residents with access to care.
(877) 587-7222 /DOI.CAPOmbudsman@ky.gov