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Three insurers offer plans through the exchange; average rate increase of less than 5% for 2023
New Hampshire is one of seven states that utilize a state-federal partnership health insurance exchange for enrollment.
Three insurers are offering 2023 exchange plans in New Hampshire. And although average pre-subsidy premiums increased by nearly 5% for 2023, they are still the lowest in New England.
New Hampshire is one of seven states that operates a partnership exchange with the federal government. These exchanges are considered federally facilitated, they use Healthcare.gov’s enrollment platform and call center, and receive federal Navigator funding.
But the state also takes an active role, and operates Covering New Hampshire, a resource site for residents to learn about the exchange and the plans that are available. The Department of Insurance has an inclusive overview of exchange information on their website to serve as a resource for state residents, and maintains a monthly enrollment report that shows how many people have plans purchased through the exchange from each participating insurer. As of October 2022, there were 50,305 people enrolled in on-exchange plans in New Hampshire.
For 2023 coverage, there are three insurers that offer exchange plans in New Hampshire:
For 2014, only one health insurance carrier — Anthem Blue Cross Blue Shield — applied to participate in the state-federal partnership exchange in New Hampshire, offering 14 health plan options. But that changed significantly for 2015, when the New Hampshire exchange grew to include policies from five carriers. Not all carriers offered plans in all counties, but there were an average of 38 plans available in each county, up from 10 in 2014.
Two of the new carriers that joined the New Hampshire exchange in 2015 were ACA-created CO-OPs: Minuteman Health, based in Boston, and Community Health Options (formerly Maine Community Health Options, or MCHO) that garnered 83 percent of the market share in neighboring Maine during the 2014 open enrollment. CHO had a limited presence in New Hampshire 2015, offering coverage in four NH counties: Coos, Carroll, Rockingham, and Strafford.
Harvard Pilgrim Health Care and Assurant also joined the New Hampshire exchange in 2015, although Assurant announced in mid-2015 that they would exit the entire market nationwide, and they no longer had any enrollees in the New Hampshire exchange as of September 2015.
For 2017, Community Health Options was no longer offering coverage in the exchange (they opted to focus entirely on Maine instead, and exited the New Hampshire market at the end of 2016), but plans continued to be available from Anthem, Ambetter, Minuteman Health, and Harvard Pilgrim.
But Minuteman Health was ultimately placed in receivership, and was not allowed to offer coverage past the end of 2017. They had intended to reopen as a new, for-profit insurer in 2018, but did not raise enough capital to make that possible. As a result, Minuteman Health enrollees had to switch to new plans for 2018, and residents did not have an opportunity to buy a for-profit version of Minuteman coverage (the New Hampshire Insurance Department published a list of FAQs about Minuteman’s departure from the market).
So for 2018, plans were available in the New Hampshire exchange from Anthem, Ambetter, and Harvard Pilgrim. All three insurers have continued to participate in the exchange ever since.
The open enrollment period for individual/family coverage runs from November 1 through January 15 in New Hampshire. Outside of open enrollment, a qualifying event is necessary to enroll or make changes to your coverage.
If you have questions about open enrollment, you can learn more in our comprehensive guide to open enrollment.
Health insurance premiums in New Hampshire’s individual market increased by about 4.8% for 2023, after declining for three consecutive years and then increasing by less than 1% for 2022.
The New Hampshire Insurance Department has noted that average full-price 2023 premiums in New Hampshire are the lowest in New England, and are 13% lower than they would have been without the state’s reinsurance program that took effect in 2021.
The following average rate changes were approved for 2023, applicable to full-price premiums (ie, these rate changes are calculated before subsidies are applied, and most exchange enrollees receive subsidies):
Across all plans, the weighted average rate increase is about 4.8%, although the state noted that the average benchmark premium (upon which subsidies are based) would increase by 4.6% for 2023.
The cost of cost-sharing reductions (CSR) has been added to silver plan rates in New Hampshire, as has been the case since 2018. This results in disproportionately large premium subsidies, and after-subsidy rates on bronze and gold plans that are lower than they would have been if the federal government had continued to directly reimburse insurers for the cost of CSR.
And the American Rescue Plan’s subsidy enhancements have resulted in larger premium subsidies as well, which are still in effect for 2023 thanks to the Inflation Reduction Act. Due to these extra subsidies, coverage is more affordable than it used to be, and more people are subsidy-eligible.
State law prevents the New Hampshire Insurance Department from publishing health insurance rate information until open enrollment begins on November 1. But the Department is proactive in sharing the information that the federal government publishes at the beginning of August in terms of proposed rates for the coming year.
For perspective, here’s a look at how average premiums have changed in New Hampshire’s exchange over the years:
During the open enrollment period for 2022 coverage, 52,497 people enrolled in plans through New Hampshire’s exchange. This was the highest enrollment had been since 2017.
As is the case in many states that use HealthCare.gov, enrollment in New Hampshire’s exchange peaked in 2016, then declined each year through 2020, and began to increase again in 2021 and 2022. Here’s an overview of enrollment since the exchange began operating in 2014:
(These numbers do not include Medicaid members who were enrolled in private plans via New Hampshire’s Premium Assistance Program (PAP) prior to 2019; PAP enrollees were in the same qualified health plans as other enrollees, but the policies were funded by Medicaid.)
Enrollment in states that use HealthCare.gov dropped for a variety of reasons from 2016 through 2020:
But enrollment has increased since then, due in large part to the additional affordability enhancements created by the American Rescue Plan, as well as record-high Navigator funding provided by the Biden administration.
As of 2021, New Hampshire and Pennsylvania joined a dozen other states that had implemented reinsurance programs to stabilize their individual insurance markets. (As of 2023, there are 17 states using reinsurance programs.)
Reinsurance works by taking on some of the risk that the health insurers would otherwise have to bear, and the result is lower premiums in the individual market. That translates to smaller premium subsidies, which reduces federal spending. By using a 1332 waiver, a state can recoup the savings (instead of having the federal government keep the money) and use the money to fund the reinsurance program.
New Hampshire’s reinsurance program is designed to kick in when a claim reaches $60,000. At that point, the state planned to pay approximately 74% of the claim costs, until the total claim reaches $400,000. But the state’s waiver plan notes that the exact parameters (in terms of the percentage of the claim that will be covered and the upper limit for claims to be paid by the reinsurance program) will depend on how much funding the state has for the reinsurance program each year (for 2021, New Hampshire received $31.5 million in pass-through funding, which was considerably more than initially projected, thanks in part to the American Rescue Plan. For 2022, they received $26.6 million).
New Hampshire submitted its reinsurance proposal to CMS in April 2020, and the federal government approved it in early August. The state’s initial projection was that the planned reinsurance program would result in 2021 individual market premiums being 16% lower than they would otherwise have been. The state also projected that enrollment in the individual market would increase by about 6% with a reinsurance program in place, due to the reduced premiums (plan selections in the exchange during open enrollment had dropped each year since 2016, so stabilizing enrollment with a reinsurance program was a priority).
Ultimately, enrollment ended up increasing by about 5% for 2021, with 46,670 people buying coverage during open enrollment. Individual market enrollment normally declines throughout the year and then increases during open enrollment. But enrollment remained fairly steady in New Hampshire’s exchange in 2021, due to increased enrollment during the COVID-related enrollment window that continued until mid-August 2021.
As noted above, all three of New Hampshire’s insurers decreased their overall average premiums for 2021, due in large part to the reinsurance program, and average rates increased by less than 1% for 2022. Although average premiums increased by nearly 5% for 2023, the state noted that they were still 13% lower than they would have been without the reinsurance program.
It’s important to understand, however, that the reinsurance-related reduction in premiums applies to people who pay full price for their coverage. In New Hampshire, that’s about 15,600 exchange enrollees (the rest get premium subsidies) plus about 5,500 people who buy their coverage outside the exchange.
For people who get premium subsidies, the subsidies decreased in 2021 in line with the premium decreases (after-subsidy premiums can end up decreasing, staying the same, or increasing, depending on how the benchmark premiums change). Across the entire state, the average proposed benchmark plan premium for 2021 was 21.2 percent lower than the average benchmark premium in 2020. This represented a more significant drop than the overall proposed average rate decrease – across all plans – for 2021.
When the decrease in benchmark premiums is sharper than the overall average rate decrease, the result can be higher after-subsidy premiums for people who get premium subsidies (about 72% of New Hampshire exchange enrollees).
However, the American Rescue Plan has boosted premium subsidies at all income levels for 2021 and 2022, and has also eliminated the “subsidy cliff” for those two years (and these provisions were extended through 2025 by the Inflation Reduction Act). This more than offsets any potential net premium increases that people may have seen due to lower benchmark premium rates in 2021; in almost all cases, coverage is more affordable under the American Rescue Plan than it would otherwise have been.
The rate decreases for 2019 were likely due in large part to the fact that the state changed the way Medicaid expansion is handled. Through the end of 2018, New Hampshire used Medicaid funds to purchases private plans (qualified health plans, or QHPs) in the exchange for Medicaid expansion enrollees, via the state’s Premium Assistance Program (PAP).
However, New Hampshire enacted legislation in 2018 that directed the state to seek federal approval to abandon the PAP system and switch to regular Medicaid managed care instead. New Hampshire submitted a waiver proposal to this effect to CMS in July 2018. Approval was granted by CSM in late November, but that appeared to be just a formality, as the state had already sent notices to enrollees in October, and the QHP insurers had mentioned the impending transition from PAP to Medicaid managed care in their filings that were submitted over the summer.
The new Medicaid expansion program in New Hampshire is called the Granite Advantage Health Care Program, and it took effect in January 2019. The Granite Advantage program initially had a Medicaid work requirement, which was already approved by CMS under the terms of a separate waiver, and also took effect in January 2019. But the work requirement was challenged in court and overturned in July 2019, the same month that the state enacted legislation to modify the work requirement. The work requirement approval was officially withdrawn by the Biden administration in March 2021, so it is no longer part of the state’s Medicaid expansion program.
There is a correlation between lower income and poorer health, so with the Medicaid expansion population moved out of the QHP risk pool, the overall health of the pool improves. This reduced morbidity will translate into lower premiums for everyone who remains in the QHP pool. As expected, average premiums in New Hampshire’s QHP market declined in 2019, 2020, and 2021 (for 2021, it was due in large part to the state’s new reinsurance program), and increased only slightly for 2022.
Residents were able to begin enrolling in New Hampshire’s expanded Medicaid program as of July 1, 2014, with policies effective August 15 (Medicaid enrollment during the winter and spring was only possible for people who qualified under the state’s pre-expansion guidelines).
Medicaid expansion in New Hampshire was a contentious issue, but ultimately then-Governor Maggie Hassan prevailed in her efforts to expand Medicaid, albeit in a privatized fashion. Gov Hassan signed Senate Bill 413 into law on March 27, 2014, paving the way for New Hampshire to become the 26th state to accept Medicaid expansion.
For the first couple of years, the program operated in much the same fashion as it did in other Medicaid expansion states, with the state using federal Medicaid funds to provide New Hampshire Health Protection Program coverage to residents with incomes below 139 percent of poverty.
But starting in January 2016, the state transitioned the NH Health Protection Program’s participants to subsidized, private coverage (dubbed the Premium Assistance Program). As described above, New Hampshire abandoned that plan at the end of 2018, and switched to a Medicaid managed care model (the Granite Advantage Health Care Program) with a work requirement. The work requirement was subsequently overturned by a judge, and the Biden administration officially rescinded approval for the work requirement in March 2021.
The exchange creation process in New Hampshire was a legislative battle. In February 2013, then-Gov. Hassan announced that New Hampshire would operate its health insurance marketplace as a partnership with the federal government.
Prior to the 2012 elections, New Hampshire seemed firmly on a path to relying on the federally facilitated exchange. Former Democratic Gov. John Lynch had no effective means to push back against a Republican-dominated state Legislature that was united against a state-run exchange.
And in 2011, lawmakers passed a bill (enacted into law without Lynch’s signature) that prohibited any sort of penalties for New Hampshire residents who fail to obtain health insurance — in direct conflict with the ACA’s individual mandate and shared responsibility penalty. The law had no real impact however, because the IRS (a federal agency, not under state control) was responsible for assessing the ACA’s penalties, and because the ACA is a federal law that cannot be superseded by state law (the federal penalty was eliminated after the end of 2018; people who are uninsured in 2019 and beyond are no longer subject to a penalty).
But the 2012 elections gave control of the state House to Democrats, put more Democrats in the Senate, and kept the governor’s office in Democratic hands. The political shift and a law that allowed the state to take on specific exchange functions enabled the state to adopt a partnership model.
New Hampshire is responsible for plan management and consumer assistance, and the federal government is managing all other marketplace functions. The NH Health Exchange Advisory Board held monthly meetings from 2012 through 2015, the minutes of which are available here.
New Hampshire Department of Insurance: Health Benefit Partnership Exchange Advisory Board
Includes meeting agendas and documents from November 2012 until the present.
State Exchange Profile: New Hampshire
The Henry J. Kaiser Family Foundation overview of New Hampshire’s progress toward creating a state health insurance exchange.
New Hampshire Consumer Assistance Program
Assists consumers who have purchased insurance on the individual market or who have insurance through an employer who only does business in New Hampshire.
(800) 852-3416 / [email protected]
Covering New Hampshire – a statewide effort by the New Hampshire Health Plan to inform residents of their coverage options in the exchange and the resources that are available for those who need assistance.
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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