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Ohio uses a federally facilitated health insurance exchange, which means residents in Ohio use HealthCare.gov to enroll in exchange plans.
Eleven insurers offer plans in Ohio’s exchange for 2023, up from ten in 2022. UnitedHealthcare is new to the exchange, and nearly all counties in the state have at least four insurers offering plans for 2023.
Ohio has a federally facilitated exchange, which means residents in Ohio use HealthCare.gov to enroll in exchange plans. But Ohio is one of five that participates in plan management and the qualified health plan (QHP) certification process.
In November 2012, then-Governor John Kasich formally announced that Ohio would not implement a state-run health insurance exchange. In the same letter, Kasich indicated that Ohio would retain control of plan management activities and determining eligibility for the state’s Medicaid and Children’s Health Insurance Plan (CHIP).
The open enrollment period for individual/family health insurance runs from November 1 to January 15 in Ohio.
Outside of open enrollment, a qualifying event is generally necessary to enroll or make changes to your coverage. These enrollment windows are used regardless of whether you’re applying for coverage through the exchange or off-exchange.
There is also an ongoing enrollment opportunity for people who are eligible for premium tax credits and whose household income doesn’t exceed 150% of the poverty level (for a household of three enrolling in 2023 coverage, that’s $34,545 in annual income).
And there is always an ongoing enrollment opportunity for Native Americans.
For 2023 coverage, UnitedHealthcare has joined the exchange in Ohio, and the ten existing insurers have continued to offer coverage. So eleven insurers offer plans in the exchange for 2023, with varying coverage areas:
Sidecar Health, which launched an ACA-compliant off-exchange plan in Ohio for 2022, had filed rates and plans for on-exchange coverage in 2023 (SERFF filing number SDCR-133290550), and their entry on ratereview.healthcare.gov does indicate that their plans were intended to be available through the exchange for 2023. However, Sidecar Health plans did not end up being available on-exchange for 2023, and they confirmed that their ACA-compliant plans continue to only be available off-exchange for 2023 (and still only in Ohio). The CMS insurer participation map shows just one additional carrier in Ohio’s exchange for 2023, which is UnitedHealthcare (all of the 2022 carriers continued to participate as well).
Humana announced in early 2017 that they would exit the individual market altogether, nationwide, at the end of 2017. So Ohio residents who had individual/family coverage from Humana in 2017 had to select new plans for 2018. Humana had already sharply reduced its individual market footprint, nationwide, at the end of 2016.
Anthem also pulled out of the exchange in Ohio, and their individual market offerings in 2018 consisted of a single off-exchange plan in Pike County. This prevented a full market exit in Ohio, allowing them the option to re-enter the state in 2019 — which Anthem did, with plans available in 25 counties. A full statewide exit would have prevented them from returning to Ohio’s individual market for five years, under long-standing HIPAA rules.
There were 67,000 people in Ohio with Anthem coverage who needed to select new plans for 2018. Eleven insurers offered plans in Ohio’s exchange in 2017, but their participation was localized. And in 20 of Ohio’s 88 counties, Anthem was the only participating exchange insurer in 2017 (Anthem was the only insurer in Ohio that offered exchange coverage in every county in 2017).
Premier Health Plan also exited the Ohio exchange at the end of 2017. They continued to offer one bronze plan outside the exchange (in the same 16 western Ohio counties where they offered coverage for 2017), but coverage under that plan ended on March 31, 2018. The rate filing indicated that only 40 members were expected to have coverage under Premier in 2018. Average rates for the remaining bronze off-exchange plan increased by an average of 34.63% in 2018, and anyone who had that plan in the first quarter of 2018 needed to purchase a new plan with coverage effective April 1, 2018. Premier noted in their rate filing that “members who choose to stick with a Premier plan until the exit date are likely to be sicker members who need the plan.” Premier is no longer offering any coverage in Ohio.
According to the federal rate review site (ratereview.healthcare.gov) the following average rate changes were approved for Ohio’s insurers for 2023:
According to ACA Signups, the weighted average rate increase for 2023 is just under 7% for Ohio’s individual/family plans. But whenever we talk about average rate changes for the coming year, it’s important to keep some caveats in mind:
For perspective, here’s a summary of how rates have changed in previous years in Ohio’s exchange:
2022: Average rate increase of 8.4%. At ACA Signups, Charles Gaba calculated a weighted average 2022 rate increase of about 8.4% for Ohio’s individual market health plans (based on 2021 enrollment and an assumption that enrollees keep their existing plans for the coming year). But the Ohio Department of Insurance calculated a weighted average rate increase of 4.76%. It’s not entirely clear how the Ohio Department of Insurance’s calculation differs, although we’ve seen a similar discrepancy in previous years with Ohio data, as noted above. It could have to do with wider coverage areas for some of the insurers and an average that’s based on projected membership as opposed to the existing membership.
259,999 people enrolled in private plans through the Ohio exchange during the open enrollment period for 2022 coverage. This was by far a record high, and was up 29% over the year before, when only about 201,000 people enrolled.
The record-high enrollment is due in large part to the American Rescue Plan’s subsidy enhancements, which make subsidies larger and more widely available through the end of 2022
Here’s a summary of sign-ups during open enrollment each year:
This mirrors the general trend that we’ve seen in states that use HealthCare.gov, with enrollment declining from 2016 through 2020 and then increasing in 2021 and growing to record or near-record highs for 2022. (states that run their own exchanges were much more likely to see increased enrollment during at least one of those years from 2016 through 2020).
Numerous factors contributed to the decrease in enrollment in previous years: In 2017 and 2018, premiums were sharply higher for people who don’t get premium subsidies. For 2018 and 2019, the Trump administration sharply reduced funding for enrollment assistance and exchange marketing. For 2019, the individual mandate penalty was eliminated and the Trump administration expanded access to short-term health plans as alternatives to ACA-compliant individual market coverage. But rates have been much more stable over the last few years, insurers have joined or rejoined the exchanges in many states, and enrollment began to rebound nationwide in 2021.
Ohio passed legislation in 2015 that requires the state to propose a 1332 waiver that would, if federal permission is granted, allow the state to eliminate the ACA’s individual and employer mandates. In March 2018, the state submitted a 1332 waiver to HHS, requesting the elimination of the individual mandate in Ohio as of January 1, 2019. But HHS deemed the application incomplete, and the state would have to revise it in order to have it reconsidered (that has not happened as of 2021, and it does not appear that the state has any plans to revisit the waiver proposal).
The federal government has already eliminated the individual mandate penalty as of January 1, 2019, but not the mandate itself (this was done via the Tax Cuts and Jobs Act that GOP lawmakers passed in December 2017). So under federal law, people are still technically required to maintain coverage, but the penalty, if they fail to do so, is now $0. Ohio went ahead and submitted their (ultimately incomplete) 1332 waiver proposal to HHS, requesting the elimination of the mandate itself in Ohio, as of 2019. But the waiver proposal noted that the impact would be negligible since the penalty is $0 in 2019 and beyond.
Ohio has not yet submitted a proposal to eliminate the employer mandate in the state. That change, if proposed and approved, would certainly have an impact on federal revenue, since nothing has changed about the employer mandate penalty, and the federal government is still collecting it. In order to receive federal approval for the elimination of the employer mandate in Ohio, the state would have to demonstrate a way to do so that would be budget-neutral for the federal government. That’s unlikely, given the reduction in employer mandate revenue that would result, along with the likely uptick in the number of people seeking subsidized individual market coverage if their employers were to stop offering coverage.
It’s noteworthy that there are a few states that are taking the opposite approach when it comes to the individual mandate, and have implemented state-based individual mandates — with state-based penalties — to replace the federal individual mandate penalty: New Jersey, Massachusetts, California, Rhode Island, and DC all have individual mandates with penalties for non-compliance (Vermont also has an individual mandate, but the state has not instituted a penalty for non-compliance). Those states are driven by the understanding that an insured population is a healthier population, and that a stable risk pool requires as many healthy enrollees as possible.
When Anthem announced that they would exit the exchange at the end of 2017, there were 20 rural counties — which had more than 11,000 exchange enrollees in 2017 — that did not have any insurers slated to offer exchange coverage. But on July 31, 2017, Ohio’s Department of Insurance announced that five existing exchange insurers had agreed to offer coverage in 19 of the 20 bare counties. Buckeye Health Plan, CareSource, Medical Mutual, Molina, and Paramount Health Care agreed to offer coverage in those counties.
Only Paulding County, in northwest Ohio, was still without any insurers slated to offer coverage at that point. State regulators continued to work with insurers to devise a solution for Paulding County, and On August 24, the Ohio Department of Insurance announced that CareSource had agreed to offer coverage in Paulding County. CareSource offered plans in 51 Ohio counties in 2017, and their 2018 rate filing indicated that they would expand to offer coverage in 59 counties in 2017, although the recent additional expansion further increases that number; CareSource agreed in late July to cover eight of the bare counties, and added a ninth with Paulding.
Nineteen of the 20 counties continued to have just a single insurer offering exchange plans, although Hancock County had 2018 plans available from both Medical Mutual and Molina. Each of the five insurers agreed to offer coverage in a handful of the bare counties (including one additional coverage area expansion announced later by CareSource), and the combined result was that every country in Ohio had at least one insurer offering coverage for 2018.
This happened in other states too, and insurers stepped in to fill the bare spots. Previously “bare” counties in Tennessee, Washington, Kansas, Missouri, Indiana, Wisconsin, and Nevada were all ultimately filled, and all areas of the country had plans available in the exchange in 2018.
In a July 2017 statement, the Ohio Department of Insurance noted that they “will continue working with the industry, but those efforts are heavily dependent on market stability and clarity from Washington. We encourage Congress to work on ways to stabilize our health insurance markets.” Insurers repeatedly stated in 2017 that the best way to stabilize the insurance markets would be for Congress to allocate funding for cost-sharing reductions (CSR) and enforce the individual mandate. But instead, the Trump Administration has cut off CSR funding and refused to commit to robust enforcement of the individual mandate — both of which contributed to a substantial portion of the rate increases that insurers implemented for 2018 plans.
But things were different in 2018 in terms of market stabilization efforts. Insurers in most states, including Ohio, added the cost of CSR to silver plan premiums for 2018, which ended up creating larger premium subsidies and making coverage more affordable for many enrollees. With that strategy, known as “silver loading,” people who don’t qualify for premium subsidies can purchase non-silver plans in order to avoid having to pay the extra premiums that were added to cover the cost of CSR, or can shop off-exchange for silver plans if the state allowed insurers to add the cost of CSR only to on-exchange silver plans (Ohio did allow this, so consumers were well protected for 2018). So while federal funding for CSR was at the top of the list in terms of market stabilization proposals in 2017, that is no longer the case. As long as insurers can continue to add the cost of CSR to silver plan premiums, the lack of federal funding for CSR will not destabilize the market or cause insurers to exit the market.
There are 16 counties in Ohio where gold plans were not available in the exchange for 2018 (Auglaize, Coshocton, Crawford, Erie, Hancock, Hardin, Hocking, Holmes, Knox, Marion, Mercer, Ottawa, Putnam, Richland, Williams, and Wyandot). In all of those counties, a single insurer offers coverage (either Medical Mutual or Paramount).
The lack of gold plans in 16 counties is despite the fact that the 2018 Benefit and Payment Parameters, finalized by HHS in late 2016, calls for all insurers in the federally-facilitated exchange to offer at least one gold plan and one silver plan in all parts of their service areas.
The ACA itself requires exchange insurers to offer at least one silver plan and one gold plan, but it doesn’t specify that they must do so in all parts of their service areas. As a result, there were 209 counties (in Iowa, Missouri, Nebraska, and Tennessee) where there were no gold plans available in the exchange in 2016. The rule change for 2018 was an effort to address this issue and ensure that all enrollees have access to at least silver and gold plans.
However, CMS clarified that Ohio has some flexibility on this issue because they’re a plan-management exchange (ie, the state retains plan management functions and certifies plans as qualified health plans to be sold in the exchange). As such, Ohio regulators allowed Medical Mutual and Paramount to offer gold plans in only part of their service areas. Both insurers do offer at least one gold plan in at least some areas of the state, thus satisfying the underlying statute of the ACA.
InHealth Mutual (Coordinated Health Mutual Inc.) was one of the 23 CO-OPs that were created by the ACA. By the end of 2015, 12 of those CO-OPs had closed, although InHealth Mutual was among the 11 that continued to provide coverage in 2016.
But in May 2016, the Ohio Department of Insurance announced that InHealth would be liquidated, and that 21,800 Ohio residents — most of whom had individual plans — would need to select new coverage. The DOI announced that there would be a 60-day special enrollment period (through July 26, 2016) during which InHealth Mutual members would be able to select new plans.
For members who did not select new plans, InHealth Mutual coverage technically remained in place until the end of 2016. But the state guaranty association stepped in to pay claims, which meant that the coverage was no longer considered minimum essential coverage, and had a benefit cap of $500,000. So a member who continued to pay premiums for InHealth Mutual throughout the rest of 2016 was not in compliance with the ACA’s individual mandate, potentially ending up with a penalty as a result. They also lost eligibility for any subsidies through Healthcare.gov. The Ohio DOI estimated that there were still about 7,800 people with InHealth Mutual coverage as of early August 2016.
Ironically, InHealth Mutual may have avoided the first round of CO-OP shut-downs because of the fact that they didn’t get their Ohio license in time to offer subsidized plans in the exchange in 2014. As a result, they had to rely on small group enrollments outside the exchange for 2014, and only ended up with 11% of their projected enrollment by the end of the year.
But that first wave of 2014 enrollees turned out to be sicker than expected, and nationwide, carriers lost money. Since InHealth Mutual hadn’t been able to offer plans in the exchange, they were spared the high claims that the other CO-OPs experienced, and ended up with a net income of negative $6 million for 2014 (that’s obviously still not good, but only four other CO-OPs did better that year).
By mid-2015, InHealth’s membership had more than tripled, to 22,000 people. But they still had a loss of $9 million during the first half of 2015, and were placed under enhanced regulatory oversight.
For 2016, InHealth had proposed an average rate increase of 7.7 percent, but later revised their request to 15 percent. The final approved average rate increase for their plans was 14.8 percent. However, regulators noted that in order to stem their losses, InHealth would have needed a rate increase of about 60 percent for 2017 if they had remained operational.
In June 2013, the Ohio Department of Insurance issued a press release announcing that 14 insurers filed plans to offer more than 200 options for individual insurance, and seven insurers would offer 84 options for small businesses (ultimately, two carriers backed out, leaving 12 in the exchange in 2014). Then-Lt. Gov. Mary Taylor, who also directed the state’s insurance department until 2017, stated in the press release that “consumers will have fewer choices and pay much higher premiums for their health insurance starting in 2014.”
Both opponents and supporters of the Affordable Care Act jumped on the press release. Opponents claimed Ohio was the latest example of “rate shock.” Supporters dismissed the announcement for making “apples-to-oranges” comparisons and pointed out that both Kasich and Taylor had been outspoken about their opposition to the ACA.
Laws were enacted in Ohio to make it more difficult for navigators to be certified, which means that the state has fewer people available to assist applicants, and there was a delay in getting them started as navigators after the exchange opened in October 2013.
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