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

State sees modest rate changes for 2022, and nearly all counties have 3+ insurers offering plans; ACA open enrollment for 2022 coverage has started

Image: Denise Kappa / stock.adobe.com

Ohio exchange overview

Ohio has a federally facilitated exchange, which means residents in Ohio use HealthCare.gov to enroll in exchange plans. But Ohio is one of seven states that participates in plan management and the qualified health plan (QHP) certification process.

201,069 people enrolled in plans through Ohio’s exchange during the open enrollment period for 2021 coverage.

Ohio expanded Medicaid under the ACA, due in large part to the efforts of then-Governor, John Kasich, a Republican who opposed the ACA in general but supported Medicaid expansion. Ohio residents can enroll in QHPs or Medicaid via the exchange, with eligibility dependent on income. Enrollment in Medicaid runs year-round.

When can I enroll in health insurance in Ohio?

Open enrollment for 2022 health plans in Ohio runs from November 1, 2021 through January 15, 2022. In order to have coverage effective January 1, you’ll need to enroll or switch plans by December 15 (enrollments completed between December 16 and January 15 will have coverage effective February 1).

The fall open enrollment period is an excellent opportunity to take advantage of the American Rescue Plan’s subsidy enhancements. Subsidies are larger and more widely available as a result of this law, and those benefits will continue to be in effect throughout 2022.

If you have questions about open enrollment, you can learn more in our comprehensive guide to open enrollment.

Although the open enrollment window in the fall of 2021 is for coverage that will take effect in 2022, you may still be able to enroll in coverage for 2021 if you experience a qualifying life event, or if you’ve received unemployment compensation at any point in 2021.

2022 rates and plans: Mostly single-digit rate changes, all but two counties have at least three participating insurers

The ten insurers that offer coverage in Ohio’s exchange in 2021 will all continue to do so in 2022. And some are expanding their coverage areas, resulting in all but two counties having at least three participating insurers; 20 counties have six or more insurers offering plans for 2022 (in 2021, there were 10 counties that had just two participating insurers, and in 2020, there were 29).

According to SERFF, the following average rate changes were approved for Ohio’s insurers for 2022:

  • AultCare: 6.5% increase
  • Ambetter (Buckeye Community Health Plan): 21.2% increase
  • CareSource: 6.5% increase
  • Community Insurance Company (Anthem BCBS): 2% decrease
  • Medical Health Insuring Corp. of Ohio (Medical Mutual): 1.46% increase
  • Molina: 4% increase
  • Oscar Buckeye State Insurance Corporation: 0.5% decrease
  • Oscar Insurance Corporation of Ohio: 4.1% increase
  • Paramount: 5.6% decrease
  • Summa: 20.6% decrease

As ACA Signups’ Charles Gaba noted, that works out to a weighted average rate increase of about 8.4% (based on current enrollment and an assumption that enrollees keep their existing plans for the coming year). But the Ohio Department of Insurance has 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 (more details below in the specifics for each year). It could have to do with wider coverage areas for some of the insurers and an average that’s based on projected membership in 2021 as opposed to rate changes for existing 2021 membership.

And whenever we talk about average rate changes for the coming year, it’s important to keep some caveats in mind:

  • The approved rate changes only apply to full-price premiums. Most exchange enrollees get premium tax credits (subsidies), which means they don’t pay full price for their coverage. For subsidized enrollees, the net rate change from one year to the next will depend on how their own plan’s rates change, as well as any changes in their subsidy amount (which depends on the cost of the benchmark plan, as well as the enrollee’s projected income for the coming year).
  • Overall average rate changes don’t account for the fact that premiums increase with age. Even if your insurance company doesn’t increase its overall rates at all, your rate will increase from one year to the next, just because you’re getting older (if you get a subsidy, your subsidy will also increase to keep pace with your age; subsidies are larger for older enrollees).
  • A weighted average lumps all the plans together to come up with one average premium and percentage change. But different insurers offer plans in each region, and each insurer’s rate change is different. So the exact rate change that applies to a given enrollee can vary quite a bit from the average.

For perspective, here’s a summary of how rates have changed in previous years in Ohio’s exchange:

  • 2015: Average rate increase of 12%. After reviewing plans and rates, the Ohio Department of Insurance announced in the fall of 2014 that the average rate increase for 2015 would be 12 percent in the individual market, although this was not a weighted average (which likely would have indicated a lower overall average increase). Fifteen carriers sold 2015 individual plans in the Ohio exchange, up from twelve in 2014. All except Time/Assurant returned to the exchange for 2016. Ohio was tied with Michigan for having the most carriers of any exchange in the country for 2015.
  • 2016: Overall rates up 9-13% (but benchmark plan rates decreased). There were 15 insurers offering plans in Ohio’s exchange in 2016. According to ACA Signups, average premiums increased by about 9.4%, although the Dayton Daily News indicated that overall rates in the Ohio exchange increased by an average of about 13% for 2016. But average benchmark premiums (on which subsidy amounts are based), declined in Ohio for 2016 (of the 37 states that used HealthCare.gov that year, only four had an average decrease in their benchmark premiums — and Ohio was among them).
  • 2017: Weighted average rate increase of about 17%. Three insurers that offered exchange plans in Ohio in 2016 — InHealth Mutual, Aetna, and All Savers/UnitedHealthcare — did not offer plans in 2017. And HealthSpan was purchased by Medical Mutual; HealthSpan’s individual market plans ended on December 31, 2016, and were replaced with Medical Mutual coverage — but enrollees had the option to pick a different carrier instead. The rest of the carriers that offered coverage in the Ohio exchange in 2016 continued to offer plans for 2017. At ACA Signups, Charles Gaba calculated a weighted average rate increase of 17.33% for the individual market in Ohio. This was lower than the national average that year, which was about 25%.
  • 2018: Weighted average rate increase of 34%. Eight insurers offered plans in Ohio’s exchange for 2018, including Oscar, which was new to the exchange that year (but Humana, Anthem, and Premier stopped offering plans at the end of 2017). The weighted average rate increase in Ohio for 2018 was about 34%, although it would have been about 23% if the Trump administration hadn’t eliminated funding for cost-sharing reductions (CSR) in the fall of 2017. The insurers initially filed 2018 rates based on the assumption that CSR funding would continue in 2018, but the Ohio Department of Insurance later directed them to refile new rates based on the assumption that CSR funding would not continue, and with the cost of CSR added to silver plan premiums for 2018. The Ohio Department of Insurance also allowed insurers to create off-exchange-only silver plans with the same benefits as the on-exchange silver plans, but without the cost of CSR added to the premiums (in areas where such plans are available, they present a good option for people who don’t qualify for premium subsidies, but who want to purchase a silver plan; for people who do qualify for premium subsidies, the additional premiums are offset by larger premium subsidies in the exchange).
  • 2019: Average rate increase of about 6%. Anthem returned for 2019 in 25 counties. Oscar Insurance Corporation of Ohio joined the exchange in 2018, but the company expanded into the Columbus area for 2019, with a new entity called Oscar Buckeye State Insurance Corporation. According to the Ohio Department of Insurance, average premiums in Ohio’s exchange increased by 6.3% for 2019. But average benchmark premiums (on which premium subsidies are based) increased by just 3% in Ohio in 2019.
  • 2020: Average rate decrease of more than 7%. Ten insurers offered plans in Ohio’s exchange for 2020, which was also the case for 2019. But there were some coverage area expansions for 2020, resulting in more choices for some residents. In 2018, there were 42 counties with only one insurer, and that had dropped to just one county (Logan) by 2020. Two of the ten insurers, with a combined total of 46,514 policyholders, implemented average rate decreases for 2020. The other eight insurers, with a combined total of 100,140 policyholders, implemented average rate increases. But ACA Signups’ Charles Gaba reported that the Ohio Department of Insurance had indicated that the average approved rate change would be a 7.7% decrease. Given the market share of the insurers and their average rate changes, it appeared that average premiums in Ohio were increasing for 2020, rather than decreasing. It’s possible, however, that insurers introduced new (lower-cost) plans for 2020, and that the average premiums, including the rates for those plans, ended up being lower than the average premium was in 2019. Indeed, once plan selections for 2020 were finalized, the overall average pre-subsidy premium amount in Ohio’s marketplace was $518/month in 2020, down from $533/month in 2019. This reflects actual plan selections for the new year, however, as opposed to how rates would have changed if everyone had kept their existing coverage from one year to the next.
  • 2021: Average rates nearly unchanged. When the rates were filed for 2021, the Ohio Department of Insurance noted that “Premiums for 2021 are projected to stay relatively stable from 2020 — though individual companies’ rates will vary from the average. Weighted average annual premiums for the individual market for 2021 is projected to be $5,670.63. In 2020 weighted average annual premiums were $5,690.26 — a decrease of .4%.” The approved rates were all the same or very similar to the rates the insurers filed. But the overall average rate increase seems to come to about 3.3% by our calculations, based on 2020 membership (at ACA Signups, Charles Gaba calculated a similar weighted average rate increase of 3.23%). As noted above, the Ohio DOI seems to take a different approach to determining average rate changes, and doesn’t base it on existing plans and enrollment.

2021 enrollment: Up 2% from 2020, but still well below peak enrollment in 2016

201,069 people enrolled in private plans through the Ohio exchange during the open enrollment period for 2021 coverage. That was up about 2% from the year before, but still well below the Ohio exchange’s peak enrollment, when more than 243,000 people enrolled in 2016.

Enrollment continued to grow in 2021, due to the COVID-related enrollment period, which ended August 15, 2021. CMS reported that more than 48,000 people enrolled in coverage through Ohio’s exchange between February 15 and August 15, 2021. That was more than two and a half times the enrollment pace during the same timeframe in previous years, when a qualifying event would have been necessary in order to enroll.

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. (states that run their own exchanges have been 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 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 and association 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 wants to eliminate the individual and employer mandates

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.

Humana, Anthem, and Premier exited at the end of 2017; Oscar joined

Humana announced in early 2017 that they would exit the individual market altogether, nationwide, at the end of 2017. Humana was one of the insurers that offered plans in the Ohio exchange in 2017. But at the end of 2016, Humana sharply reduced its individual market footprint, nationwide. They remained in 11 states (down from 19 in 2016), but only offered plans in a total of 156 counties across those 11 states (for reference, there are 88 counties in Ohio alone).

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.

Initially, 20 counties had no plans filed for 2018. But other insurers agreed to cover them.

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.

16 counties had no gold plans available for 2018

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 CO-OP liquidated in 2016

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.

Medicaid expansion in the Buckeye state

Former Ohio Governor John Kasich was not an ACA proponent, but he actively pushed for Medicaid expansion in Ohio, which was approved in late October 2013. Eligible residents were able to begin enrolling in expanded Medicaid on December 9, 2013. Net enrollment in Ohio’s Medicaid program has grown by 43% since the fall of 2013.

However, opponents of Medicaid expansion brought a lawsuit against the Ohio Department of Medicaid and the state’s Controlling Board because the General Assembly was bypassed in the decision to expand Medicaid. The plaintiffs hoped to block the state from expanding Medicaid, but on December 20th, 2013 the Ohio Supreme Court sided with Governor Kasich and kept Ohio Medicaid expansion on track. The Court’s ruling came less than two weeks before expanded Medicaid took effect.

Exchange history in Ohio

In November 2012, Governor 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). Ohio is one of five states that use the marketplace plan management model.

Ohio residents can compare plans, determine subsidy eligibility and enroll in coverage at Healthcare.gov.

Leadership’s opposition to the ACA

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.

Ohio health insurance exchange links

HealthCare.gov
800-318-2596

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

Ohio Department of Insurance — Federal Health Reform FAQs

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