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15 insurers offer 2023 coverage in Texas exchange, including three newcomers and two exits. Subsidies larger than ever due to new Texas rate-setting rule.
Texas uses the federally run exchange at HealthCare.gov to enroll Texans in marketplace plans. Although their future is uncertain, there are bills under consideration in Texas in the 2023 legislative session (HB700, HB2554, and SB344) that would create a state-run health insurance exchange.
Fifteen health insurance carriers offer 2023 coverage through the Texas marketplace/exchange. That includes three newcomers (Ascension Personalized Care, Cigna, and Imperial Insurance Companies), but there were also two insurers that left the exchange at the end of 2022 (Bright and Friday).
Texas has the nation’s second-highest exchange enrollments in the country, and leads the nation in terms of how fast new enrollees are signing up for coverage (enrollments count both new enrollees and renewing enrollees). Enrollment in the Texas exchange reached a record high 2.4 million people during the open enrollment for 2023 coverage; the previous record high had been 1.8 million enrollees the year before.
Premiums for individual/family health coverage increased sharply in Texas in 2018, and insurers mostly started adding the cost of cost-sharing reductions (CSR) to silver plan rates, resulting in particularly large premium subsidies (which are based on the cost of silver plans). Rate changes have been mostly modest since then, but it’s important to note that Texas implemented a new rule — for coverage effective in 2023 and future years — requiring health insurers to add a 35% load to the cost of silver plans to account for CSR. This effectively makes silver plan prices higher than most gold plan prices, resulting in larger subsidies and even more affordable premiums for bronze and gold plans.
In addition, the American Rescue Plan and Inflation Reduction Act have resulted in larger and more widely available subsidies.
Texas uses the federally run exchange at HealthCare.gov, and the state has taken a very hands-off approach with regards to implementing the ACA. Texas has not expanded Medicaid, and through 2021, was one of just three states that left the rate review process for ACA-compliant plans to CMS. That has changed as of 2022, however, with the implementation of a state-based rate review program (details below).
And lawmakers in Texas are considering bills in 2023 (HB700, HB2554, and SB344) that would create a state-run health insurance exchange.
Texas has one of the highest exchange enrollments in the country, trailing only Florida. During the open enrollment period for 2023 coverage, more than 2.4 million people enrolled in private qualified health plans (QHPs) through the Texas exchange. This was by far a record high, eclipsing the previous record high of 1.8 million enrollees the year before.
According to US Census Bureau data, Texas had the highest uninsured rate in the country in 2013, at 22.1%, and it has continued to have the highest uninsured rate in the nation ever since. Although 18.4% of Texans were still uninsured as of 2019, a substantial number of Texas residents have obtained health coverage since the ACA was implemented.
However, the number of people gaining coverage would be far higher if Texas were to accept federal funding to expand Medicaid under the ACA. Among adults with income up to 138% of the poverty level (ie, the population that would be Medicaid-eligible if Texas were to expand Medicaid), Texas still has the highest uninsured rate in the country; 45% of the state’s lowest-income residents are without health coverage.
The open enrollment period for individual/family health coverage runs from November 1 to January 15 in Texas.
Outside of that annual open enrollment window, you’ll need a special enrollment period to enroll or make a change to your coverage. In most cases, you’ll need a qualifying life event in order to qualify for a special enrollment period. But some special enrollment periods (such as the enrollment opportunity for Native Americans, or for people earning under 150% of the poverty level) aren’t tied to a specific life event.
If you want more information about health insurance enrollment opportunities, you can read more in our guide to open enrollment and guide to special enrollment periods, both of which are comprehensive resources.
For 2023, three new insurers joined the Texas individual/family market: Cigna, Imperial Insurance Companies, and Ascension Personalized Care. But Friday and Bright both left the Texas market at the end of 2022 (the Texas Department of Insurance asked Friday to stop offering plans and the company has since been placed into receivership and ordered to liquidate; Bright opted to exit the individual market in every state where they had offered coverage in 2022). So Texas has 15 insurers offering exchange plans for 2023, up from 14 in 2022.
The following insurers offer plans in the Texas exchange for 2023, with plan availability varying from one location to another:
The exchange in Texas had 15 carriers offering plans in Texas for 2015, up from 12 in 2014. Only Michigan and Ohio had more carriers in their exchanges, with 16 each. By 2018, the number of participating insurers had dropped to eight, but it had rebounded to 14 as of 2022.
UnitedHealthcare, Aetna, Cigna, Allegian Health Plan, and Scott & White Health Plan all exited the Texas marketplace at the end of 2016. So by 2017, only ten insurers were offering plans in the Texas exchange, and most of them only offered coverage in a fraction of the state’s 254 counties. In the majority of the counties, there were one, two, or three carriers offering plans. And there were no PPO plans available in the exchange by 2017; insurers had opted to switch to more economical HMOs and EPOs as a cost-saving measure.
At the end of 2017, Humana and Prominence left the Texas marketplace (and the entire individual market). But both insurers had only offered plans in a tiny fraction of the counties in Texas, so their exits did not affect most of the state.
By 2021, insurers had started to return to the Texas exchange. Friday Health Plan joined the exchange, and Scott & White Health Plan rejoined the exchange, after previously exiting at the end of 2016. This brought the total number of participating insurers to ten. Molina expanded its coverage area into five counties that previously only had plans available from Blue Cross Blue Shield of Texas and/or Ambetter.
And for 2022, there was an influx of insurers: United Healthcare rejoined the exchange, along with Aetna/CVS. In addition, Moda Health Plan and Bright Health Care also joined the exchange, bringing the total number of exchange insurers to 14.
For 2023, Friday and Bright exited the Texas exchange, while Ascension Personalized Care, Imperial Insurance Companies, and Cigna joined, bringing insurer participation to 15.
According to the federal rate review website, the following average rate changes were implemented by insurers in Texas for 2023, applicable to full-price premiums (keeping in mind that very few enrollees pay full price, as most are eligible for premium subsidies; caveats described in more detail below):
Bright had proposed an 11% rate increase and Friday had proposed a 30% rate increase, but both insurers ultimately opted to leave the market so their rates were not applicable for 2023.
According to ACA Signups, the weighted average rate increase (after accounting for Bright and Friday leaving the market) amounted to about 4.9% for 2023.
As of 2022 (for health plans effective in 2023), Texas conducts its own rate review. In previous years, the federal government did the rate review, as Texas was one of only three states that didn’t have its own effective rate review program. That changed as of 2022, so the Texas Department of Insurance now conducts the rate review for ACA-compliant health plans.
Whenever we talk about average rate increases — from a single insurer or as a statewide average — it’s important to keep in mind that the actual rate changes that individual enrollees see from one year to the next can be very different from the average. There are several reasons for this:
For perspective, here’s a look at how rates have changed in the Texas exchange over the years:
2015: Twelve carriers offered a total of 95 different health plans in the Texas exchange in 2014. This increased to 15 in 2015, and a Commonwealth Fund analysis found an average rate increase of 5% in the Texas exchange for 2015. For silver plans, it was just 2%. Rate increases tended to be lower in urban areas of Texas.
2016: Average premiums in the individual market in Texas increased by 15.8% for 2016, although there was considerable variation from one insurer to another. Rates decreased for five carriers, and increased by between 5% and 34% for the remaining carriers. Statewide, the average benchmark plan was 5.1% more expensive in 2016, which means subsidies were higher, but only modestly so.
2017: For 2017, average premiums in the individual market in Texas rose by about 34%. Although premium subsidies grow to keep pace with premiums, they’re based on the cost of the benchmark plan (second-lowest-cost silver plan) in each area. HHS reported that for a 27-year-old enrollee, the average second-lowest-cost silver plan in the Texas exchange was 18 percent more expensive in 2017 than it had been in 2016 (that’s a little lower than the 2017 national average increase of 22% for second-lowest-cost silver plans). So although subsidies did increase in 2017 in Texas, the increase may have been smaller than the premium increase that some enrollees experienced, leaving them with higher net premiums.
2018: In most cases, Texas insurers filed rates in the spring/early summer 2017 that assumed federal funding for cost-sharing reductions (CSR) would continue in 2018. But by the time CSR funding was officially eliminated by the Trump Administration in October 2017, all of the Texas insurers had filed rates that were based on the assumption that CSR funding would not continue. Texas did not instruct insurers on how to add the extra cost to their premiums, so they had to option of spreading it across the premiums for all plans, adding it to all silver plan rates, or adding it to only on-exchange silver plan rates. In some cases, the Texas filings make it clear that the cost of CSR was only being added to silver plans, and at least one insurer (CHRISTUS) filed an additional revised rate structure to ensure that the cost of CSR would only be added to on-exchange silver plans. Sendero’s rate filing indicated that they would market an off-exchange-only silver plan in addition to their exchange plans (off-exchange-only plans do not have to include the cost of CSR in their rates).
There was some uncertainty in terms of exactly how large the approved rate increase was for 2018. But the average premium (before any subsidies were applied) in the Texas exchange was $404/month in 2017, and it grew sharply, to $543/month, in 2018.
2019: At ACA Signups, Charles Gaba calculated an average rate increase of 2.25% for 2019, including a few insurers that only offer plans outside the exchange. As was the case for 2018, the Texas Department of Insurance did not instruct insurers on how to add the cost of cost-sharing reductions (CSR) to premiums for 2019. The CSR approach was instead left to each insurer’s discretion. Adding the cost of CSR only to silver plan premiums (in many cases, only to on-exchange silver plan premiums) is the most popular approach across the country, but insurers also had the option to add the cost of CSR to all plans.
2020: Eight insurers offered plans in the Texas marketplace for 2020. Gaba calculated a weighted average rate decrease of 1.4% for 2020, including the insurers that only offer plans outside the exchange.
2021: Ten insurers offered plans in the Texas marketplace for 2021. Gaba calculated a weighted average rate increase of 7.4%, although as always, the average doesn’t tell the whole story.
2022: Across all of the existing carriers, the average rate change was somewhere in the range of a 1.5% to 5% increase, although some of the enrollment numbers are unavailable, making it impossible to determine a fully weighted average. Nationwide, the average rate change for 2022 amounted to an increase of about 3.5%, making the Texas rate changes very much in line with the national average.
In June 2021, Texas enacted House Bill 3924. The legislation, which took effect in September 2021, allows Texas Farm Bureau to sell medically underwritten health plans that are not considered health insurance. This means that the plans are exempt from state and federal health insurance regulations.
The Texas Farm Bureau made these plans available as of mid-2022.
Since the plans are not subject to insurance rules, they are not required to cover essential health benefits, cap out-of-pocket costs, or provide guaranteed-issue coverage. H.B.3924 specifies that the plans cannot exclude a pre-existing condition for more than six months after a person enrolls. But the plans are allowed to charge applicants higher premiums based on their medical history, or reject the application altogether.
People who aren’t eligible to enroll in the Farm Bureau plans due to their medical history will still be able to sign up for ACA-compliant health insurance (through the Texas exchange or directly through an insurance company) during open enrollment or a special enrollment period. But consumer advocates worry that if healthy enrollees shift over to the Farm Bureau plans, they will leave the ACA-compliant risk pool with less healthy membership and thus higher premiums for everyone.
It’s worth noting, however, that the American Rescue Plan’s temporary elimination of the “subsidy cliff” means that most people are now eligible for premium subsidies in the exchange, at least through the end of 2025 (and Congress might extend that again). There are no subsidies available for Farm Bureau plans, so they’re really only an attractive alternative for healthy people who would otherwise have to pay full price for an ACA-compliant plan. And since more people are now eligible for premium subsidies in the exchange, there are fewer people who are likely to enroll in Farm Bureau plans instead.
Indiana, Iowa, Kansas, South Dakota, and Tennessee have similar laws on their books, allowing medically underwritten, non-insurance, Farm Bureau plans to be sold (Nebraska also has Farm Bureau health plans available, but they can only be purchased by people actively involved in agriculture, and they do not use medical underwriting).
Surprise balance billing has long been a thorny issue in health care reform. After several years of working on a solution, the federal government did ultimately enact legislation to protect consumers from most instances of surprise balance billing as of 2022.
But many states had stepped up to protect their own residents who had state-regulated health coverage, and Texas was among them. Surprise balance billing occurs when a patient uses an out-of-network provider, but not by choice. It can be an emergency situation in which the closest hospital is out-of-network, or it can be a situation in which the patient goes to an in-network facility but is treated by out-of-network providers. This might be an assistant surgeon, anesthesiologist, radiologist, laboratory, durable medical equipment supplier, etc. And while the patient did their due diligence in terms of finding an in-network facility, it can be challenging — or next to impossible — to ensure that every provider who works with the patient will also be in the patient’s insurance network.
With the enactment of S.B.1264, Texas joined a growing list of states that had addressed the issue of surprise balance billing. And the Texas legislation, which applies to medical services provided on or after January 1, 2020, is among the most comprehensive in the country, providing solid consumer protections (see more details from the Texas Department of Insurance, in a mid-2021 report about the implementation of S.B.1264).
The legislation, which passed in the Texas Senate by a vote of 29 to 2 and unanimously in the House, is robust. But it only applies to the 16% of Texas residents — those who have state-regulated private plans (self-insured plans, which are used by most very large businesses, are not state-regulated). This is why the federal No Surprises Act was so important, as it protects people who don’t have state-regulated health insurance.
The Texas law prohibits the out-of-network provider from billing the patient for amounts in excess of the patient’s regular cost-sharing responsibilities (ie, copays, deductible, coinsurance), and instead requires the provider and the patient’s insurance to enter into mediation or arbitration, overseen by state regulations, to come to a payment agreement, without the patient being stuck in the middle of the financial dispute.
The Texas Department of Insurance was tasked with developing the rules related to the mediation and arbitration process; updates on that process are available here. The Department announced in November 2019 that FAIR Health had been selected as the benchmarking database that will be used in arbitration cases.
The process of rulemaking for the implementation of SB1264 was complicated. Controversy arose when the Texas Medical Board proposed having all out-of-network providers give patients consent forms (the law intended for those forms to only be used when a patient knowingly wants to use an out-of-network provider). Consumer advocates were concerned that the Board’s proposal would essentially result in patients having to deal with confusing paperwork and potentially signing away their balance billing protections. But the Board withdrew that proposal in early December.
Texas also enacted SB1037 in 2019, ensuring that when a surprise balance bill is sent to collections, it won’t show up on the person’s credit report. As long as the person had health insurance at the time of the treatment and the bill is for out-of-network emergency care or out-of-network providers who treated the patient at an in-network facility, the unpaid bill won’t affect the person’s credit report.
SB1742, also enacted in 2019, requires health plan provider directories to make it clear whether specialists practicing at in-network facilities are also in-network. In addition, the legislation imposes new rules related to prior authorization, including a readily available list of services that are subject to prior authorization requirements, and information about the insurer’s total volume of prior authorization requirements and denials.
Enrollment is far higher in the Texas marketplace in 2023 than it was in any previous year: More than 2.4 million people enrolled in private plans during open enrollment for 2023 coverage. The prior record-high enrollment had been set just the year before, when more than 1.8 million signed up during the open enrollment period that ended in mid-January 2022.
The record-high enrollment is due primarily to the enhanced premium subsidies created by the American Rescue Plan, as well as the longer open enrollment period and the additional federal funding provided for outreach and enrollment assistance.
Here’s a look at how enrollment has changed over the years in the Texas marketplace (in terms of the number of people signing up for private plans through the exchange during the open enrollment window):
In 2021, Texas enacted S.B.1296. This legislation creates a rate review program in the state, which means that Texas no longer defers to the federal government for the rate review process, starting with the 2023 rates that were filed by insurers in 2022 (prior to 2022, Texas, Wyoming, and Oklahoma were the only states that had the federal government conduct their rate reviews, rather than doing it themselves).
Texas lawmakers noted that a state-based rate review program will allow them to ensure that health insurance companies take a uniform approach to “silver loading” the cost of cost-sharing reductions, which will increase the size of premium subsidies that Texas residents receive.
As of the 2023 plan year, insurers in Texas must add a 35% load to the cost of silver plan rates to account for CSR (in prior years, many Texas insurers did add the cost of CSR to silver plan rates, but the approach wasn’t uniform or universal). This results in larger subsidies — because subsidies are based on silver plan rates — and effectively makes most silver plan rates higher than most gold plan rates. So bronze and gold plans will be more affordable for many Texas exchange enrollees in 2023.
As a result of the Affordable Care Act, federal law only allows a self-employed married couple to purchase small group health insurance if there is at least one additional employee. Even if both spouses are work for their business, they aren’t considered to be two separate employees (and thus eligible for group health coverage, which requires at least two employees) under federal law. But Texas law is different, and takes precedence in this case. In Texas, a small group insurer must issue coverage to any group of two or more employees, even if the group only has two employees who are married to each other.
At the end of May 2015, the Texas state senate passed House Bill 1514, and Governor Abbott signed it into law the following month. The law became effective in September 2015, and requires insurance carriers to label policy ID cards with “QHP” (qualified health plan) if the plan was purchased through the exchange.
The initial version of the House bill called for two different designations for exchange-purchased policy ID cards: “QHP” for plans purchased without a subsidy, and “QHP-S” for plans purchased with a subsidy (86 percent of the exchange enrollees in Texas are receiving subsidies). But the version that was ultimately signed into law dropped the “S” and simply calls for identifying all exchange enrollees with the “QHP” designation.
Many provider organizations were in support of HB 1514, because there’s a 90-day grace period for subsidized exchange enrollees who fall behind on their premiums, as opposed to the 30-day grace period for plans purchased outside the exchange and for non-subsidized exchange plans. During that time, carriers have to pay claims from the first 30 days, but can retroactively deny claims from the following 60 days (assuming the patient doesn’t pay the past due premiums) and can require the provider to refund payments made during that time.
Supporters of the bill claim that the QHP designation simply serves to keep providers aware of the need to remind their patients to remain current with their premiums. But the QHP label lets providers know that chances are, the patient is receiving a subsidy and thus has a 90 day grace period to remain current on premiums. It’s not unreasonable to assume that some providers would then choose to not work with those patients. The bill generated considerable controversy between provider organizations and consumer advocates.
In November 2013, the federal government announced that states could allow non-grandfathered, pre-2014 health plans (dubbed “grandmothered” plans) to renew again and remain in force in 2014. In March 2014, they issued another extension for these transitional policies, allowing states to let them continue to renew as late as September 2016. The majority of the states have accepted that proposition, but in 2014, Texas regulators simply didn’t issue any guidance whatsoever on the matter (in interviews with insurance officials in each state, Texas was alone in this regard – every other state took a position either for or against renewal of grandmothered plans).
Because Texas didn’t issue any guidelines for renewal of grandmothered plans, regulators initially said that grandmothered plans would not be allowed to renew in Texas in 2014. But they eventually reversed course on this, with the Department of Insurance simply noting that they do not object to carriers renewing grandmothered plans in accordance with federal guidelines. HHS has since issued additional guidance (in early 2022), allowing transitional plans to continue to renew until further notice (at states’ and insurers’ discretion). Texas is allowing this, so it’s up to each insurer to decide whether to continue to renew transitional plans or not.
Former Texas Gov. Rick Perry formally notified the Department of Health & Human Services (HHS) in July 2012 that Texas would not implement a state-run health insurance exchange. In his notification letter, Perry — a long-standing opponent of the Affordable Care Act — called the ACA provisions “brazen intrusions into the sovereignty of our state.”
Texas State Representative Eric Johnson, a Democrat from Dallas, did introduce bills in early 2013 that would have created a state-run exchange and expanded Medicaid, but neither was successful. HHS is running the exchange in Texas, and the state is one of only 12 where Medicaid still has not been expanded as of 2022.
The Texas High-Risk Pool (a health plan for people with pre-existing conditions that pre-dates the ACA) remained open for the first three months of 2014, after originally being scheduled to cease operations at the end of 2013. This was the case in several states, as HealthCare.gov had some significant glitches in the first open enrollment period, which hampered enrollment efforts.
In January 2014, the Perry Administration’s efforts to make it more difficult to be a navigator in Texas drew criticism from ACA supporters and Democratic lawmakers, who claimed that Perry was simply trying to impede enrollment in the Texas exchange.
According to a Kaiser Health News article, Blue Cross Blue Shield of Texas played a major role in educating state consumers about the federal health insurance marketplace in its early days. The Blues plan used many strategies to reach consumers: creating a website, launching a texting campaign, and engaging churches, community clinics, nonprofits, and other community organizations.
Texas Health Plan Compare (a service of the Texas Department of Insurance)
State Exchange Profile: Texas
The Henry J. Kaiser Family Foundation overview of Texas’ progress toward creating a state health insurance exchange.
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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