- COVID-related enrollment window runs through August 15, 2021 (no qualifying event necessary) and larger premium subsidies are available as a result of the American Rescue Plan.
- Friday Health Plans has entered the Texas marketplace for 2021, along with Scott & White Health Plan.
- Rate changes for 2021 range from a 33% decrease to a 12% increase (but subsidies are larger than ever, thanks to the American Rescue Plan).
- Texas law that protects consumers from surprise balance billing took effect in 2020.
- Nearly 1.3 million Texans enrolled for 2020, bringing enrollment nearly to the record-high point it reached in 2016 (and enrollment continues at a rapid pace during the COVID-related enrollment window in 2021).
- A self-employed married couple can buy small-group coverage in Texas.
What type of health insurance marketplace does Texas operate?
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 is one of just three states that leaves the rate review process for ACA-compliant plans to CMS. (The state does also review filings to make sure they’re compliant with Texas law.)
Texas is also leading an 18-state lawsuit that challenges the legality of the ACA now that the individual mandate penalty has been repealed. The case was heard by the Supreme Court in November 2020, and a ruling is expected by June 2021.
But Texas also has one of the highest exchange enrollments in the country, with 1,291,972 people enrolling in private plans through the Texas exchange during the open enrollment period for 2021 coverage. The state has a very large population, many of whom were uninsured pre-ACA. Only two states — Florida and California — have higher enrollment in their exchanges (not counting Medicaid) than Texas. And Texas was one of only a handful of HealthCare.gov states where enrollment increased from 2019 to 2020 (it increased again in 2021, but that was also the case in many other states, with nationwide average enrollment increasing for 2021).
Rates increased sharply in 2018, and insurers 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) in 2018. For 2019, however, the average rate increase was much more modest, at just over 2%. For 2020, average rates decreased slightly. And although the average rate increase was still in the single digits for 2021, it was a larger rate increase than we saw across most states. The cost of CSR is still being added to silver plan rates, so subsidies are still disproportionately large in Texas. And the American Rescue Plan has made subsidies larger than ever for 2021 and 2022.
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. Athough 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.
When can I enroll in health insurance in Texas?
Due to the COVID pandemic and the additional premium subsidies provided by the American Rescue Plan, there’s a one-time enrollment window that continues through August 15, 2021 in Texas. A qualifying event is not necessary during this window, and it can be used by people who want to newly enroll in coverage through the marketplace, as well as those who already have marketplace coverage and wish to make a plan change (in order to best take advantage of the newly enhance premium subsidies, plan changes are necessary in some cases).
During the first several weeks of the COVID-related enrollment window, more than 98,000 Texas residents enrolled in coverage. This was more than triple the enrollment pace during the same time frame in 2020 (when a qualifying event would have been necessary to enroll).
After August 15, 2021, the normal rules will once again apply. A qualifying event will be necessary in order to enroll or make a plan change for 2021 coverate. Open enrollment for 2022 health plans in Texas will begin November 1, 2021, for coverage effective January 1, 2022.
Which insurers offer 2021 coverage in the Texas marketplace?
As of 2021, there are ten insurers that offer exchange plans in Texas. That includes two newcomers: Friday Health Plan joined the marketplace in Texas as of 2021, as did Scott & White Health Plan. The following insurers offer plans in the Texas exchange as of 2021, with plan availability varying from one location to another:
- Celtic/Ambetter (Ambetter from Superior Health Plan)
- Blue Cross Blue Shield of Texas
- Friday Health Plan
- Community Health Choice
- Scott & White Health Plan
Friday Health Plan’s options are available in several metro areas: Austin, Dallas, El Paso, Houston, Lubbock, and San Antonio. Friday Health Plans also expanded into the marketplaces in Nevada and New Mexico for 2021.
Scott & White Health Plan (see basic details in SERFF filing number SWHP-132428675) is offering exchange plans in the northern part of Texas as of 2021. Scott & White Health Plan previously participated in the exchange, but exited after the end of 2016. Scott & White purchased FirstCare/SHA in 2019, and those plans were already available on-exchange in western Texas. So Scott & White has had an on-exchange presence in 2019 and 2020, via FirstCare, and those plans are more widely available in 2021. But in addition, the Scott & White Health Plan HMOs are also available on-exchange in some areas as of 2021.
Molina expanded its coverage area into some new areas — including parts of Fort Worth and Houston — that previously only had plans available from Ambetter and/or Blue Cross Blue Shield of Texas. Molina plans are newly available in Denton, Tarrant, Bexar, Ft. Bend, and Montgomery counties.
How did individual health insurance premiums change in Texas for 2021?
The following average rate changes were implemented in Texas for 2021, applicable to full-price premiums (keeping in mind that very few enrollees pay full price, as most are eligible for premium subsidies):
- Celtic/Ambetter (Ambetter from Superior Health Plan): 11.7% percent increase.
- Blue Cross Blue Shield of Texas: 3% increase (rates decreased in both 2019 and 2020).
- CHRISTUS: 3.16% increase (Christus initially proposed a slight rate decrease, after also decreasing premiums in 2020)
- Molina: 5.4% increase (6% increase for Consumer Choice plans (HMOs with deductibles); 3.4% decrease for Standard Plans (HMOs without deductibles))
- Oscar: 9.9% increase
- Sendero: 7.1% increase (Sendero also introduced an off-exchange-only platinum plan sold under the name El Paso First Health Plans).
- SHA/FirstCare: 2.8 percent increase (As of 2019, Scott & White Health Plans acquired FirstCare)
- Community Health Choice: 8.7% increase
- Scott & White Health Plan: Average rate decrease of 33.4%. (plans were only available off-exchange in 2020)
- Friday Health Plans: New to the state, so no applicable rate change.
The rate review process for Texas is conducted by the federal government.
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 percent in the Texas exchange for 2015. For silver plans, it was just 2 percent. Rate increases tended to be lower in urban areas of Texas.
2016: Average premiums in the individual market in Texas increased by 15.8 percent for 2016, although there was considerable variation from one insurer to another. Rates decreased for five carriers, and increased by between 5 percent and 34 percent for the remaining carriers. Statewide, the average benchmark plan was 5.1 percent 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 percent. 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 percent 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.
Does Texas protect consumers from surprise balance billing?
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 SB1264, Texas joined a growing list of states that have addressed the issue of surprise balance billing. And the new 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.
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). It 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. (Note that the federal legislation that takes effect in 2022 will protect people who weren’t protected by the state legislation).
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 has been complicated, and the details were still up in the air as of early December. 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.
How many people buy coverage through the Texas marketplace?
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):
- 2014: 733,757 people enrolled (Open enrollment for 2014 coverage lasted six months — October 2013 through March 2014 — plus an extension at the end that continued into April. As of March 1, private plan enrollment in the Texas exchange had been at just 295,000. The increase during March and the extension period in the first half of April was the largest of any state in the country.)
- 2015: 1,205,174 people enrolled
- 2016: 1,306,208 people enrolled (This was the highest enrollment to date in the Texas exchange. The Texas Hospital Association mounted a significant marketing campaign to get people enrolled in health insurance through the exchange, and their efforts seemed to pay off. Across all 38 states that used Healthcare.gov, eight of the ten local areas with the fastest-growing enrollment numbers in the final week of the 2016 enrollment period were in Texas: Corpus Christi, Harlingen, Laredo, El Paso, Odessa-Midland, San Antonio, Abilene-Sweetwater, and Lubbock.
- 2017: 1,227,290 people enrolled (The Trump administration’s decision to suspend HealthCare.gov’s marketing campaign in the final days of open enrollment likely played a role in the enrollment declines, as did uncertainty about the future of the ACA combined with fairly substantial rate increases — offset by subsidies for those who were subsidy-eligible, but not for those who had to pay full-price for their plans.)
- 2018: 1,126,838 people enrolled (The enrollment drop was similar to the national trend across states that use HealthCare.gov, where average enrollment declined by 5% in 2018. The Trump administration reduced funding for HealthCare.gov’s marketing and enrollment assistance, and premiums in the individual market increased significantly again.)
- 2019: 1,087,240 people enrolled (The individual mandate penalty was eliminated, and access to short-term plans was expanded. Both of these changes likely resulted in fewer people enrolled in ACA-compliant plans.)
- 2020: 1,116,293 people enrolled (Most states that use HealthCare.gov saw another enrollment decline in 2020, but enrollment grew in Texas.)
- 2021: 1,291,972 people enrolled.
Carrier participation in the Texas marketplace since 2014
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.
But 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.
Several insurers exited at the end of 2016
UnitedHealthcare exited the individual market in Texas (both on- and off-exchange) at the end of 2016, as was the case in most of the states where United offered exchange plans in 2016.
According to a Kaiser Family Foundation analysis, United only offered plans in 30 of the 254 counties in Texas in 2016. But they were the counties with the most enrollees: 80 percent of Texas exchange enrollees had UnitedHealthcare as an option in 2016. But the total number of enrollees in United’s plans (including All Savers and UnitedHealthcare Life Insurance Company) was under 157,000, including on- and off-exchange members.
In August 2016, Aetna announced that they would exit the exchanges in 11 of the 15 states where they had been offering exchange plans. Texas was one of the states where Aetna’s exchange enrollees had to secure new coverage for 2017.
Scott & White Health Plan also announced in August that they would exit the exchange in Texas at the end of 2016. They continued to offer bronze plans outside the exchange in 61 counties in 2017, but they discontinued all of their silver and gold plans. Scott & White previously offered plans in the Texas exchange in 58 counties. A subsidiary, the Insurance Company of Scott & White, also indicated in their rate filing that their plans would only be available outside the exchange in 2017. [Scott & White Health Plan will return to the exchange as of 2021.]
Cigna’s plans were also only available off-exchange in Texas for 2017. For Cigna’s HMOs, they had initially filed an average rate increase proposal of about 23 percent for 2017, but later filed a new average rate increase of 48.9 percent, which the federal government found to be “not unreasonable.” For EPOs, the average rate increase was about 35 percent. All of these rates applied to off-exchange plans only, so subsidies were not available to offset the premiums.
Allegian Health Plan announced their exit from the exchange just as open enrollment for 2017 began. They continued to offer HMO plans outside the exchange in just seven of the 254 counties in Texas.
Oscar reduced coverage area in 2017, but expanded it in 2018 and again in 2019
Oscar remained in the Texas exchange in 2017, but only in one county (Bexar) in San Antonio. They stopped offering exchange plans in the Dallas area. They offered plans in a total of four counties in Texas for 2017, but in three of them — all but Bexar — the plans were only available off-exchange.
But Oscar expanded to two additional San Antonio-area counties (Comal and Guadalupe, according to their plan filing) for 2018. They also expanded into the Austin area, with both on and off-exchange plans. Oscar continued to offer off-exchange coverage in the Dallas area in 2018. And they expanded again for 2019, with on-exchange plans becoming available in the Dallas/Fort Worth and El Paso areas.
Humana and Prominence left at the end of 2017; impact was minimal due to small market area
The spate of insurer exits at the end of 2016 was followed by two more exits at the end of 2017. Humana exited the individual market (on and off-exchange) at the end of 2017, and so did Prominence.
Humana only offered plans in ten of the 254 counties in Texas in 2017, however, so their exit did not impact most of the state. The counties where Humana plans were available in 2017 — on and off-exchange — were clustered in the Corpus Christi, San Antonio, and Waco areas. In each of those counties, there were two other insurers offering exchange plans (Christus and Blue Cross Blue Shield of Texas).
Prominence offered plans in 11 Texas counties in 2017, so as was the case for Humana, their exit did not impact most of the state. Most of the counties where Prominence offered exchange plans had fairly low populations, although Prominence plans were available in McAllen and Amarillo
Sendero remained in the exchange
In September 2018, the Central Health Board of Managers (which oversees Sendero/IdealCare) voted to cap funding for Sendero and cease offering Sendero plans at the end of 2018. Under the terms of the funding cap, only the Sendero/IdealCare Bronze plan was going to be available for 2019. The vote came after years of losses for the plan, and an uncertain financial future, although it still had to be approved by the Travis County Commissioner’s Court.
But ten days later, the Central Health Board of Managers reversed their decision, voting to allocate $26 million to keep Sendero afloat for at least another year. Central Health planned to move some of their Medical Access Program members and patients with chronic health conditions over to Sendero plans, if the members choose that option, with Central Health providing premium assistance to eligible members.
Central Health reported that 223 members opted to switch to Sendero. Moving to Sendero gave members access to a broader network of providers in Travis County, and Sendero also benefits as a result of the way the ACA’s risk adjustment program is structured. In 2018, Sendero owed $47 million into the risk adjustment program. Insurers that have healthier members end up having to pay into the risk adjustment program, while those with less healthy members receive risk adjustment funding. By enrolling sicker members, Sendero hoped to be a net recipient of risk adjustment funds in future years. And the program was expanded for 2020.
Sendero’s future is still uncertain, but for the time being, Sendero plans continue to be available in the eight Austin-area counties in the Travis service area. Bronze, silver, and gold plans were available from Sendero in 2019, as opposed to the single bronze plan that would have been available if Central Health hadn’t voted to reverse their earlier funding cap. And for 2020, according to Sendero’s rate filing information, plans are also available at the platinum level. Sendero is also newly offering “replica Bronze, Bronze HSA, and Bronze HD plans on a narrow network.”About 14,000 people enrolled in Sendero coverage for 2019.
2020: Still eight insurers in the exchange
For 2020, the eight insurers that offered plans in the Texas exchange in 2019 have continued to do so, with some coverage area expansions.
2021: Ten insurers, including Friday and Scott & White Health Plan
For 2021, Friday Health Plan joined the exchange in Texas, 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.
A self-employed married couple can still purchase small group coverage in Texas
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.
Exchange enrollees identified on ID cards
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 considerably controversy between provider organizations and consumer advocates.
Grandmothered plans may renew
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 extensions (at states’ discretion) for transitional plans, allowing them to renew as late as October 2021, and remain in force until the end of December 2021. Texas has confirmed that they will allow insurers to go along with the latest federal extension, with grandmothered plans allowed to remain in force until the end of 2021.
Exchange history and legislation
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 not expanding Medicaid.
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 claim that Perry is 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 insurance exchange links
Federal Health Care Reform Resource Page
From 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.