- Special enrollment period continues through August 15, 2021 (no qualifying event necessary, and subsidies are larger as a result of the American Rescue Plan).
- Washington will require state-regulated health plans to cover gender-affirming care as of 2022
- 12 insurers will offer 2022 coverage in the exchange (Providence is exiting, Premera is reducing coverage area, but four other insurers are expanding coverage areas for 2022.
- Across the entire individual market in Washington, insurers have proposed an average rate increase of 5.5% for 2022 (after two years of rate decreases).
- Washington has standardized plans and public option plans available for 2021, although the public option plans are only available in 20 of the state’s 39 counties in the first year (Cascade Care 2.0, enacted in 2021, aims to make the plans more widespread in future years).
- Washington will have state-based premium subsidies as of 2023, for enrollees earning up to 250% of the poverty level.
- Legislation was enacted in 2019 to protect consumers from surprise balance billing.
- Short-term health plans can be sold with terms of up to three months in Washington, but not during ACA open enrollment for a January effective date.
- More than 220,000 people enrolled for 2021, plus a look back at enrollment in prior years.
Washington exchange overview
Washington runs its own exchange, Washington Healthplanfinder. Carrier participation in the exchange is robust, with 13 insurers offering plans for 2021, up from nine in 2020 and just seven in 2019. Washington Healthplanfinder is offering a COVID-related enrollment period (described below in more detail) that continues through August 15, 2021.
Providence Health Plan and PacificSource Health Plans both joined the exchange as of 2020, and four additional insurers joined the exchange for 2021: UnitedHealthcare of Oregon, Community Health Network of Washington, Regence BlueShield, and Regence BlueCross BlueShield of Oregon.
The state also has a strong off-exchange market, but subsidies are only available through Washington Healthplanfinder. Washington expanded eligibility for Medicaid (Apple Health) under the ACA, and residents can enroll via Washington Healthplanfinder.
Legislation to require state-regulated health plans to cover gender-affirming health care was enacted in Washington in 2021 and takes effect in 2022.
In 2019, Washingon implemented fairly strict rules for short-term health plans. As a result, there were no short-term plans available in the state in late 2018 and early 2019. LifeMap, which was the only insurers that offered short-term plans in the state, revised their plans to be compliant with the state’s new rules, and began selling the new plans in April 2019. But they’ve since suspended sales again, with plans not available in Washington with 2021 effective dates.
Washington also enacted legislation in 2019 to codify various ACA consumer protections into state law. As long as the ACA remains in effect, the legislation is essentially redundant. But if the ACA were to be repealed by Congress or overturned by the Supreme Court, Washington’s new law would continue to provide extensive consumer protections in the state. Washington’s law requires insurers to cover pre-existing conditions and essential health benefits without any annual or lifetime benefit caps, and places limits on annual out-of-pocket costs.
COVID-related special enrollment period continues through August 15, 2021
Washington Healthplanfinder’s open enrollment period for 2021 health plans ran from November 1, 2020 through January 15, 2021, which is a month longer than the open enrollment period in states that use HealthCare.gov (most of the other fully state-run exchanges also extended open enrollment for 2021 coverage).
But amid the ongoing COVID pandemic, and in line with action that the Biden administration has taken for HealthCare.gov, Washington Healthplanfinder announced a special enrollment period that was initially slated to end May 15, 2021, but has since been extended through August 15, 2021.
Initially, when the enrollment window was only through mid-May, the exchange clarified that this was not an opportunity for current exchange enrollees to make a plan change — it only applied to people who were uninsured or enrolled in some type of coverage outside the exchange. But after the American Rescue Plan increased the size of premium tax credits and made them more widely available, Washington Healthplanfinder’s extended enrollment period was also expanded to include an opportunity for current enrollees to change their coverage in order to better take advantage of the enhanced subsidies.
The exchange made the new subsidy amounts visible on their website as of May 6, but for people who have been enrolled in a plan through Washington Healthplanfinder all year, the new subsidy amounts are retroactive to January 2021, and can be claimed on 2021 tax returns. The exchange will automatically update subsidy amounts for current enrollees, with the new amounts reflected on invoices as of June.
By February 24, Washington Healthplanfinder announced that 1,700 people had already enrolled in coverage during the COVID-related enrollment period.
Washington will require state-regulated health plans to cover gender-affirming care as of 2022
Washington S.B.5313, enacted in May 2021, requires Washington’s Medicaid program (Apple Health) and state-regulated health insurance plans to cover medically necessary gender-affirming health care as of January 2022. The Medicaid program added this care in May 2021, well in advance of the requirements in the new legislation.
All plans sold in the Washington exchange are regulated by the state, so the new requirement for gender-affirming care coverage will apply to all of them. State laws do not affect self-insured group health plans, however, as they are regulated at the federal level instead. Nationwide, the majority of workers with employer-sponsored health coverage are enrolled in self-insured plans.
12 insurers will offer plans in Washington’s exchange for 2022 (one exit, one coverage area reduction, and four coverage area expansions); average proposed rate increase of 5.5%
The Washington Office of the Insurance Commissioner has published average proposed individual/family market rate changes for 2022, along with a chart showing the counties where each insurer will offer plans for 2022.
Providence Health Plan, which joined Washington’s exchange as of 2020, plans to only offer coverage outside the exchange as of 2022 (they offer plans in the exchange in six counties in 2021: Benton, Clark, Franklin, Spokane, Thurston, and Walla Walla).
Premera will continue to offer plans in the exchange, but is reducing its coverage area, eliminating Skamania and Wahkiakum counties.
However, four of Washington’s exchange insurers plan to expand their coverage areas for 2022:
- Community Health Network’s coverage area will grow from nine to 18 counties
- Coordinated Care’s coverage area will go from 28 to 29 counties (Klickitat is being added)
- Lifewise’s coverage area will go from 33 to 35 counties (Skamania and Wahkiakum are being added)
- Molina’s coverage area will go from 14 to 18 counties (Benton, Cowlitz, Franklin, and Lewis are being added)
The dozen insurers that will offer plans in Washington’s exchange in 2022 have proposed the following average rate changes:
- BridgeSpan Health Company: 3.79% increase
- Community Health Network of Washington: 4.08% decrease
- Coordinated Care Corporation: 1.31% increase
- Kaiser Foundation Health Plan of the Northwest: 0.96% increase
- Kaiser Foundation Health Plan of Washington: 0.49% increase
- LifeWise Health Plan of Washington: 6.84% increase
- Molina Healthcare of Washington: 7.22% increase
- PacificSource Health Plans: 5.76% decrease
- Premera Blue Cross: 28.98% increase (rates decreased 9% in 2021 and 6% in 2020)
- Regence BlueCross BlueShield of Oregon: 3.6% increase
- Regence BlueShield: 2.74% increase
- UnitedHealthcare of Oregon: 4.07% decrease
In addition, three insurers plan to offer coverage only outside the exchange: Asuris Northwest, Health Alliance Northwest, and Providence Health Plan. Across all 15 insurers, the average proposed rate increase amounts to 5.47%.
Regulators in Washington are reviewing the rates over the summer, and will announce final rate changes before open enrollment begins in the fall. Last year, insurers proposed an overall average rate decrease of 1.8%, but regulators ended up approving rates that were even lower, with an average rate decrease of 3.2% for 2021. As noted below, there was a similar overall average rate decrease in Washington’s individual market in 2020.
When the exchange began offering health plans for 2014, premiums were essentially an educated guess, as there was no ACA-compliant individual market claims experience on which to base rates. Here’s a summary of how full-price (ie, pre-subsidy) premiums have changed over the years in Washington’s exchange:
- 2015: Increase of 1.9%: Washington Healthplanfinder’s rates increase by an average of just 1.9 percent for 2015.
- 2016: Increase of 3.8%: The average rate increase for 2016 was 3.84 percent. A Kaiser Family Foundation analysis determined that the benchmark plan for a 40-year-old in Seattle was $254 in 2015, and dropped to just $227 in 2016 (the benchmark plan isn’t necessarily from the same carrier that offered it the year before — it’s just the second-lowest-cost silver plan in a given year). That’s more than a 10 percent decrease, which means that premium subsidies (which are based on the cost of the benchmark plan) were smaller in 2016.
- 2017: Increase of 13.6%: The average premium increase in the individual market in Washington was 13.6 percent for 2017 (nationwide, the average premium increase, before any subsidies were taken into consideration, was about 25 percent). Premera had the largest segment of Washington Healthplanfinder market share in 2016, at 22 percent. And their approved rate increase for 2017 was the highest of any of the state’s plans, at 18.9 percent.
- 2018: Increase of 36.4%: In September 2017, Washington Healthplanfinder announced that the exchange had finished certifying plans for 2018, with an average rate increase of 24 percent for plans sold in the exchange (final rate changes available here). At that point, the approved rates were still based on the assumption that CSR funding would continue, but the exchange noted that the premium increases were due to “cost trend and federal uncertainty, particularly enforcement of individual mandate” (the individual mandate penalty was eventually eliminated altogether, at the end of 2018). Regulators also approved a backup set of rates for silver plans sold in the exchange, which were high enough to make up for the loss of federal CSR funding. Ultimately, the Trump Administration announced just two weeks later, on October 12, that CSR funding would end immediately. At that point, Washington regulators had to switch to the backup rates, and they announced on October 26 that the higher rates for on-exchange silver plans had been finalized, driving the overall average rate increase up to 36.4 percent.
- 2019: Increase of 13.8%: The average approved rate increase was 13.8 percent for 2019, which was a little lower than the insurers had proposed.
- 2020: Decrease of 3.3%: Overall average premiums in Washington’s exchange decreased by 3.27 percent for 2020. And two new insurers — Providence Health Plan and PacificSource Health Plans — began offering plans in the exchange for 2020.
- 2021: Decrease of 3.2%: There are 13 insurers offering plans through Washington Healthplanfinder for 2021, and average premiums decreased by 3.2%. Thirteen of the state’s 15 insurers offered plans in the exchange for 2021, and five of them are offering the new “Cascade Care” public option plans. The participating exchange insurers for 2021 include two that are new to the state’s individual market (UnitedHealthcare of Oregon and Community Health Network of Washington, both of which only offer public option plans), as well as two that already offered coverage outside the exchange, but joined the exchange for 2021 (Regence BlueShield and Regence BlueCross BlueShield of Washington). So Washington’s exchange went from nine insurers in 2020 to 13 insurers in 2021. And three existing exchange insurers (BridgeSpan, Coordinated Care, and PacificSource) all expanded their coverage area in 2021.See Washington Healthplanfinder’s comprehensive overview of plan availability and coverage details for 2021.
The 15 insurers that offer individual market plans in Washington in 2021 (including Asuris Northwest Health and Health Alliance Northwest Health Plan, both of which only offer plans outside the exchange) proposed an overall average rate decrease of 1.8 percent. Once the rate review process was complete, the overall average rate decrease was even more significant, with rates dropping by an average of 3.2 percent for 2021. Some insurers ended up with higher rates than they had initially proposed while others ended up with lower rates than they had initially proposed, but overall the average decrease is more significant than the insurers had proposed in May. The insurers offering plans through Washington Healthplanfinder implemented the following average rate changes for 2021.
Standardized plans and a public option available starting in 2021, but public option only available in 20 of the state’s 39 counties and premiums are higher than officials had hoped; Cascade Care 2.0, enacted in 2021, makes improvements and funds state-based subsidies
In May 2019, Washington enacted legislation (S.B.5526; the House version was H.B.1523) calling for the creation of standardized health plans and a “public option” health plan that would be available as of 2021 (with enrollment beginning in November 2020), plus additional premium subsidies that are expected to be available by 2022. The legislation is known as “Cascade Care” and implementation work began as soon as the bill was enacted.
HealthCare.gov briefly offered standardized plans in many areas of the country, and several states already had standardized plans. Washington joined them for 2021, with standardized plans — and a public option in about half of the state’s counties — available through Washington Healthplanfinder.
Washington’s insurance commissioner announced in May 2020 that the proposed rate filings for the Cascade Care plans had been submitted by insurers. In early July, the state confirmed that five insurers would offer Cascade Care public option plans in 2021, but noted that the public option plans would only be available in 20 of the state’s 39 counties in 2021.
Of the 41,000 new enrollees who had signed up for coverage through Washington Healthplanfinder by January 14, the exchange noted that 40 percent had selected Cascade Care plans. But they did not break that down further to indicate how many of those enrollees had selected public option plans versus standardized plans, and both are under the Cascade Care umbrella.
Standardized plans (Cascade Care Standard)
Under the terms of the Cascade Care legislation, Washington officials were tasked with designing up to three standardized plan designs at the bronze, silver, and gold metal levels. In October 2019, the exchange published a draft proposal with four standardized plan designs: One gold, one silver (plus CSR variations), and two bronze, one of which is an HDHP and would allow an enrollee to contribute to an HSA. A detailed report of the standardized plan designs and their expected impact on the market is available here.
The standardized plan designs include a wide variety of services, all of which would be covered with the same cost-sharing regardless of which insurer offers the plan (ie, the deductible, out-of-pocket maximum, coinsurance, and various copays would be the same from one plan to the next). The idea is to make it easier for a consumer to compare plans based on things like provider networks and customer service, since the dollar-level benefits wouldn’t vary. The exchange sought public comments on the proposed plan designs, and announced in early December that the plan designs had been approved.
Insurers that offer plans in the exchange have to offer at least one standardized plan at the silver and gold level starting in 2021. If an insurer offers plans at the bronze level, they have to offer at least one standardized bronze plan, but some Washington insurers choose to not offer bronze plans (for the public option, discussed below, insurers would have to offer plans at each metal level, including bronze).
Cascade Care 2.0 legislation, which was enacted in 2021, simplifies the standardized plans so that there is just one at each metal level; participating exchange insurers must offer the standardized silver and gold plans, and if they offer any bronze plans, they must offer the standardized bronze plan.
For the time being, insurers are able to continue to also offer non-standardized plans, but the state will have to analyze what the expected impact would be if all plans were required to be standardized starting in 2025, with a report that has to be delivered to the legislature by 2023. California requires all plans to be standardized, but all of the other states with standardized plan designs also allow insurers to offer non-standardized plans.
Public option (Cascade Care Select) and changes under Cascade Care 2.0 (2021 legislation)
Washington’s public option plan, which became available for purchase in the fall of 2020, for coverage effective in 2021, is the first of its kind in the nation. But some have argued that its design is different from what people tend to think of as a “public option,” as that term is often used to describe Medicaid buy-in programs and new coverage options that would be administered by the government. But Washington is taking an approach that involves private insurers. (Colorado lawmakers were working on a public option proposal in 2020 but the legislation was postponed amid the COVID-19 crisis and the 2021 legislation involves standardized, highly regulated private plans instead of a government-run public option; Nevada lawmakers passed a Medicaid buy-in public option in 2019, but the governor vetoed it).
Washington’s Cascade Care “public option” program involves the state contracting with five private health insurance companies (as of 2021) to offer standardized qualified health plans at the bronze, silver, and gold levels in the Washington exchange. The standardized plan designs are the same as the regular standardized plans detailed above, but the public option versions were expected to have lower premiums due in large part to lower reimbursements for medical care. This has not turned out to be the case however, with the public option rates as much as 29% higher than other plans’ rates in 2021.
The idea behind S.B.5526 was to provide additional plan options to individual market enrollees. But the legislation does not require the Cascade Care plans to be available statewide. An insurer’s contract with the state would be to offer the plans “in a single county or in multiple counties,” and it was not clear until mid-2020 how widespread the public option plans would be in 2021. They are available in 20 of the state’s 39 counties for 2021. In six of those 20 counties, public option plans are offered by two or three different insurers. The other 14, including King County (Seattle), have public option plans offered by a single insurer. The remaining 19 counties in Washington do not have public option plans available in 2021, although the state is hoping that the plans will be more widely available in future years.
Ultimately, only about 2.5% of all new enrollees in Washington’s marketplace selected Cascade Care Select (public option) plans during the open enrollment period for 2021 coverage.
For most services, the plans cap provider reimbursements at 160% of the Medicare reimbursement amounts in 2021 (there are exceptions for rural hospitals and primary care, and also for situations in which the plan can’t maintain an adequate network under the prescribed reimbursement constraints).
The initial Cascade Care legislation went through several iterations, and the cap on provider reimbursements changed each time, but lawmakers ultimately settled on 160% of Medicare rates — a middle-of-the-road approach designed to keep pricing at least a little lower than other comparable plans (the state was aiming for 5-10% lower), while still ensuring adequate provider participation (Colorado’s 2021 proposal calls for private insurers to offer a “state option” with reimbursements no lower than 165% of Medicare rates for hospitals, and 135% of Medicare rates for providers).
Legislation (S.B.5377) introduced in 2021 initially called for capping the hospital reimbursement rate at 135% of Medicare rates, and requiring hospitals and surgical facilities that receive reimbursement from public health plans (Medicaid, as well as the plans for public employees and school employees) to be in-network with a public option plan, if the public option plan requests this.
S.B.5377 was signed into law in May 2021, but those initial measures were watered down substantially. There is no longer a reimbursement cap of 135% of Medicare rates (instead, it’s still 160%), and the participation requirements have been changed as well. Under the final version of the bill (which was still controversial), if there are areas of the state that still don’t have public option plans available as of 2022, any hospital that contracts with the state for Medicaid or public employee health benefits would have to enter into a network agreement with at least one public option plan, assuming it receives a network offer.
State-based premium subsidies will debut in 2023
2019’s S.B.5526 also called for the state to “develop a plan to implement and fund” premium subsidies for people with modified adjusted gross income up to 500% of the poverty level. (At that time, federal ACA premium subsidies extended to enrollees with MAGI up to 400% of the poverty level, creating a subsidy cliff above that level. But for 2021 and 2022, the American Rescue Plan has eliminated the subsidy cliff nationwide.)
S.B.5526 was an effort to help make coverage more affordable for people in this income range, and called for net premiums to be capped at 10% of MAGI. Washington Healthplanfinder worked with stakeholders to develop a state-based premium proposal, and submitted their report to the legislature in October 2020. The idea was that lawmakers would then be able to act on the report during the 2021 legislative session, to create state-based premium assistance. (H.B.2901 was introduced in 2020, calling for the creation of state-based premium subsidies that would have been available by 2022. But it did not advance in the 2020 session.)
S.B.5377, which was enacted in 2021, creates the framework for the state-based premium subsidies and cost-sharing reductions, which will be available in 2023 and 2024. But the income limit for eligibility has been reduced to 250% of the poverty level, in an effort to concentrate financial assistance on enrollees with income at the lower end of the spectrum (the text of the final legislation does not specify an income cap, but the Washington State Senate clarified the specifics in a letter to Governor Inslee).
S.B.5377 clarifies that eligible enrollees will be able to receive the state-based subsidies as long as they’re enrolled in a silver or gold standardized plan (an earlier version of S.B.5377 would have required the enrollee to be covered under the lowest-cost bronze, silver, or gold standardized plan available in their area, but this has been amended during the legislative process).
Massachusetts and Vermont both already had state-based premium subsidies (which pre-date the ACA) for lower-income enrollees. California implemented a new state-based premium subsidy program as of 2020, offering subsidies to households with income up to 600% of the poverty level (these subsidies are no longer necessary in 2021, now that the American Rescue Plan has been implemented and federal subsidies are larger). New Jersey debuted a state-based subsidy program in 2021. Colorado will start to offer a similar program as of 2022.
Legislation to protect consumers from surprise balance billing
Governor Jay Inslee signed H.B.1065 into law in 2019, after similar bills failed in the two previous legislative sessions. The new law, summarized here by Insurance Commissioner Mike Kreidler’s office, took effect in January 2020 and provides strong consumer protections against surprise balance billing when a patient receives emergency treatment at an out-of-network facility, or visits an in-network facility but is treated by an out-of-network provider.
- The law requires insurers to maintain adequate networks.
- Out-of-network providers will not be allowed to balance bill patients in emergency situations or in situations in which the out-of-network services were received at a facility that was in-network with the patient’s insurance.
- In these situations, insurers must pay out-of-network providers “a commercially reasonable amount, based on payments for the same or similar services provided in a similar geographic area.”
- If the provider and insurer disagree on what the payment amount should be, it is sent to binding arbitration. But the provider cannot bill the patient.
- H.B.1065 applies to plans that are regulated by the Washington Insurance Commissioner. This does not include self-insured group plans — which account for the majority of very large group plans — as those are regulated by the federal government instead, under ERISA. Self-insured group plans can choose to opt into the state’s balance billing protection rules.
2021 enrollment, plus a look back at enrollment since 2014
Open enrollment for 2021 coverage began began on November 1, 2020, and the exchange extended the enrollment deadline to January 15, 2021. By January 14, more than 220,000 people had purchased coverage. That was up from the prior year’s enrollment, with one more day left in the enrollment period.
For perspective, here’s a look back at enrollment in Washington Healthplanfinder since the exchange opened for business in 2014:
- 2014: As of April 2019, 163,207 people had enrolled in private health plans through Washington Healthplanfinder and paid their premiums to effectuate their coverage. In addition to the private plan enrollments, 909,752 people had enrolled in Medicaid through the Washington exchange by mid-April (nearly half of those people were already enrolled previously, but renewed their Medicaid coverage through the exchange).
- 2015: Total enrollment in qualified health plans through Washington Healthplanfinder amounted to 160,732 people by the end of open enrollment. On April 22, Washington Healthplanfinder announced that total private plan enrollment for 2015 had reached 170,101 people. This was the third-highest total (behind California and New York) of any of the state-run exchanges. All of these enrollees had paid for their coverage; Washington only reported enrollments in 2014 and 2015 if they were paid-up.
- 2016: HHS announced that Washington Healthplanfinder’s total enrollment for 2016 was 200,691 as of February 1 (this was the first year that Washington switched to reporting all enrollments — instead of only effectuated enrollments — bringing them into line with how most other states’ enrollments are reported). In June 2016, Washington Healthplanfinder reported that 169,182 people had effectuated their coverage for 2016.
- 2017: By the time 2017 open enrollment ended on January 31, more than 225,000 people had enrolled in private plans (QHPs) through the exchange. This was a 13 percent increase, which was notable given that total enrollment among states using HealthCare.gov was slightly lower in 2017 than it was in 2016 (the Trump Administration reduced advertising for HealthCare.gov in the final week of enrollment, while state-run exchanges like Washington Healthplanfinder were able to continue their advertising efforts as planned).
- 2018: Enrollment in Washington’s exchange reached a record high in 2018, with 242,850 people enrolled in private plans (CMS reported a slightly higher official enrollment total of 243,227). Although HealthCare.gov switched to a much shorter enrollment window (just over six weeks long) for 2018 coverage, Washington Healthplanfinder was one of ten state-run exchanges that opted for a longer enrollment window that year, allowing people to enroll until January 15, 2018.
- 2019: Enrollment dropped in 2019, with 220,765 people purchasing plans during open enrollment. Nationwide, there was an average decline in enrollment, although it was only about 2.4 percent. And among state-run exchanges, average enrollment increased slightly in 2019. Washington Healthplanfinder was one of just four state-run exchanges (out of 12 total) where enrollment declined in 2019.
- 2020: Enrollment dropped again, to 212,590.
How rates changed for an average enrollee in 2019
As of 2018, 63 percent of Washington’s exchange enrollees were receiving premium subsidies, while the other 37 percent were paying full price. Nationwide, 87 percent of enrollees were receiving subsidies, so while subsidies are less common in Washington, they still apply to the majority of the enrollees there. Let’s take a look at how an enrollee’s after-subsidy premiums changed for 2019 in a couple of different areas of the state.
First, in Wenatchee, where Coordinated Care is the only insurer offering plans: A 40-year-old earning $30,000 could get a premium subsidy of about $195/month. After the subsidy is applied, the available plans (eight different options offered by Coordinated Care) range from $191/month to $262/month. There are no bronze plans available, so the lowest-priced plan is silver.
In 2018, a 40-year-old in Wenatchee earning $30,000 was eligible for a premium subsidy of about $122/month, but the after-subsidy premiums were fairly similar to 2019’s prices, ranging from $194/month to $274/month. There were 10 Ambetter plans available in that area for 2018, but again, all silver and gold, with no bronze options. (Washington was one of a handful of states where some counties had no bronze plans available starting in 2018, and that situation was the impetus for new HHS and IRS rules allowing people to qualify for an affordability exemption based on the lowest-cost plan, rather than the lowest-cost bronze plan in a given area.)
Now let’s consider the same 40-year-old earning $30,000 but living in Seattle. For 2018, this applicant was eligible for a premium subsidy of about $134/month. There were 21 plan options available from Kaiser, Premera, Molina, and Coordinated Care, with after-subsidy premiums ranging from about $130/month to $472/month (including mostly silver plans, as well as four gold plans and four bronze plans).
For 2019, a 40-year-old applicant earning $30,000 in Seattle can choose from among 19 plans, and qualifies for a premium subsidy of about $177/month. After the subsidy is applied, the premiums range from about $142/month to $435/month.
As described above, the exchange fee (which is built into the premiums) is 55 percent lower for 2019 than it was for 2018. That helps to keep premiums a little lower than they would otherwise have been, but adjustments in the cost of the benchmark plan (and the resulting adjustments in premium subsidies) tend to have more of an impact.
Small business coverage no longer available through the exchange
Washington Healthplanfinder Business, the state-run SHOP exchange, reported in June 2015 that more than 100 small businesses had enrolled in small group plans for 2015. They also announced that they would make coverage available for businesses with up to 100 employees starting in November 2015. But that changed in October 2015 when President Obama signed HR1624 (the PACE Act) into law. The law repealed the ACA provision that would have expanded the definition of “small group” to include businesses with up to 100 employees. States are free to independently define small groups as businesses with up to 100 employees, but in Washington, Insurance Commissioner Mike Kreidler announced that the state would go along with the PACE Act and continue to define small group plans as those with up to 50 employees.
By March 2016, a total of 174 employers had enrolled in coverage through Washington Healthplanfinder. The plans were covering 606 employees, and 164 dependents. UnitedHealthcare offered small group plans statewide through Washington Healthplanfinder Business in 2016, and Kaiser offered plans in Clark and Cowlitz counties (Moda had planned to offer small business plans state-wide as well, but their last-minute exit from the Washington market at the end of 2015 meant that there was just one state-wide SHOP option in 2016).
And for 2017, United’s exchange exit left Washington Healthplanfinder’s SHOP exchange limited to only Kaiser, and only in Clark and Cowlitz counties. The state noted however, that there continued to be a robust off-exchange market for small businesses, with 11 insurers offering plans in 2017 — although the small business health insurance tax credit is only available through the exchange.
By 2018, even Kaiser had stopped offering SHOP plans in Washington, so there are no longer SHOP plans for sale in the state. Small businesses can select from a wide range of off-exchange small group plans, however, all of which are compliant with the ACA.
Washington Healthplanfinder history
Washington was one of the first states to move ahead with a state-run health insurance marketplace as envisioned by the Affordable Care Act. Former Gov. Chris Gregoire signed legislation creating the state exchange in May 2011. In March 2012 Gregoire signed additional legislation, which further defined how the exchange would be governed and operated.
The Washington Health Care Authority (HCA) helped establish the Washington marketplace. HCA transitioned governing authority to an 11-member board of directors in March 2012. The governor appointed eight voting members and a board chairperson who votes only if needed to break a tie. In addition, the insurance commissioner and the administrator of the Health Care Authority are non-voting members.
In March, 2014, Washington legislators tried to pass a bill that would have created much more transparency in the state’s health insurance industry, providing consumers with data on how much insurers are paying for services in each region of the state. It had widespread support, but opposition from Premera Blue Cross — the state’s largest insurer — sank the bill and Washington did not join the 11 other states that had all-payer claims databases by 2014. But lawmakers persisted, and in 2015, SB5084 was signed into law, advancing the process of creating an all-payer claims database in Washington state (S.B.5741 was enacted in 2019, and will improve the state’s all-payer claims database).
The federal government funded the Washington Healthplanfinder in 2014. In 2015, marketplace operations were funded by the state with $21 million that was previously earmarked for the state’s high-risk insurance pool, and with an additional tax on premiums on plans sold through the exchange.
Washington Healthplanfinder charges a per member per month fee to fund the exchange. For 2016 through 2018, the fee was $7.46 per member per month. So a family of four was paying almost $30/month in fees to fund the exchange, as part of their health insurance premiums. But because enrollment grew so much in 2018, and because the exchange has been working to improve its financial efficiency, the fee was reduced by 55 percent for 2019, to just $3.36 per member per month. Although enrollment declined in 2019, the exchange kept the $3.36 per member per month fee in effect for 2020 as well (and reduced the fee on dental plans from $1.54 to $0.81 per member per month).
For the first two years it was in operation, Washington Healthplanfinder collected premiums from enrollees and sent them to insurers (enrollees had the option to send payments directly to the insurers, but about 80% opted to pay premiums to the exchange). But the exchange struggled with billing problems and ultimately decided to switch to the approach used in other states, in which enrollees pay their premiums directly to insurers, rather than the exchange. This change took effect in September 2015.
The first reported cases of COVID-19 in the US were diagnosed in Washington state, so it was not surprising that Washington Healthplanfinder was the first state-run exchange to issue a special enrollment period related to the pandemic. The special enrollment period was initially scheduled to end on April 8, 2020, but was extended until May 8. The special enrollment period was specifically for people who were uninsured; it was not an opportunity for insured residents to change their coverage. The exchange reported that roughly 19,500 people enrolled during the COVID-19 special enrollment period. Another special enrollment period has been opened in 2021, continuing through mid-August (as is the case in most of the country).
No grandmothered plans
Washington Insurance Commissioner Mike Kreidler and Governor Jay Inslee took a strong progressive stance with regards to consumer protections: existing plans that did not meet ACA standards were canceled at the end of 2013 and needed to be replaced in January 2014 with new, ACA-compliant policies. Following President Obama’s announcement that carriers could extend existing plans into 2014 if states allowed it, Kreidler and Inslee were quick to declare that Washington would not allow non-compliant plans to continue into 2014. Thus, the only non-ACA-compliant individual and small group plans in Washington are grandfathered plans; there are no grandmothered plans.
Insurer participation by year
Insurer participation in Washington’s exchange has changed significantly over time (a detailed list of the counties where each carrier offered plans is available here). The Office of the Insurance Commissioner has clarified over the last few years that federal actions had been creating instability and uncertainty in the individual market, and insurers tend to want to avoid that sort of uncertainty (this is a big reason insurers exited the market in 2017 and 2018). The federal actions include the elimination of the individual mandate penalty in 2019 (under the terms of the GOP tax bill that was enacted in late 2017), the elimination in late 2017 of federal funding for cost-sharing reductions, and the regulations that expanded access to short-term health plans and association health plans (although Washington stepped in with new regulations for short-term plans).
In 2019, there were 14 counties in Washington with only one insurer offering plans in the exchange, up from nine in 2018. And when rates were initially filed for 2018, there were two counties where no insurers had proposed plans. That was eventually remedied before the start of open enrollment, but lawmakers also wanted to address the issue in the 2018 legislative session.
H.B. 2408 (signed into law in March 2018) mandates that as of 2020, any insurer that offers coverage to school employees must also offer at least one silver and one gold plan in the individual market via Washington Healthplanfinder in any areas where the insurer offers coverage for school employees. In the meantime, if necessary, the legislation would have made coverage in the Washington state health insurance pool more affordable for people who live in counties where no insurers offer exchange plans. But all areas of the state have continued to have plans available in the exchange from at least one insurer, and there will be at least two insurers in each county as of 2021.
Here’s a summary of insurer participation in Washington’s exchange has changed over time:
- 2014: Plans were available from eight insurers in 2014: BridgeSpan, Community Health Plan of Washington, Coordinated Care (Ambetter/Centene), Group Health Cooperative, Kaiser Foundation Health Plan of the Northwest, LifeWise, Molina, and Premera.
- 2015: Plans were available from 10 insurers in 2015, with Moda and Columbia United Providers joining the exchange, along with the eight insurers that had offered plans in 2014. But both insurers’ forays into the exchange were short-lived.
- 2016: On October 28, 2015, Moda Health announced they were exiting the Washington market in order to focus on Alaska and Oregon (Moda subsequently left Alaska’s market as well, but remains in Oregon). Effective immediately, they ceased sales and renewal of health plans in Washington, and 47,000 existing policy-holders had to select coverage from a different carrier for 2016.
In November 2015, Columbia United Providers also announced that they would exit the individual market in Washington. Their plans were only available in Clark County, and they only had about 100 enrollees. But Regence BlueCross BlueShield, United Healthcare of Washington, and Health Alliance Northwest all joined the exchange for 2016, resulting in 11 insurers offering plans.
- 2017: For 2017, United Healthcare exited the exchanges in nearly every state where they participated in 2016, including Washington (United had 2,978 enrollees in the Washington exchange in 2016, or about two percent of the total exchange enrollments). And Health Alliance Northwest also exited the exchange, although the impact of that was minimal, as they only had nine on-exchange enrollees in 2016. There were no new entrants in 2017, so nine insurers offered plans in the exchange that year.
- 2018: For 2018, BridgeSpan and Regence BlueShield had both initially said they would discontinue their exchange participation and would only offer off-exchange plans after 2017. And Community Health Plan of Washington planned to exit the individual market altogether at the end of 2017. At that point, no individual market insurers had filed plans for 2018 in Klickitat County or Grays Harbor County.
So Washington Insurance Commissioner Mike Kreidler began working with insurers to fill in the bare counties. Kreidler’s first success was in Grays Harbor County; he announced on June 19 that Premera had stepped up and agreed to offer coverage there. And on June 26, Kreidler announced that two insurance companies had agreed to offer exchange plans in Klickitat County, including BridgeSpan. This was particularly notable given that BridgeSpan had initially intended to exit the Washington exchange altogether at the end of 2017. But thanks to Kreidler’s negotiations, BridgeSpan and Molina both agreed to offer plans in the exchange in Klickitat County in 2018.
Every area of the state had on-exchange options available in 2018, although nine counties (out of 39 in the state) had just one insurer offering plans: Chelan, Douglas, Ferry, Grays Harbor, Island, Pend Oreille, San Juan, Skagit, and Skamania. And there were seven counties in Washington where there were no bronze plans available in the exchange for 2018: Chelan, Douglas, Ferry, Lincoln, Pend Oreille, Skamania, and Stevens.
- 2019: Seven insurers offered plans in the Washington exchange; 14 counties had just one participating insurer.
- 2020: Providence and PacificSource joined the exchange for 2020, bringing the total number of participating insurers to nine. There are six counties with just one participating insurer.
- 2021: Thirteen insurers offer coverage in the exchange. Four insurers joined the exchange for 2021: UnitedHealthcare of Oregon, Community Health Network of Washington, Regence BlueShield, and Regence BlueCross BlueShield of Washington (the latter two were already part of Washington’s individual market, but only offered plans outside the exchange in 2020, after exiting a few years ago). Regence had previously participated in the Washington exchange, but had exited at the end of 2017. UnitedHealthcare of Oregon is new to the state’s individual market, but UnitedHealthcare of Washington had participated in the exchange in previous years, leaving at the end of 2016. Community Health Network of Washington is new to the state’s individual market, but Community Health Plan of Washington — an affiliated entity — exited the market at the end of 2017.All counties in Washington have at least two participating exchange insurers for 2021. This is a significant reversal from just a few years earlier, when insurers were exiting the market and reducing their coverage areas, leaving Kreidler scrambling to ensure that the state wouldn’t be left with areas that didn’t have any participating insurers at all.There are also bronze plans available statewide now, whereas that was not the case prior to 2020. Some counties had no available bronze options for a couple of years, making their lowest-cost options more expensive than the lowest-cost options for people in most of the state.
- 2022: Providence will exit the exchange at the end of 2021, leaving twelve insurers offering plans in the exchange in Washington for 2022. Four of them will expand their coverage areas, while one (Premera) will reduce its coverage area from seven counties to five.
Contact the Washington exchange
More Washington State health insurance exchange links
Washington Health Benefit Exchange
Information about marketplace planning and development
State Exchange Profile: Washington
The Henry J. Kaiser Family Foundation overview of Washington’s 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.