- Open enrollment for 2021 ended 15, 2021, but a new special enrollment period continues through August 15, 2021.
- 13 insurers offer 2021 coverage in the exchange, including four newcomers (UnitedHealthcare of Oregon, Community Health Network of Washington, Regence BlueCross BlueShield of Oregon, and Regence BlueShield). And all counties have at least two participating insurers.
- Across the entire individual market in Washington, insurers decreased rates by an average of 3.2% for 2021 (plus a look back at how premiums have changed in prior years).
- 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.
- Washington is also considering the possibility of state-based premium subsidies; 2020 legislation to directly create the subsidies did not advance, but a new bill has passed in the Senate in 2021 and is being considered by the House.
- 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 Medicaid (Apple Health) under the ACA, and residents can enroll via Washington Healthplanfinder.
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 percent 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.
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 revised their plans to be compliant with the state’s new rules, and began selling the new plans in April 2019. But under Washington’s new rules, short-term plans with January effective dates cannot be sold between November 1 and December 15, which is the open enrollment period that applies to ACA-compliant plans. This is an effort on the state’s part to make sure that consumers aren’t confused during open enrollment and inadvertently purchasing short-term plans. (Note that open enrollment for ACA-compliant 2021 health coverage was extended through January 15 in Washington, but plans purchased between December 16 and January 15 have a February effective date instead of a January effective date.)
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 runs from February 15 to 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 will make 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.
First state-run exchange to issue a COVID-19 special enrollment period in 2020
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, 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.
Thirteen insurers plan to offer coverage in Washington’s exchange in 2021, up from 9 in 2020 and 7 in 2019; Average premiums decreasing by 3.2% for 2021
There are 13 insurers offering plans through Washington Healthplanfinder for 2021, and average premiums decreased by 3.2 percent, after a similar drop in 2020.
Washington’s Insurance Commissioner, Mike Kreidler, announced in May 2020 that 15 insurers had filed individual market health plans for 2021, with 13 of them planning to offer coverage in the exchange. As described below, the state’s new standardized plans and public option are available for 2021. All insurers are offering standardized plans (although they’re allowed to continue to offer additional, non-standardized plans), although only five of them are offering 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 will 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 will go 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.
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.
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:
- BridgeSpan Health Company: 0.17 percent decrease (versus a proposed 0.03 percent increase; will offer public option plans)
- Community Health Network of Washington: New for 2021 (will only offer public option plans)
- Coordinated Care Corporation: 0.93 percent increase (versus proposed 2.1 percent increase; will offer public option plans)
- Kaiser Foundation Health Plan of the Northwest: 1.87 percent decrease (versus a proposed 1.93 percent decrease)
- Kaiser Foundation Health Plan of Washington: 4.86 percent decrease (second year in a row with nearly a 5 percent decrease)
- LifeWise Health Plan of Washington: 2.06 percent decrease (versus a proposed 3.44 percent increase; will offer public option plans)
- Molina Healthcare of Washington: 3.19 percent decrease (versus a proposed 0.27 percent increase)
- PacificSource Health Plans: 7.63 percent increase (versus a proposed 3.54 percent increase)
- Premera Blue Cross: 8.67 percent decrease (following a 6 percent decrease in 2020)
- Providence Health Plan: 3.18 percent increase (versus a proposed 2.99 percent increase)
- Regence BlueCross BlueShield of Oregon: 4.08 percent decrease (new to the exchange for 2021, but already in the individual market in 2020; Regence BCBSOR had initially proposed an average decrease of 4.71 percent)
- Regence BlueShield: 5.35 percent decrease (new to the exchange for 2021, but already in the individual market in 2020; Regence had initially proposed an average decrease of 2.71 percent)
- UnitedHealthcare of Oregon: New for 2021 (will only offer public option plans)
The coronavirus pandemic did not appear to be a factor in the proposed rates for most of those insurers. Molina accounted for an expected 3 percent increase in claims in 2021 due to COVID-19, while UnitedHealthcare added 2.5 percent. The rest of the insurers did not adjust their 2021 projections based on COVID-19.
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.
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 percent: Washington Healthplanfinder’s rates increase by an average of just 1.9 percent for 2015.
- 2016: Increase of 3.8 percent: 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 percent: 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 percent: 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 percent: 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 percent: 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.
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
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.
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).
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.
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 (Colorado’s was expected to debut in 2022, but has been postponed amid the COVID-19 crisis). 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 (so is Colorado, if and when the program gets revived; 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 percent 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.
For most services, the plans cap provider reimbursements at 160 percent of the Medicare reimbursement amounts, at least initially (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 legislation went through several iterations, and the cap on provider reimbursements changed each time, but lawmakers ultimately settled on 160 percent of Medicare rates — a middle-of-the-road approach designed to keep pricing at least a little lower than other comparable plans (the state is aiming for 5-10 percent lower), while still ensuring adequate provider participation (Colorado’s proposal calls for private insurers to offer a “state option” with reimbursements capped at 175 to 225 percent of Medicare rates).
Legislation (S.B.5377) introduced in 2021 initially called for capping the hospital reimbursement rate at 135 percent 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 passed in the Senate in early March 2021 and is now under consideration by Washington’s House of Representatives. But those initial measures have been watered down substantially. In the version that passed the Senate, there is no longer a reimbursement cap of 135 percent of Medicare rates (instead, it’s still 160 percent), and the participation requirements have been changed as well. Under the updated version of the bill, a hospital system that owns at least four hospitals would have to contract with at least two public option plans in each county where the hospital system has one or more hospitals. So the participation requirements would no longer apply to independent hospitals or hospital systems with fewer than four hospitals.
State-based premium subsidies
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 percent of the poverty level. The federal government provides ACA premium subsidies to people with MAGI up to 400 percent of the poverty level, but people with income between 400 and 500 percent of the poverty level are not eligible for federal subsidies, and are thus often impacted by the subsidy cliff.
S.B.5526 was an effort to help make coverage more affordable for people in this income range, and calls for net premiums to be capped at 10 percent 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. S.B.5377, which passed in the Washington Senate in March 2021 — and discussed above in relation to the public option program — also calls for the creation of premium subsidies. (A similar bill, 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 calls for the state to create a program that provides premium assistance (and possibly cost-sharing assistance) to people with income up to 500 percent of the poverty level, 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). Because the premium subsidies would extend to 500 percent of the poverty level (as opposed to the 400 percent cap that applies to the federal subsidies), the program would help to make coverage more affordable for people who are currently impacted by the ACA’s subsidy cliff. For perspective, a family of four earning up to $104,800 can qualify for the ACA’s subsidies in 2021; if subsidy eligibility extended to 500 percent of the poverty level, it would be $131,000 for a family of four.
It’s also important to note that the federal government is considering COVID relief legislation that would temporarily (for 2021 and 2022) remove the income cap for federal premium subsidies, instead capping benchmark plan premiums at 8.5 percent of income, regardless of how high a person’s income is.
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 percent of the poverty level. New Jersey debuted a state-based subsidy program in 2021, offering additional state-funded subsidies to people who earn up to 400 percent of the poverty level (ie, overlapping completely with the population that qualifies for federal premium subsidies). 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.
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: Proposed plans for 2021 include 13 insurers offering coverage in the exchange. Four insurers plan to join the exchange: UnitedHealthcare of Oregon, Community Health Network of Washington, Regence BlueShield, and Regence BlueCross BlueShield of Washington (the latter two are already part of Washington’s individual market, but only offer plans outside the exchange in 2020, after exiting a few years ago).
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.