West Virginia health insurance marketplace guide 2023

West Virginia has a partnership exchange. So residents enroll in exchange plans through HealthCare.gov, but the state oversees the plans that are sold through the exchange and participates in plan management and certification of qualified health plans.

Prior to announcing in 2013 that West Virginia would be expanding Medicaid, former Governor Earl Ray Tomblin’s administration had hired out cost analyses for both Medicaid expansion as well as setting up a state-run exchange, and ultimately decided that Medicaid expansion would provide more value.

So after initially developing plans to operate a state-run health insurance exchange, West Virginia submitted a blueprint for a partnership exchange to the U.S. Department of Health and Human Services (HHS), which was approved in March 2013.

Gov. Tomblin’s administration cited cost, particularly the expense associated with information technology systems, as a key factor in ultimately deciding against a fully state-run exchange. Administration officials also said the partnership gives the state some control over the exchange.

Under the partnership, West Virginia is responsible for regulating companies that sell health insurance policies on the exchange.

The state also oversees the In-Person Assister (IPA) program. Assisters are under contract with the state and provide individuals with impartial help with the enrollment process. In November 2014, the state announced that it would be hiring an additional 100 people to help residents enroll in the exchange and the state’s expanded Medicaid program.

In December 2014, during the King v. Burwell lawsuit (over the availability of premium subsidies in states—like West Virginia—that use the federally-run exchange) West Virginia’s Attorney General Patrick Morrisey joined AGs from five other states in an amicus brief submitted to the Supreme Court in support of the plaintiffs in King v. Burwell. Despite the fact that about 25,000 West Virginia residents would have lost subsidies if the plaintiffs had prevailed in the case, West Virginia’s Attorney General supported that outcome.

Governor Tomblin made it clear however that he did not support Morrisey’s amicus brief position, and has argued that when the state opted to use the federally-run exchange, they were under the impression that subsidies would be available either way. Ultimately, the Supreme Court ruled that premium subsidies would continue to be available nationwide, including in states that use HealthCare.gov.

For 2023 coverage, there are two insurers that offer exchange plans in West Virginia:

• CareSource
• Highmark

West Virginia’s exchange had just one carrier (Highmark) in 2014 and 2015. But CareSource joined the exchange in 2016. Health Plan of West Virginia (Optum) also offers ACA-compliant coverage in the state, but only outside the exchange (and their enrollment is very low).

In 2014 and 2015, West Virginia’s exchange had just one carrier—Highmark Blue Cross Blue Shield. West Virginia was the only state in the country that had just one participating exchange carrier in 2015, although Wyoming had just one by 2016, and several states had only one exchange insurer by 2017 (that trend has been reversing itself more recently, with insurers joining the exchanges nationwide for 2019 and 2020).

Starting in 2016, CareSource — a nonprofit insurer — began offering plans with competitive rates in 10 of West Virginia’s 55 counties (Brooke, Cabell, Hancock, Kanawha, Lincoln, Marshall, Mason, Ohio, Putnam, and Wayne). In February 2016, CareSource announced that they had enrolled 1,800 people through the West Virginia exchange for 2016.

CareSource had planned to “significantly” increase the areas of West Virginia where they would offer plans in 2017, and began the process of opening an office in Charleston. For 2016, the vast majority of the state’s exchange enrollees signed up with Highmark, which had the lion’s share of the market in West Virginia—so there was still plenty of room for competition state-wide. For 2017, CareSource had planned to double their membership in West Virginia.

CareSource’s rate filing noted that they offered coverage in the exchange in 10 counties in 2016, but were planning to “expand to additional counties” in 2017. In September 2016, Metro News reported that CareSource would offer coverage in the exchange in 32 counties in West Virginia in 2017. In addition to the ten counties where they offer coverage in 2016, they began offering exchange plans in Barbour, Boone, Calhoun, Clay, Doddridge, Fayette, Gilmer, Harrison, Jackson, Logan, Marion, Monongalia, Pleasants, Preston, Raleigh, Ritchie, Roane, Taylor, Tyler, Wetzel, Wirt, and Wood counties. CareSource’s enrollment more than tripled in West Virginia in 2017.

By 2019, CareSource had expanded to 35 counties, covering the western and north-western areas of the state. And they added nine more counties for 2020: Braxton, Grant, Nicholas, Lewis, Pocahontas, Randolph, Summers, Tucker, and Upshur. By 2021, CareSource was offering plans statewide, giving all residents in West Virginia a choice of two health insurers in the exchange.

Highmark has continued to offer exchange plans statewide in West Virginia each year. In Highmark’s redacted rate filing memo for 2017, they noted that “These projections reflect expected changes in market share due to an expected increase in market competition” — presumably referring to CareSource’s planned expansion.

Kentucky Health Cooperative (a CO-OP created under the ACA) had planned to expand into the West Virginia exchange in 2015, but in early November 2014, the CO-OP announced that they were postponing their expansion into West Virginia by a year. Then in September 2015, The West Virginia Office of the Insurance Commissioner confirmed that the Kentucky CO-OP would not be offering plans in the West Virginia exchange for 2016.

Ultimately, it was a moot point, as Kentucky Health CO-OP announced in October 2015 that they would cease operations at the end of 2015. The CO-OP is no longer operational.

In West Virginia, the open enrollment period for individual/family coverage runs from November 1 through January 15. Outside of that window, a special enrollment period is necessary in order to enroll or make a change to your coverage.

In most cases, special enrollment periods are linked to a qualifying life event, although some special enrollment periods (such as the enrollment opportunity for Native Americans, or for people earning under 150% of the poverty level) don’t depend on a specific qualifying event.

If you have questions about open enrollment or special enrollment, you can read more in our comprehensive guide to open enrollment and guide to special enrollment periods.

West Virginia continues to have two insurers offering plans in the exchange for 2023, plus one insurer (the Health Plan of West Virginia) that only offers coverage outside the exchange (their offering for 2023 is limited to only a bronze plan, as was the case in previous years). The state’s exchange insurers, both of which offer coverage statewide, implemented the following average rate changes for 2023, according to the federal rate review website:

• Highmark Blue Cross Blue Shield: 0.91% average increase (13,923 members)
• CareSource: 11.9% average increase (8,201 members)

Across both insurers, that amounted to an overall average rate increase of about 5% for 2023.

As is always the case, the rate changes apply to full-price premiums. Most exchange enrollees in West Virginia receive premium subsidies (94% as of early 2022), and the year-to-year variation in after-subsidy premiums is much different from the variation in full-price premiums. But everyone who buys coverage outside the exchange pays full price. Subsidy eligibility has been greatly expanded through the end of 2025 under the American Rescue Plan and Inflation Reduction Act, thanks to the elimination of the “subsidy cliff.” This is particularly helpful given how high full-price premiums are in West Virginia.

Average pre-subsidy premiums in West Virginia’s exchange were already the highest in the nation in 2022, at $1,144/month (versus an average of $594/month across all states that use HealthCare.gov). 

But average after-subsidy premiums were more affordable for many enrollees in West Virginia in 2022, thanks to the state’s decision to start adding the cost of cost-sharing reductions (CSR) only to on-exchange Silver plan rates as of 2022.

For the previous few years, West Virginia had been one of only three states (the others are Indiana and Mississippi) where the cost of CSR was spread across the prices for all plans (ie, a broad load), rather than being concentrated on silver plans and resulting in disproportionately large premium subsidies. But for 2022, West Virginia’s Office of the Insurance Commissioner confirmed that insurers would be switching to silver loading, adding the cost of cost-sharing reductions just to silver plans. This resulted in larger premium subsidies, due to the spiking cost of on-exchange Silver plans.

2015: Average rate increase of about 7%. West Virginia had just one carrier in its exchange in 2015 – Highmark Blue Cross Blue Shield – although the carrier only offered 12 plans in 2014, and bumped that up to 14 in 2015.

In 2014, the lowest-cost bronze plan in the WV exchange was an average of $280/month, higher than the national average of $249. For 2015, the average rate increase in the individual market in West Virginia was 6.7%. Because the Kentucky CO-OP filed rates alongside Highmark for 2015, experts believed (and Highmark confirmed) that Highmark was forced to be more competitive with their rates for 2015. Highmark’s rates were not able to be adjusted heading into the 2015 open enrollment, even after the CO-OP withdrew their plan to join West Virginia’s market (and subsequently collapsed altogether). So despite the fact that Highmark remained the only carrier in the state’s exchange in 2015, rates were as competitive as they would have been with a second participating carrier.

2016: Average increase of 24%. Highmark initially requested an average rate increase of 19.7% for individual plans in the West Virginia exchange, but the requested average rate increase was subsequently changed to 24%, and was approved by regulators at that level. Because West Virginia had just one carrier in 2015, it was one of just three states where 100% of the existing exchange plans requested double-digit rate increases for 2016 (CareSource joined the exchange in 10 counties in 2016).

Highmark noted that they considered pulling out of the exchange at the end of 2015. But the carrier ultimately felt they have a “social mission” to provide coverage to residents in West Virginia. And the 24% rate increase that was approved by regulators made it possible for Highmark to continue to offer plans for 2016.

2017: Average increase of 47%. Highmark’s average premium increased by 36%, and CareSource’s increased by 50%. These were steep rate increases, but for the nearly 88 % of West Virginia exchange enrollees who were receiving premium subsidies, the increases were mostly offset by higher subsidies. But for people with income too high to qualify for subsidies, and for everyone who purchases coverage outside the exchange, the rates were considerably higher in 2017 than they were in 2016.

West Virginia’s average rates were already among the highest in the country, and although average rate increases for 2017 were substantial all across the country, West Virginia’s average rate increases were higher than the national average.

Highmark also introduced a tiered hospital network in West Virginia in 2017; patients who go to a preferred hospital have lower out-of-pocket costs than patients who go to hospitals in the enhanced or standard tiers. Horizon Blue Cross Blue Shield rolled out a similar program in New Jersey in 2016. Tiered network plans tend to be controversial, but the cost-savings is popular with consumers.

CareSource expanded its coverage area to 32 counties as of 2017.

2018: Average increase of 25%. Highmark’s average rate increase for 2018 was almost 29% and CareSource’s was 19%.

CareSource’s revised filing noted that the West Virginia Office of the Insurance Commissioner had directed insurers to assume that CSR funding would not continue, and to add the cost of CSR to premiums for 2018. But rather than adding the cost of CSR only to silver plan premiums (which is what insurers in most states did), insurers in West Virginia were instructed by the Office of the Insurance Commissioner to spread the cost of CSR across premiums at all metal levels. As noted above, this “broad load” approach continued through 2021, but was replaced by silver loading as of 2022.

2019: Average increase of 9%. CareSource expanded its coverage area again, offering plans in 35 counties for 2019. CareSource’s average premium increased by 9.5%, while Highmark’s increased by 9%. Highmark noted in their filing that they “experienced an unanticipated financial gain in 2017,” after losing money in the ACA-compliant individual market in prior years.

The average benchmark premium (second-lowest-cost silver plan, on which subsidy amounts are based) in West Virginia was 9% higher for 2019 than it was in 2018. That was the fifth-largest increase across the 39 states that use HealthCare.gov; the average across all of those states was a 1.5 percent decrease for 2019

2020: Average rate increase of 6.7%. Across all three carriers (including The Health Plan of WV, which only offers off-exchange coverage), the average rate increase was 6.7% for 2020—versus a national average of less than half a percent.

2021: Average rate increase of less than 5%. The state’s exchange insurers, both of which offered coverage statewide for 2021, implemented the following average rate changes for 2021:

• Highmark Blue Cross Blue Shield: 4.34% average increase, approved as filed (coverage available statewide).
• CareSource: 8% average increase (CareSource initially proposed a 6.26% average increase). Coverage area was expanded again for 2021 to encompass the entire state, up from 44 counties in 2020 (CareSource joined the exchange in 2016 and increased their coverage area in each of the subsequent years).

Outside of the exchange, the Health Plan of West Virginia, which offers just one bronze plan, increased premiums by an average of 3.68% for 2021.

2022: Average rate increase of almost 13%. Highmark BCBS raised prices by an average of 11.6%, while CareSource raised prices by an average of 14.9%. Across both insurers, that amounted to an overall weighted average rate increase of 12.9%. As of 2022, insurers in West Virginia began adding the cost of cost-sharing reductions (CSR) only to silver plan rates, instead of spreading the cost across the rates for plans at all metal levels. The new approach (which was already used in nearly every other state) results in larger premium subsidies, since subsidy amounts are based on the cost of the benchmark plan, which is a silver-level plan.

28,325 people enrolled in private plans through West Virginia’s exchange during the open enrollment period for 2023 coverage. Although this was higher than the last several years, it was still well below the record set in 2016, when more than 37,000 people enrolled. Nationwide, enrollment grew to new record highs in 2022 and again in 2023, but that was not the case in West Virginia. 

From 2016 to 2021, enrollment in private individual market plans dropped by 48% in West Virginia. Although there was a nationwide decrease in enrollment from 2016 through 2020, the drop was much more significant in West Virginia. And although there was a small increase in nationwide enrollment in 2021, enrollment decreased again in West Virginia during the open enrollment period for 2021 coverage. West Virginia’s enrollment actually reached a record low for 2021, dropping below the level it was at in 2014 when the exchanges were brand new.

For 2022, however, enrollment rebounded, and it grew again in 2023. This was likely due to the subsidy enhancements created by the American Rescue Plan (ARP), the state’s decision to add the cost of CSR to silver plan rates, resulting in even larger subsidies, and the increased federal funding for Navigators who help people enroll in coverage.

Here’s a summary of the number of people who have signed up for private individual market coverage through the West Virginia exchange each year, during open enrollment:

• 2014: 19,856 people enrolled
• 2015: 33,421 people enrolled
• 2016: 37,284 people enrolled
• 2017: 34,045 people enrolled
• 2018: 27,409 people enrolled
• 2019: 22,599 people enrolled
• 2020: 20,066 people enrolled
• 2021: 19,381 people enrolled
• 2022: 23,037 people enrolled 
• 2023: 28,325 people enrolled

(Several other states also had record-low exchange enrollment in 2021: Louisiana, Idaho, New York, Vermont, and Kentucky. Louisiana and Idaho both expanded Medicaid after 2014, resulting in a sharp drop in private plan enrollment when people became eligible for Medicaid instead. New York debuted its Basic Health Program in 2016, with the same sort of effect. Vermont initially didn’t allow off-exchange enrollment but began to allow it in 2016, encouraging non-subsidy-eligible enrollees to use it. Kentucky experienced a sharp decline in enrollment when the state abandoned its highly successful state-run exchange in favor of using HealthCare.gov.)

There are various factors that contributed to the declining enrollment in West Virginia after 2016, including the Trump administration’s decision to sharply reduce funding for marketplace marketing and enrollment assistance, the expansion of short-term plans to serve as an alternative to ACA-compliant coverage, the sharp premium increases in 2017 and 2018 (this primarily only affected people who don’t get premium subsidies, as those who do get subsidies were protected with increasing subsidies) that drove full-price premiums to record highs, and the elimination of the individual mandate penalty at the end of 2018.

But enrollment in Medicaid has grown during the pandemic, likely accounting for much of the recent drop in private plan enrollments. Prior to the pandemic, Medicaid enrollment in West Virginia stood at about 517,000 people. By March 2023, that had grown to about 650,000 people.