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Two insurers offer 2023 health plans through state's exchange; Average pre-subsidy premiums increase by 5% for 2023
West Virginia uses a partnership health insurance exchange so residents enroll through HealthCare.gov. As of 2022, West Virginia directs its insurers to add the cost of cost-sharing reductions (CSR) to the cost of silver plans, instead of “broad loading” it across all plans. This silver-loading approach is by far the most common, and it results in larger premium subsidies and more affordable coverage. West Virginia joined most of the rest of the country in using it as of 2022.
Two insurers offer 2023 coverage through the exchange. West Virginia’s average pre-subsidy premiums are the highest in the nation, but most enrollees get premium subsidies which are also the largest in the nation (more than $1,000 per month, on average, in 2022). For 2023, average premiums in West Virginia’s individual market increased by about 5%, which was slightly smaller than the national average percentage rate increase.
During the open enrollment period for 2022 coverage, more than 23,000 West Virginians enrolled in private individual market plans through the West Virginia exchange.
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, 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 bang for their buck.
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). The blueprint for the West Virginia Health Insurance Marketplace 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 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:
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 2022 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.
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 are continuing to offer coverage statewide, implemented the following average rate changes for 2023, according to the federal rate review website:
Across both insurers, that amounts 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 result 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 ended up among the 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 tiered a 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:
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.
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. 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 has rebounded somewhat. By December 15, 2021, enrollment had reached 21,435, which was higher than total enrollment had been during either of the two previous open enrollment periods. And at that point, there was still a month remaining in open enrollment, so the total likely grew even more, potentially even surpassing 2019’s enrollment. The higher 2022 enrollment is 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:
(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. Medicaid expansion enrollment in West Virginia stood at 154,412 as of January 2020. That had grown to 162,169 as of May 2020, likely as a result of the widespread job losses amid the COVID-19 pandemic. And it had increased to nearly 200,000 by mid-2021, due to the pandemic and the federal pandemic response that prevents states from removing people from the Medicaid rolls during the public health emergency period.
When the ACA’s individual mandate penalty was repealed under the Tax Cuts and Jobs Act, a group of 18 Republican attorneys general and two Republican governors filed a lawsuit (Texas v. Azar/US, subsequently called California v. Texas), seeking to have the entire ACA ruled unconstitutional (two states later withdrew from the lawsuit after Democratic governors took office, so there were ultimately 18 states challenging the ACA). Their argument was that the individual mandate is unconstitutional without the associated enforcement tax, and the mandate is inseverable from the rest of the ACA — if one falls, the rest falls.
Although that argument might sound tenuous at best, the case did make its way to the Supreme Court. The Supreme Court ultimately ruled to uphold the ACA in mid-2021. This was good news for consumers; if the law had been overturned, it would have created utter chaos (and not just for people who buy their own health insurance).
Patrick Morrisey is West Virginia’s attorney general, and was one of the plaintiffs in Texas v. Azar/US, which means he was part of the group that was actively working to overturn the ACA. But in early 2020, Morrisey and West Virginia State Senate President Mitch Carmichael announced new legislation that would be considered in 2020 in an effort to protect West Virginia residents from the very lawsuit that the state is supporting. The West Virginia Healthcare Continuity Act, SB284, ultimately did not pass in the state legislature. If it had passed, it would only have taken effect if and when the ACA had been overturned, and would have prohibited insurers from rejecting applicants due to pre-existing conditions. It would also have required insurers to cover the essential health benefits, and would have allowed insurers to use limited enrollment windows in order to mitigate risk, just as the ACA does.
In a press conference to announce the legislation, which Carmichael sponsored, Morrisey explained that the bill would be modeled on similar legislation that Louisiana enacted in 2019 (Louisiana was also a plaintiff in the lawsuit seeking to overturn the ACA). In response to a question about how the state would cover the cost (literally a billion-dollar question), Morrisey indicated that West Virginia’s bill would call for the same sort of “invisible risk-sharing” fund called for in Louisiana’s legislation.
But under the ACA, West Virginia had (at that point, pre-COVID) more than 160,000 people enrolled in Medicaid expansion (with 90% federal funding) and more than 16,000 people receiving premium subsidies that averaged $835/month (Medicaid expansion has since grown significantly, and WV’s average premium subsidies were over $1,000/month by 2022). If West Virginia had enacted the WV Healthcare Continuity Act, it would have provided a regulatory framework for health insurance in the state. But without federal funding, it’s unlikely that coverage would have been anywhere near as affordable as it is under the ACA. The legislation outlined a reinsurance (ie, what Morrisey called “invisible risk-sharing”) program, and did note that the state would consider whether funding that’s currently used for the health insurance provider fee might be used to help cover the cost of a reinsurance program, since the health insurance provider fee is no longer being collected by the federal government after 2020.
Democrats did not support SB284, as they noted that it would make more sense for West Virginia to not be trying to overturn the ACA while simultaneously scrambling to enact some sort of backstop in case they’re successful. It bears repeating that if Morrisey and the other GOP attorneys general in the Texas v. Azar case hadn’t challenged the ACA in the first place, none of this would have been necessary in the first place.
West Virginia initially did not allow non-grandfathered pre-2014 policies in the individual market to renew again in 2014; they had to be replaced with ACA-compliant coverage as of their renewal date in 2014.
But in April 2014, the state reversed course, agreeing to allow grandmothered (transitional) plans to be renewed as late as 2016.
In February 2016, HHS agreed to give states additional flexibility on grandmothered plans, allowing the plans to renew as late as October 1, 2017, and remain in force until as late as December 31, 2017. States have freedom to accept that proposal as-is, reject it, or implement it with additional restrictions—which is what West Virginia has done
In May 2016, the WV Office of the Insurance Commissioner confirmed by phone that West Virginia was allowing small group transitional plans to remain in force until the end of 2017, at the carriers’ discretion, as long as the plans were renewed by January 2017. The state did not allow small group transitional plans to renew after January 2017—But the OIC noted that there were no longer any grandmothered individual plans in West Virginia, as the state’s carriers had already terminated those plans and replaced them with ACA-compliant coverage.
The state also filed a lawsuit in 2014 against the Obama Administration because the federal government deferred to the states on the decision about whether or not to renew grandmothered plans. A district court found that West Virginia lacked standing in the case, because they did not suffer an injury-in-fact as a result of HHS letting states decide whether or not to allow grandmothered plans to continue to exist. The state appealed that decision.
Then in July 2016, the US Court of Appeals concurred with the district court, ruling that the state lacked standing. The ruling states that West Virginia’s “injury is nothing more than the political discomfort in having the responsibility to determine whether to enforce or not – and thereby annoying some West Virginia citizens whatever way it decides. And no court has ever recognized political discomfort as an injury-in-fact“
In West Virginia, federal regulations limit initial durations of temporary health insurance plans to 364 days.
As of 2022, total Medicaid enrollment in West Virginia had grown by 77% since 2013.
West Virginia is among the minority of states where there is no rule guaranteeing access to Medigap for people under 65.
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