Idaho has a state-run exchange, Your Health Idaho. They used Healthcare.gov’s enrollment platform during the first open enrollment period, but transitioned to their own enrollment platform in time for the second open enrollment period, and have been successfully using it ever since.
While the majority of exchanges across the country had at least one carrier exiting at the end of 2016, all of Idaho’s exchange carriers continued to participate in the exchange in 2017. Unlike many states, there are more plan options (including dental) for consumers in 2017 than there were in 2016 in the Idaho exchange.
Your Health Idaho was the first exchange to open up window shopping for 2017 plans, doing so on October 1, 2016 — a full month ahead of the November 1 start of open enrollment. A total of 225 health and dental plans are available through the exchange for 2017.
Looking ahead to 2018: BridgeSpan exiting exchange, 4 other insurers remaining in exchange
Insurers in Idaho had to submit forms for 2018 plans by May 15, but they have until June 2 to file rates. Mountain Health CO-OP, SelectHealth, PacificSource and Blue Cross of Idaho all filed forms to continue to offer Your Health Idaho plans in 2018.
There are currently five insurers that offer plans in Your Health Idaho, but BridgeSpan’s form filing only shows off-exchange plans for 2018. BridgeSpan confirmed by phone that their plans will not be available on-exchange in Idaho in 2018; current Your Health Idaho enrollees who have BridgeSpan coverage will need to switch to a different plan during open enrollment (November 1, 2017, through December 15, 2017), as on-exchange BridgeSpan plans will be terminated at the end of 2017. BridgeSpan noted that the switch to only offering off-exchange plans is a cost-control measure, but is also a result of uncertainty and instability for the exchanges.
Regence Blue Shield of Idaho (BridgeSpan’s sister company) will also only offer off-exchange plans in 2018, but their plans are already only available off-exchange.
On December 16, Your Health Idaho announced that over 98,000 people had enrolled in plans for 2017, including renewals and new enrollees. The exchange noted that this was the highest their enrollment had ever been at the mid-way point of an open enrollment period.
By January 18, 2017, Your Health Idaho reported that “more than 100,000” people had enrolled. And on February 8, they announced that 105,977 people had signed up for private plans during the 2017 open enrollment period.
For perspective, 102,353 by the end of the previous open enrollment period. So enrollment climbed by 3.5 percent in Idaho for 2017. Enrollment also grew in other state-based exchanges, including Colorado and Washington. But HealthCare.gov enrollment declined for 2017, likely due to the uncertainty surrounding the ACA under President Trump, and the Trump Administration’s move to cut back on advertising and outreach in the final week of open enrollment.
Your Health Idaho and the Trump Administration
Although there’s considerable uncertainty about the future of the ACA, nothing has changed for the time being. Coverage — with subsidies for those who are eligible — is still available in 2017, regardless of pre-existing conditions, as long as you have a qualifying event (open enrollment ended on January 31, so qualifying events are necessary — both on and off the exchange — to enroll for the remainder of the year).
HHS reported that 109,000 people in Idaho had gained coverage as a result of the ACA between 2010 and 2015. That number has continued to grow since 2015, as exchange enrollment grew in 2016 and again in 2017. But the Trump Administration and Republican lawmakers are pushing to repeal and replace the ACA. House Republicans passed the American Health Care Act (AHCA) on May 4, but its future is very uncertain (both of Idaho’s representatives voted for the bill). The Senate is creating their own version of the legislation, and it’s not clear whether the two chambers will agree on a measure to send to the president.
Idaho has not expanded Medicaid under the ACA, so people with income below the poverty level are already in dire straits in Idaho (with essentially no coverage options available), and their situation is unlikely to change if the ACA is repealed.
But nearly 82 percent of Idaho exchange enrollees are receiving premium subsidies, and nearly 67 percent are receiving cost-sharing subsidies. Premium subsidies make coverage more affordable, and cost-sharing subsidies reduce out-of-pocket costs for people with modest incomes. Under the House version of the AHCA, premium subsidies would generally be smaller than the ACA’s subsidies — particularly for lower-income and older enrollees. And cost-sharing subsidies would be eliminated altogether, driving up out-of-pocket costs for people who can least afford the additional expense. Even without the AHCA, there is uncertainty surrounding future funding of
Even without the AHCA, there is uncertainty surrounding future funding of cost-sharing subsidies (CSRs). Insurers must provide more robust coverage to eligible enrollees, and the federal government reimburses them for the cost of doing so. But House Republicans sued the Obama Administration in 2014, arguing that the money to fund CSRs was never appropriated by Congress. A court sided with House Republicans in 2016, but the Obama Administration appealed and CSR money has continued to flow to insurers ever since. The case has been pended for the first several months of 2017, and an update is expected on May 22. The Trump Administration has been very noncommittal in terms of whether they will continue to fund CSRs, which has made insurers understandably nervous. A Kaiser Family Foundation analysis indicated that premiums in the individual market would rise by 19 percent if CSR funding is eliminated, and that’s before any other factors that drive rate increases are taken into consideration.
2017 rates and carriers:
The average individual market premium increased by 24 percent in Idaho for 2017, but that doesn’t take subsidies into account. Nearly 88 percent of Your Health Idaho’s enrollees were receiving subsidies as of March 2016, and subsidies offset much of the rate increase as long as enrollees are flexible about the possible need to switch plans in order to take advantage of the most robust subsidies.
The Idaho Department of Insurance does not have the authority to prevent health insurers from implementing rates that are deemed unjustified. But they do have a review and negotiation process during which they analyze the rates that have been filed for the coming year and work with carriers to ensure that proposed rates are actuarially justified.
Idaho’s six individual market carriers (five of which offer plans in the exchange) proposed an average rate increase of 28 percent for 2017. But the carriers all eventually settled on rates that were different from what they had proposed (some higher, some lower), and the end result is an average rate increase of 24 percent:
- Blue Cross of Idaho: 19 percent
- BridgeSpan: 23 percent (BridgeSpan is a sister company to Regence Blue Shield of Idaho; BridgeSpan was established specifically to offer policies through Your Health Idaho, while Regence provides off-exchange coverage and had an average rate increase of 25 percent in 2017).
- Mountain Health CO-OP (an ACA-created CO-OP): 29 percent
- SelectHealth: 29 percent
- PacificSource: 15 percent
Average rates in the small group market will only increase by 4 percent for 2017. Nationwide, the small group market is currently much less volatile than the individual market.
Enrollment 5% higher in 2016
102,353 people enrolled in private plans through for 2016 Your Health Idaho by mid-February (up from 101,073 as of February 1; open enrollment ended on January 31, 2016, but enrollments can continue to be submitted if enrollees have qualifying events). The exchange reported that their per-capita enrollment was second in the nation for 2016 – trailing only Florida – after being fourth in the nation in 2015. By March, effectuated enrollments (ie, premiums paid) through Your Health Idaho stood at 95,522. At the end of March, effectuated enrollment was 94,270.
For perspective, in-force enrollment in mid-December 2015 stood at about 86,000 people, and during the 2015 open enrollment period, 97,079 people selected coverage in private plans (enrollment is expected to decline somewhat throughout the year; attrition is a normal part of the individual health insurance market, and relatively few people are able to enroll outside of open enrollment).
As of early 2016, Idaho had a surplus of nearly $29 million in its Catastrophic Health Care fund, thanks to a declining uninsured rate in Idaho, and more people obtaining coverage through Your Health Idaho. The CAT fund is state money that’s used to cover a portion of catastrophic medical bills for uninsured residents (residents whose medical bills are paid end up with liens on their homes and other assets, but most of the money is never recovered). The CAT fund has $29 million in unspent funds, which will be transferred to the state’s general fund.
The CAT fund will continue to operate, however, and still has cash left over after the transfer to the general fund. Idaho has not yet expanded Medicaid, so there are still tens of thousands of residents without any access to health insurance. Senator Dan Schmidt, D-Moscow, recently announced his resignation from the board of the Catastrophic Health Care fund, stating “I cannot continue to serve on a program board I fundamentally believe should not exist.” Schmidt’s position is that if Idaho were to expand Medicaid, the CAT fund would no longer be needed, and that the state should focus on making sure that low-income individuals have health insurance rather than sorting through CAT fund applications for help.
Assessment fee increased to 1.99% — still far lower than Healthcare.gov fee
Your Health Idaho was previously funded with a 1.5 percent assessment fee on all health insurance plans sold through the exchange (unlike many other states, the fee is not collected for plans sold outside the exchange). The fee increased to 1.99 percent in 2016, which is still considerably lower than the 3.5 percent assessment that Healthcare.gov collects in states that use the federally-facilitated marketplace.
The exchange does not receive any state funding. They received $104 million in federal funds for 2014 and 2015, but most of that money has already been spent, although the exchange notes that they have about $6 million in cash reserves. The exchange must be self-sustaining going forward, which is why the assessment has been increased. The board has approved a $9.7 million operational budget for 2016, plus a $15 million project budget. For the 2017 fiscal year, the operational budget is expected to drop to about $9 million.
As noted above, a recent Leavitt Partners study found Your Health Idaho to be an excellent example of an exchange that is operating well on a much smaller-than-average budget. Your Health Idaho mostly uses in-house support for its systems, and only contracts with vendors for highly specialized services, like marketing. Many other state-run exchanges contract with vendors for much of their day-to-day operations, while Your Health Idaho staff handles most of the day-to-day operations of the exchange. This is part of the reason they’re able to operate at a lower cost than the rest of the state-run exchanges.
But at the same time, Your Health Idaho has limited itself to only essential functions. The exchange leaves plan oversight and rate review entirely to the Idaho Department of Insurance, and the Idaho Department of Health and Welfare does all of the subsidy and Medicaid eligibility determination for exchange enrollees. The exchange does not have to spend time or money being involved in these processes, or creating systems that would essentially duplicate the functionality of the DOI or DHW.
Your Health Idaho – a “model” exchange
Your Health Idaho is a state-run exchange, and is offering a total of 211 health and dental plans for 2016 (adult dental is offered through Your Health Idaho for the first time in 2016; previously the exchange only sold pediatric dental).
Your Health Idaho used Healthcare.gov’s enrollment platform in 2014, but switched to being a fully state-run exchange in time for the 2015 open enrollment period. Your Health Idaho’s Executive Director Pat Kelly has said that the exchange worked hard to make sure that the 2016 open enrollment period would be even better than the prior year, noting that “we’ve worked tirelessly over the last 9 months to improve our technology, make it easier for consumers, and also for those agents and brokers.”
Your Health Idaho debuted anonymous browsing for 2016 plans on their website starting October 1 – a full month ahead of the start of open enrollment. California had already enabled browsing, but Idaho and Maryland became the second and third states to do so in advance of the 2016 open enrollment period. Your Health Idaho didn’t previously have an anonymous browsing tool at all, so this was a big improvement for the exchange.
In December 2015, a Leavitt Partners study called Your Health Idaho a “model for state based adoption [of an exchange]” and noted that the exchange has a budget well below average, a “lean organizational structure” and “strong financial controls.” The Leavitt study also indicates that Your Health Idaho benefited from the fact that they used Healthcare.gov during the first open enrollment, and waited until the second open enrollment period to debut their own enrollment platform; that allowed them to obtain lower-cost, better-developed software solutions, with the benefit of hindsight in terms of seeing what worked and what didn’t for the other state-run exchanges during year one.
2016 rates and carriers
Of the five carriers selling individual health plans through Your Health Idaho, three proposed double-digit rate hikes for 2016: Blue Cross Blue Shield of Idaho, Mountain Health CO-OP, and SelectHealth. Rates were finalized by regulators at the end of August, and ACAsignups’ Charles Gaba has filled in some additional details.
- Blue Cross of Idaho = proposed average rate hike of 24.28 percent (average approved rate increase is 23 percent).
- BridgeSpan = proposed average rate hike of 6.3 percent (average approved rate increase is 7 percent).
- Montana Health CO-OP (Mountain Health CO-OP in Idaho; an ACA-created CO-OP) = proposed average rate hikes of 25.75 percent for LINK plans and 22.88 percent for Access Care; overall proposed average = 25.4 percent. (approved average rate increase is 26 percent).
- SelectHealth = 14.68 percent (approved average rate increase is 15 percent)
- PacificSource = In 2015, PacificSource had rate increases in excess of 30 percent for their individual market exchange plans in Idaho. But for 2016, regulators approved an 8 percent decrease.
Two additional carriers offered individual coverage outside the exchange in Idaho in 2015: Regence Blue Shield and Time. Regence had an average rate increase of 10 percent for 2016, but Time exited the insurance market nationwide and is no longer offering coverage anywhere for 2016.
Blue Cross of Idaho does not have to publicly release its CEO and board members’ compensation, under Idaho law. The other four carriers in the exchange are based in neighboring states, and their CEO and board compensation is public information.
Your Health Idaho is also offering dental coverage from five carriers: Dentegra (new for 2016), BEST Life and Health Insurance Company, Delta Dental of Idaho, The Guardian Life Insurance Company of America, and Willamette Dental.
There are not any Platinum plans available in the Idaho exchange for 2016. Only about 2 percent of Idaho exchange enrollees selected platinum plans in 2015, and the carriers opted not to offer those plans in 2016, as they aren’t required by the ACA and clearly were not a popular choice among enrollees.
For the most part, approved rates in Idaho are virtually the same as the proposed rates, although the Idaho Department of Insurance noted that they were able to work with carriers to reduce the overall rate hikes on some plans, particularly at the Silver and Bronze level. But the DOI explained that “carriers propose rates based on claims experience, premiums, network provider agreements, administrative and other costs. Based on these criteria, the Department could not find the carrier rate proposals to be unreasonable.” Hence, rates were mostly finalized as-proposed.
Kaiser Family Foundation analyzed data on benchmark plan (second-lowest-cost Silver plan) premium changes from 2015 to 2016 in metropolitan areas across the country. In Boise, they found that the average benchmark plan for a 40-year-old non-smoker would be increasing from $210/month to $273/month – a 30 percent increase, which is three times the average they found nationwide.
But that’s before any premium subsidies are applied. If that 40-year-old applicant earns $30,000 in both 2015 and 2016, and was willing to switch plans in order to still have the benchmark plan in 2016 (the second-lowest-cost Silver plan isn’t necessarily offered by the same carrier that offered it the year before), the after subsidy premium will actually be slightly lower in 2016 than it was in 2015, because the subsidy will increase to offset the higher premiums (the poverty level is also slightly higher, so if enrollees have the same income they had in 2015, their income is now a slightly lower percentage of the poverty level, making them eligible for a slightly higher subsidy).
In 2015, nearly 82 percent of Your Health Idaho enrollees were receiving premium subsidies that averaged $227/month. Since the cost of the benchmark plans across Idaho increased for 2016, the average subsidy also increased, and more enrollees are eligible for subsidies in 2016.
CO-OP still solvent
By the end of 2015, 12 of the 23 CO-OPs created by the ACA had closed. But Montana Health CO-OP (which operates as Mountain Health CO-OP in Idaho) appears to be on somewhat solid ground. CEO Jerry Dworak noted in October 2015 that the CO-OP didn’t expand too quickly, and maintained substantial reserves; they were not relying as heavily on risk corridor payments to shore up their financial position (as Charles Gaba has noted, the CEO’s proclamation that they’re doing well doesn’t necessarily mean they don’t have financial troubles – but for now, they managed to avoid being shut down by regulators, which is more than can be said for almost half of the CO-OPs).
The CO-OP was due to receive $6 million in risk corridor payments, and ultimately only received 12.6 percent of that amount (just like all of the other carriers that were owed risk corridor payments). But unlike nine other CO-OPs that were doomed by the risk corridor shortfall and shut down by the end of 2015, Montana Health/Mountain Health CO-OP was still viable heading into 2016. Their average rates increased by 26 percent, but that was very comparable to the average rate hike for BCBS of Idaho.
SHOP exchange – direct enrollment
As part of their cost-saving plan, Your Health Idaho opted not to build a SHOP (small business) exchange enrollment platform, and instead relies on direct enrollment through health insurance carriers (with agents and brokers providing enrollment assistance) when businesses want to enroll in SHOP plans. There are six carriers (including Dental carriers) that offer SHOP-certified plans in Idaho:
- BEST Life and Health Insurance Company
- Blue Cross of Idaho
- Mountain Health CO-OP
- PacificSource Health Plans
- SelectHealth, Inc.
- Willamette Dental of Idaho, Inc
Your Health Idaho has a paper application that small businesses can complete, with contact information that the exchange can use to get in touch with the business and help them move forward with the enrollment process. But in general, Your Health Idaho recommends that small businesses reach out to a broker or agent for assistance with SHOP enrollment.
This approach saves the exchange from having to administer and fund a SHOP platform, and in hindsight, is probably a wise decision – SHOP enrollments nationwide have been relatively lackluster, and Idaho’s decision means that the exchange is not having to fund and maintain a low-use enrollment platform.
2015 enrollment data
During the second open enrollment period, Idaho ranked fourth in the nation in terms of per-capita enrollment in the exchange. Only three states (Maine, Georgia, and Florida) had higher per-capita exchange enrollment, and they all use Healthcare.gov. Idaho’s per-capita enrollment was the highest of the state-run exchanges.
Idahoans had until Feb. 15 to complete an application on Your Health Idaho and until Feb. 21 to finalize their plan selections. As of Feb. 21, the exchange had enrolled 97,079 people in private plans for 2015. But some of them didn’t pay their initial premiums (meaning their coverage was never effectuated), and some people cancelled their coverage early in the year. By the end of March, 84,987 people had in-force private plan coverage through Your Health Idaho. 81.3 percent were receiving premium subsidies, and 62.3 percent were receiving cost-sharing subsidies (only available on silver plans for enrollees with incomes up to 250 percent of the poverty level).
By mid-April, effectuated enrollments had climbed slightly to 85,128 people, despite the fact that Idaho was one of only three states in the US that didn’t offer a special enrollment period (SEP) to accommodate consumers who didn’t know – until they filed their taxes – that there was a penalty for being uninsured. And by the end of June, effectuated enrollment stood at 85,981. Nationwide, there was a dip in effectuated enrollment numbers from March to June, but Idaho added almost a thousand effectuated enrollments during that time.
An additional 314,398 exchange enrollees qualified for Medicaid between Nov. 15 and Feb. 22. Medicaid enrollment continues year-round, but it tends to increase during open enrollment due to outreach activities.
No impact from King v. Burwell
Because Idaho switched to being a fully state-run marketplace in 2015, subsidies were not in danger of being eliminated in the King v. Burwell lawsuit. Ultimately, the Supreme Court ruled that subsidies are legal in every state, even those that rely on Healthcare.gov. Although the verdict didn’t impact Idaho one way or the other, the state’s Congressional delegation — all Republicans — were largely unimpressed by the Court’s decision. But Gov. Butch Otter, also a Republican, praised the state’s efforts to establish and run an exchange, thereby insulating the state’s residents from any potential fallout from the King case.
State-run marketplace launch was ‘flawless’
Your Health Idaho transitioned to its own platform for the ACA’s second open enrollment period, and the launch was “absolutely flawless” according to the exchange’s executive director.
Idaho relied on HealthCare.gov, the federal exchange, for enrollment functions during the first open enrollment period. To get ready for 2015, Idaho transitioned to its own technology. The move paid off as 2015 open enrollment on Your Health Idaho was very successful.
Your Health Idaho touts a low assessment fee as one of biggest consumer benefits to running its own exchange. For both 2014 and 2015 policies, Your Health Idaho charged an assessment fee of 1.5 percent of premium cost. On the federal marketplace, the fee is 3.5 percent. Idaho’s assessment increased slightly in 2016, to 1.99 percent, but is still considerably lower than Healthcare.gov.
New insurer joined Your Health Idaho in 2015
A new insurer was approved by the Idaho Department of Insurance for 2015: Mountain Health CO-OP, which is the Idaho branch of Montana Health CO-OP. The CO-OP joined Blue Cross of Idaho, BridgeSpan Health Company, PacificSource Health Plans, and SelectHealth, all of which returned to the exchange for 2015. The same five carriers are offering coverage in 2016.
2014 enrollment recap
More than 76,000 Idahoans signed up for health insurance during the first enrollment period. That’s 36,000 more than the target set by the federal government, and in a state of only 1.7 million people, the per-capita enrollment ranks Idaho third in the nation for plans purchased during the first open enrollment period.
Among Idaho residents selecting a QHP, 92 percent qualified for financial assistance, compared to 85 percent nationally. Only Mississippi and Wyoming had higher rates of individuals eligible for assistance. A report released in June by the U.S. Department of Health and Human Services showed the average monthly premium, after tax credits, for Idaho consumers was $68. Fifty percent of those Idaho enrollees who qualified for subsidies pay $50 or less per month after subsidies.
During the 2014 open enrollment period, 15 percent of Idaho residents selected a bronze plan (20 percent nationally), 72 percent selected a silver plan (65 percent nationally), 10 percent selected a gold plan (9 percent nationally), 3 percent selected a platinum plan (5 percent nationally) and 1 percent selected a catastrophic plan (2 percent nationally). Twenty-seven percent of Idaho enrollees were between the ages of 18 and 34.
Agents and brokers: key to success
Your Health Idaho created a strong partnership with agents and brokers in the state, and 50 percent of the exchange’s 2014 enrollments were facilitated by agents and brokers. Your Health Idaho refers to agents and brokers as the “backbone” of the exchange, and credits the partnership with them as the main factor that drove enrollment in 2014.
70 percent of enrollments in the Idaho exchange in 2015 were completed with the assistance of brokers, which is far higher than most other states and reflects Your Health Idaho’s commitment to partnering with brokers.
History of Idaho’s marketplace development
Republican Gov. Butch Otter announced in December 2012 that Idaho would implement a state-run health insurance exchange, and HHS gave conditional approval of the state’s plan in early January 2013.
The state-run option was resisted by both the governor and many Republican legislators. Like those in other “red” states, Idaho leaders hoped the U.S. Supreme Court would find the Affordable Care Act (ACA) unconstitutional. However, after the Court upheld most elements of the ACA and a state task force in October 2012 strongly recommended a state-run exchange, Otter began leaning toward that option as preferable to a federally run exchange.
After Otter’s announcement in December 2012, legislators began considering legislation, and both chambers passed bills authorizing a state-run in exchange in the first quarter of 2013. However, that left scant time to set up the exchange.Idaho used the federal site for the first open enrollment period, but transitioned to its state-run platform in time for the 2015 open enrollment period.
Idaho is the only state that opted to build its own marketplace, but decided against expanding eligibility for its Medicaid program. According to the Kaiser Family Foundation, the decision means about 30,000 (possibly as many as 78,000) Idahoans fall into the coverage gap — meaning they don’t qualify for Medicaid or for subsidies to help them purchase private coverage.
The Medicaid Redesign Group, appointed by Otter, has repeatedly supported Medicaid expansion. The workgroup has recommended the Healthy Idaho Plan, which would extend Medicaid eligibility to adults up to 100 percent of the federal poverty level (FPL) and provide subsidies to help those between 100 and 138 percent of FPL to purchase private coverage through Your Health Idaho. The workgroup also supports a pilot program to use money from the state’s catastrophic care fund to purchase health insurance for people in the Medicaid gap.
In his 2015 State of State address, Otter asked state legislators to consider the recommendations from the Medicaid Redesign Group. Republican leaders said they were open to discussing the recommendations, but stopped far short of endorsing expansion. The Idaho Medical Association has asked lawmakers to support the Healthy Idaho Plan.
Idaho health insurance exchange links
Your Health Idaho
State Exchange Profile: Idaho
The Henry J. Kaiser Family Foundation overview of Idaho’s progress toward creating a state health insurance exchange.
Idaho Department of Insurance
Answers questions about insurance bought on the individual market and insurance provided by an employer who only does business in Idaho.
(208) 334-4250 / toll-free (800) 721-3272