Highlights and updates
- Bridgespan exiting, 4 other insurers remaining in exchange
- BridgeSpan members must pick new plans or exchange will pick for them
- Open enrollment will run from November 1 to December 15, 2017
- 2018 plans will be available for preview as of October 1, 2017
- Proposed rate hikes average 25-48 percent, highest for silver plans
- Proposed rate hikes are based on assumption CSRs won’t be funded
- Silver enrollees without subsidies can switch to “extended bronze” plans
- Premium subsidies will be larger, due to Idaho’s approach to CSR funding
Idaho exchange overview
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.
Open enrollment: November 1 to December 15
Open enrollment for 2018 coverage in Idaho will run from November 1, 2017 to December 15, 2017, but plans will be available to preview starting on October 1. Open enrollment for 2018 was originally scheduled to run for three months (November through January, the same schedule that was used for the past two years), and was slated to switch to the shorter November 1 to December 15 window starting in the fall of 2018.
But the Trump Administration moved up that time frame in April 2017, with market stabilization regulations that shortened the open enrollment period for 2018 coverage, setting the window to November 1, 2017 through December 15, 2017.
The new schedule applies nationwide, but state-run exchanges that use their own enrollment platform (ie, not HealthCare.gov) have the flexibility to extend open enrollment, and nine of the 12 fully state-run exchanges have done so. But Your Health Idaho has not, and a spokesperson confirmed in September that they intend to keep December 15 as the end date for open enrollment this year.
This will be the first time that open enrollment ends before the start of the new year, so it will be essential for enrollees to pay attention to the communications they get from their insurers and from Your Health Idaho this fall, as there will no longer be an opportunity to enroll or make coverage changes after the start of the year, unless you have a qualifying event.
Looking ahead to 2018: BridgeSpan withdrawing, 4 other insurers remaining in exchange
Compared with the rest of the country, Idaho is among the states with the most robust exchanges in terms of projected insurer participation for 2018. Most counties in the state will have four insurers offering plans in the exchange, and 12 counties will have three. There are only a handful of other states where most counties will have four or more insurers offering exchange plans for 2018.
Insurers in Idaho had to submit forms for 2018 plans by May 15, but they had 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 confirmed by phone in May that they would only offer off-exchange plans in 2018. The insurer noted at that point that the impending switch to only offering off-exchange plans is a cost-control measure, but is also a result of uncertainty and instability for the exchanges.
However, by late July, when the Idaho Department of Insurance publicized the 2018 rate filings, BridgeSpan’s filing had been withdrawn altogether. Your Health Idaho enrollees — as well as off-exchange enrollees — who have BridgeSpan coverage will need to switch to a different plan during open enrollment (November 1, 2017, through December 15, 2017), as existing BridgeSpan plans will terminate on December 31, 2017.
Your Health Idaho reported in September 2017 that BridgeSpan members who do not return to the exchange to pick a new plan will be automatically enrolled in a plan from a different insurer in order to prevent a lapse in coverage as of January. HealthCare.gov started using a similar mapping protocol during the open enrollment for 2017 coverage, but BridgeSpan’s exit represents the first time that Your Health Idaho has had an insurer pull out of the exchange, so it’s the first time that such a protocol has been necessary for Idaho.
2018 rate hikes steep, based on assumption that Trump will cut off CSR funding
Your Health Idaho reported on September 15 that rates would be finalized by the Idaho Department of Insurance the following week, and that consumers will be able to start window-shopping for 2018 health plans on October 1, a month ahead of the start of open enrollment. On September 26, the Idaho Department of Insurance said that the rates were expected to be finalized or or around October 1, at the same time they go live for window-shopping on Your Health Idaho.
The Idaho Department of Insurance does not have the authority to prevent health insurers from implementing rates that are deemed unjustified. But they use a review and negotiation process during which they analyze the rates that have been filed for the coming year and work with insurers to ensure that rate changes are actuarially justified.
For the four insurers that will continue to offer plans in Your Health Idaho in 2018, the following average rate increases have been proposed:
- Blue Cross of Idaho: 28 percent
- Mountain Health CO-OP (an ACA-created CO-OP): 25 percent (in neighboring Montana, the same CO-OP, which goes by Montana Health CO-OP in that state, has proposed just a 4 percent average increase).
- SelectHealth: 48 percent (SelectHealth is exiting eight counties in eastern Idaho at the end of 2017, and their coverage will be mostly confined to the southwest and central portions of Idaho in 2018).
- PacificSource: 44 percent
Regence Blue Shield of Idaho only offers off-exchange plans in Idaho. For 2018, they’ve proposed a 51 percent average increase, which is higher than any of the on-exchange insurers.
It’s noteworthy that the average proposed rate increases for silver plans in Idaho (for on-exchange insurers) are much higher than the overall averages. The overall statewide average proposed rate increase is 38 percent, while the overall statewide average proposed rate increase for silver plans is 50 percent. This is due to an assumption that the Trump Administration will not continue to fund cost-sharing reductions (CSR). Idaho Department of Insurance Director, Dean Cameron, notes that if Congress were to either appropriate funding for cost-sharing reductions or end the cost-sharing reductions program altogether, it would “reduce the proposed increase by at least 20% on the Silver plans.”
Idaho’s approach to the CSR funding uncertainty
Unless Congress repeals the cost-sharing program altogether, insurers are required to continue to provide cost-sharing reduction plans to low-income enrollees. But if the federal funding for this program is eliminated — as Trump has threatened to do — insurers have no choice but to exit the market or drastically increase premiums. In some states, insurers have filed rates based on the assumption that cost-sharing reduction funding will continue (with the option to refile higher rates later if that’s not the case), but in Idaho, the filed rates were based on the assumption that cost-sharing reduction funding will be eliminated.
The Idaho Department of Insurance clarified that “the proposed rate increases for silver-level plans on the exchange are significantly higher this year because cost-sharing reduction subsidies are assumed to not be funded by the federal government.”
According to the Idaho Department of Insurance, insurers didn’t have leeway to create new, similar-but-not-identical off-exchange plans at the silver level (that’s the approach that California has taken). Since on-exchange carriers that offer the same plan off-exchange are required to charge the same price on and off-exchange, the additional premium to cover the cost of CSRs is spread across the on and off-exchange silver plans in Idaho, unless the plan is offered only outside the exchange (this would be the case with all of Regence Blue Shield’s silver plans).
What insurers did instead to create new “extended bronze” plans, using the new de minimus range (-4/+5) that applies to bronze plan actuarial value starting in 2018 (this extended actuarial value range was part of the market stabilization rule that HHS finalized in April 2017). So insurers in Idaho will be offering bronze plans with 65 percent actuarial value for 2018. Compared with prior years’ actuarial value rules, this is in between a silver and a bronze plan, which have typically had actuarial values of roughly 70 and 60 percent, respectively.
For silver plan enrollees in the exchange who are receiving premium subsidies, the additional CSR-related premium load on silver plans will be all or mostly covered by commensurately larger premiums subsidies. And for enrollees in other metal levels who are receiving premium subsidies, net premiums will become more affordable than they were in 2017, as the larger premium subsidies (to account for the CSR load on silver plans) can be applied to plans at other metal levels that don’t have the CSR load added to their pre-subsidy premiums.
For non-silver plan enrollees who aren’t receiving premium subsidies, the cost of coverage will increase, but the CSR load won’t be a factor, since it’s only being added to silver plans.
For silver plan enrollees who aren’t receiving premiums subsidies, however, the full weight of the higher rates will apply in 2018. These enrollees can keep their silver plans if they like, but many will find that the new “extended bronze” plans, on or off-exchange, will be a better — and much less expensive — fit.
It’s important to understand that if cost-sharing reduction plans were to be eliminated altogether, health care would become largely unaffordable for many low-income exchange enrollees, as their out-of-pocket costs would climb to levels that would be unrealistic when compared with their income. Although the silver-plan rates in Idaho for 2018 are likely to have sharply higher premiums as a result of the uncertainty surrounding federal funding for CSRs, most consumers won’t bear the brunt of the higher prices. Instead, the federal government will end up paying most of the additional premiums, thanks to the additional charge being added to silver plans and thus resulting in larger premium subsidies.
Premium subsidies will be larger to offset higher rates caused by assumption that CSRs won’t be funded
Premium subsidies (which are different from cost-sharing reduction subsidies) are based on the cost of silver plans in the exchange. So an approach like Idaho is taking (ie, applying the higher rates that come with a lack of CSR funding to silver on-exchange plans and the same silver plans offered off-exchange, rather than spreading them out across all plans) will result in larger premium subsidies, as the subsidies will have to grow to keep pace with the increasing silver plan premiums. Bronze and gold plans will become an even better value for people who receive subsidies, as the larger subsidies will be applicable to those plans too, despite the fact that the additional premiums to account for the lack of CSR funding will only be added to silver plans.
The subsidies are actually just tax credits, which means the Trump Administration will be taking from one hand to give to the other (ie, not funding CSRs, but having to pay out more in premium subsidies). The people who will end up bearing the brunt of the rate increases for 2018 will those who don’t qualify for premium subsidies. That includes a few different categories of people:
- middle class (and upper class) Idaho residents who earn more than 400 percent of the poverty level.
- people caught in the family glitch.
- people who earn less than the poverty level and are stuck in the coverage gap due to Idaho’s rejection of Medicaid expansion funding.
And as noted above, the people who will bear the brunt of the additional premiums to account for the uncertainty surrounding federal funding for CSRs are only those who purchase silver plans (on-exchange, or the same qualified health plan sold off-exchange) and don’t receive premium subsidies.
Director Cameron has made it clear in past statements that he supports GOP efforts to repeal and replace the ACA, and the Department’s statement about the rate filings reiterates some of that. Cameron notes that it would be acceptable for Congress to fully terminate the CSR program as an alternative to funding it, since leaving it intact but not funding it will result in spiking premiums. This is a valid point in terms of premiums, but it fails to account for the fact that out-of-pocket costs would become unaffordable for low-income enrollees if CSR plans were to disappear.
Cameron also supports a provision like the Cruz Amendment to the Better Care Reconciliation Act, which would have allowed non-ACA-compliant plans to be sold off-exchange. These plans would certainly be less expensive, so if your only priority is lower premiums, this seems like a valid solution. But they would serve to destabilize the individual insurance market. Healthy people would opt for the less-robust plans (particularly if insurers were allowed to use medical underwriting to offer lower premiums to healthy people, as would have been the case under the Cruz Amendment), leaving sicker people on the ACA-compliant plans, which causes higher premiums, which drives more healthy people towards the non-compliant plans, and so on, until you end up with a death spiral.
Cameron’s statement also calls for federal reinsurance, which is a valid solution. The ACA included a reinsurance program, but it was temporary and only lasted through 2016. Reinstating it on a permanent basis would certainly serve to stabilize the insurance markets and minimize premium increases.
On December 16, 2016 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.
By February 2017, effectuated enrollment stood at 84,067 in Idaho’s exchange.
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 have spent much of 2017 pushing to repeal and replace the ACA. House Republicans passed the American Health Care Act (AHCA) on May 4 (both of Idaho’s representatives voted for the bill). The Senate failed to pass their version of the legislation in July, but revisited the issue in September with the introduction of the Graham-Cassidy-Heller-Johnson bill.
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 88 percent of Idaho exchange enrollees are receiving premium subsidies, and 66 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 Graham-Cassidy-Heller-Johnson legislation, premium subsidies and cost-sharing subsidies would be repealed after 2019, and replaced with a block grant system that would send money to the states to use as they see fit. But right from the start, the total amount of funding would be lower than it would be under the ACA, and that disparity would become more pronounced over time.
Even without the various ACA repeal bills that have been introduced in 2017, 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 throughout 2017, and an update is expected in October. The Trump Administration has been very noncommittal in terms of whether they will continue to fund CSRs, which has made insurers understandably nervous.
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