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Qualifying events

Our look at the ACA qualifying events which can let you buy health insurance outside open enrollment.

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Illinois health insurance exchange / marketplace

More than a million enrolled in exchange QHPs and Medicaid expansion

The Illinois exchange is a robust marketplace, with health plans available from nine carriers. The uninsured rate in Illinois dropped by more than 40 percent from 2013 to 2015, and enrollment in private plans through the exchange grew again for 2016.

75 percent of Illinois exchange enrollees are receiving premium subsidies in 2016. Their average premium before the subsidy is $385/month (lower than the $396/month average across all 38 states that use Healthcare.gov), but subsidies cover 61 percent of that, bringing the average after-subsidy premium down to $152/month. Across all the states that use Healthcare.gov, 85 percent of enrollees qualify for subsidies.

2016 enrollment

388,179 people enrolled in private plans for 2016 through the Illinois exchange during the third open enrollment period. That’s an increase of about 11 percent over 2015’s enrollment, despite the fact that HHS began accounting for early attrition during open enrollment this time around, instead of waiting until after open enrollment had ended to begin subtracting early cancellations and unpaid enrollments. The 388,179 enrollment total as of February 1 has already been reduced to account for all enrollments that were cancelled by that point.

In addition to the private plan enrollments, another 626,000 people have gained coverage under expanded Medicaid since it took effect in 2014. Illinois officials announced in late February 2016 that the total number of people covered under ACA plans (including private plans and Medicaid expansion) had exceeded one million (this does not count off-exchange enrollments, but off-exchange plans are all ACA-compliant).

The ACA has had a profound impact on the uninsured rate in Illinois. In 2013, 17.8 percent of non-elderly adults in the state were uninsured; that had fallen to 10.6 percent by 2015.

Open enrollment for 2016 ended on January 31. Coverage for 2016 is now only available – on or off-exchange – for people who experience a qualifying event (Native Americans can enroll year-round, as can anyone who’s eligible for Medicaid or CHIP).

Streamlined operations

Illinois operates a partnership exchange with the federal government; the state runs Get Covered Illinois, including a website, in-person assistance, and a help desk, and the federal government provides the IT platform – Healthcare.gov – that Illinois residents use to enroll in coverage or make changes to their plan.

Starting in August 2015, the Illinois Department of Insurance began administering Get Covered Illinois, and 15 staff positions were eliminated in the move to “streamline program processes, improve efficiency, and align services leading to increased access to health coverage for Illinoisans.”  There is less federal funding now than there was in the past two years, and Get Covered Illinois will be able to run a tighter financial ship as part of the Division of Insurance.

In January 2015, the Governor appointed Karen Woods, a former Blue Cross Blue Shield executive, to lead Get Covered Illinois.

UnitedHealthcare

UnitedHealthcare only offered plans in Cook County in 2015, but are offering plans in the exchange in 27 Illinois counties for 2016. According to Colleen Van Ham, CEO of UnitedHealthcare’s Illinois and Northwest Indiana division, the expansion in Illinois was done because “we believe it’s something we can do at an affordable price.” However, less than two weeks later, UnitedHealthcare scaled back their marketing and broker commissions nationwide, and hinted that they may not participate in the exchanges in 2017.

United has since confirmed that they will exit at least 26 of the 34 states where they currently offer exchange plans, but it’s not clear yet whether United plans will remain available in the Illinois exchange in 2017.

Although UnitedHealthcare offers plans in just 27 of Illinois’ 102 counties, they have focused on the highly-populated counties, and nearly 80 percent of the people who enrolled through the Illinois exchange for 2016 had United as an option.

In terms of rates, United offers one of the two lowest-cost silver plans in 18 of those 27 counties in Illinois. If United exits the exchange, the impact will be somewhat significant in those counties, although Illinois will continue to have a robust health insurance marketplace, with several carriers available in each county.

2016 rates

According to the Illinois Department of Insurance, the average rate increase for the lowest-cost Silver plan in the Illinois exchange was 5.3% for 2016, and the average increase for the lowest-cost Bronze plan was 11.3%. But rate changes vary considerably from one rating area to another. The lowest cost Silver plan premium changes ranged from an 8 percent decrease to a 28 percent increase.

In the Illinois exchange, five individual plan carriers (out of ten total) proposed rate increases of ten percent or more for at least some of their plans in 2016: Blue Cross Blue Shield of Illinois, Coventry Health Care of Illinois, Health Alliance Medical Plans, Humana, and Time Insurance Company.

Time had the highest proposed rate hike (42 percent), but its parent company – Assurant – subsequently announced that they would exit the health insurance market nationwide, and they’re no longer offering plans.

Blue Cross Blue Shield of Illinois proposed average rate hikes of 29 percent for their BluePrecision HMO plans, and 38 percent for their BlueChoice Preferred plans.  The carrier outlined justification for their rate proposals, noting that 2015 was the first year that accurate claims data (as opposed to educated guesses) was available for actuaries to use when calculating rates. Ultimately, the average rate increase for BCBSIL’s individual market plans was 17.89 percent, but ranged from a 17.5 percent decrease to an increase of more than 49 percent. The new rates apply to 329,427 enrollees (including off-exchange). 80 percent of Illinois exchange enrollees have BCBSIL plans.

In March 2016, Health Care Service Corp (the parent company of BCBS of Illinois and BCBS plans in four other states) announced that they had lost $1.5 billion on individual market plans in 2015, up from a $767 million loss in 2014. Health Care Service Corp also lost money overall in both years, even after accounting for group plan income and investment income. But although their individual market losses nearly doubled in 2015, their overall losses were smaller in 2015 than they had been in 2014.

State-wide, the average benchmark (second-lowest-cost Silver plan) premiums are 6.1 percent more expensive in 2016 than in 2015, which means that average subsidies have increased too. But it’s noteworthy that in the Chicago area, a Kaiser Family Foundation analysis determined that the average benchmark premium is 7.9 percent less expensive in 2016 than it was in 2015. This appears to be due in large part to Celtic’s entry to the market and their relatively low premiums.

Two carriers exited; three joined

There are nine carriers offering a total of 290 plans for individuals in the Illinois exchange in 2016 (ten if you count Coventry as two separate carriers, which the Division of Insurance does):

  • Aetna Health Inc.
  • Celtic Insurance Co. (Ambetter)
  • Coventry – including Coventry Health & Life Insurance Co. as well as Coventry Health Care of Illinois, Inc. (two separate legal entities)
  • Harken Health Insurance Company (Midwest Security Life, a UnitedHealthcare subsidiary. Harken is new in the Atlanta and Chicago areas for 2016, and it appears that they will continue to offer plans in 2017 regardless of United’s final decision – United has confirmed that they are leaving the Georgia market, but Harken is staying in Atlanta)
  • Health Alliance Medical Plans, Inc.
  • Health Care Service Corporation, (Blue Cross Blue Shield)
  • Humana Health Plan, Inc.
  • Land of Lincoln Mutual Health Insurance Co. (an ACA-created CO-OP)
  • UnitedHealthcare of the Midwest, Inc. 

Three carriers – HCSC, Land of Lincoln, and Coventry – offer plans state-wide.

Health Care Service Corp (Blue Cross Blue Shield of Illinois) covers about 80 percent of the state’s individual market enrollees.

UnitedHealthcare stopped paying broker commissions on all individual plans sold after January 1, 2016. Aetna and Blue Cross Blue Shield of Illinois both stopped paying broker commissions for individual plans sold after open enrollment had ended. This is a trend nationwide, as health insurance carriers pull back from the individual market in an effort to stem losses.

Carriers have been particularly concerned with enrollments outside of open enrollment, when consumers must have a qualifying event in order to enroll in a plan. Carriers have claimed that consumers are gaming the system, waiting until they’re sick and then enrolling under lax enforcement of special enrollment periods. HHS has vowed to tighten up special enrollment period eligibility in 2016, and consumers will be required to submit proof of a qualifying event before being allowed to enroll outside of open enrollment.

IlliniCare and Time offered plans in 2015 (both entered the exchange for the first time in 2015), but are exiting the market, and will not offer plans in 2016. But three carriers – Aetna, Celtic, and Harken – are new to the market in 2016. Celtic is the sister company of IlliniCare. Aetna offered plans in the exchange in 2014 under the name Aetna Life Insurance Company, but exited for 2015. They’ve returned for 2016 as a separate legal entity, Aetna Health Inc.

Celtic is offering the lowest-priced plans in some areas, which is good news in terms of added competition, but bad news for people who kept their 2015 plans and are now receiving lower subsidies in areas where Celtic took over the benchmark spot with a premium lower than 2015’s benchmark rate. This is the case in Cook County, where Celtic’s low prices (and very limited network) mean that subsidies have decreased for 2016. In order to obtain a plan with coverage better than what Celtic is offering, even people who receive subsidies are having to pay more than they paid last year.

There are significantly fewer plans available in Cook County for 2016, but the Department of Insurance notes that this is primarily because “IlliniCare withdrew multiple plans that offered the same medical benefit packages with the only difference in coverage being the options to have adult dental and/or adult vision. This accounts for a reduction of 44 plans.”

The Department of Insurance confirmed that there are no platinum plans available in the individual market in 2016 in Illinois. There were 81 platinum plans available in 2015, up from 25 in 2014. But they have all been discontinued for 2016. This is a trend nationwide, as platinum plans have tended to have very low enrollment rates compared with the other metal levels.

Land of Lincoln CO-OP

By the end of 2015, 12 of the original 23 CO-OPs created by the ACA had closed. And although Land of Lincoln Health is not among them, the CO-OP ceased individual and small group enrollments for 2016 mid-way through the open enrollment period, noting that they had already met their enrollment target for the year (Community Health Alliance in Tennessee did the same thing during the 2015 open enrollment period; ultimately they were one of the CO-OPs that shut down at the end of 2015).

Land of Lincoln Health is still operational, but their losses in 2015 were nearly five times as high as they had been in 2014. The CO-OP lost $90.8 million in 2015, on the heels of a $17.7 million loss in 2014. And 44 percent of the CO-OP’s 2015 losses occurred in the fourth quarter of the year; losses had been at $50 million as of September 2015.

In late December 2015 (after the December 17 deadline to enroll in a plan with a January 1 effective date), Land of Lincoln Health notified the University of Chicago Medical Center that the hospital and its affiliated physicians would be dropped from the Land of Lincoln network as of March 1. University of Chicago Medical Center is an academic hospital that treats particularly sick patients, including those with expensive chronic conditions and patients who need organ transplants. Academic hospitals like this tend to have higher costs than other hospitals.

CO-OP members were understandably upset at the news of the network change, as some of them selected Land of Lincoln specifically because it included UCMC in its network, and “several hundred” UCMC patients are insured by Land of Lincoln. Two UCMC patients filed a class-action lawsuit against Land of Lincoln Health in February, alleging that the CO-OP sold plans that included UCMC in the network, despite knowing that they would soon be terminating the network relationship between the hospital and the CO-OP.

 

But then in early April 2016, Land of Lincoln and UCMC patched things up, although there are few details in terms of what compromise was reached. Land of Lincoln announced that UCMC would remain in the carrier’s network at least through the end of 2016.

Average rates for Land of Lincoln plans are significantly higher for 2016 than they were in 2015. When the CO-OP filed 2016 plan rates in the spring of 2015, they mostly requested rate increases that ranged from about 7 percent to just under 10 percent for their individual market plans. And for some plans, they had proposed rate decreases. But when regulators finalized the rates, they were significantly higher than the CO-OP had proposed. According to Healthcare.gov’s rate review tool, the following Land of Lincoln individual products had double-digit rate hikes for 2016:

• Adventist LLH 3-Tier: 32.08%
• Centegra LLH 3-Tier: 32.95%
• Champion LLH 3-Tier: 33.72%
• Chicago Health System LLH 3-Tier: 17.20%
• CO-OPtions℠ LLH National Elite: 39.05%
• Family Health Network LLH 3-Tier: 30.67%
• Illinois Health Partners LLH 3-Tier: 31.55%
• Land of Lincoln Health 3-Tier: 32.69%
• Land of Lincoln Health Traditional: 35.71%
• Swedish Covenant LLH 3-Tier: 31.36%

The tiers refer to the tiered network structure that Land of Lincoln uses. Members have lower out-of-pocket costs if they see Tier 1 providers, and pay higher out-of-pocket costs if they see Tier 2 providers. All “3-Tier” plans included the tiered network design (the third tier is out-of-network providers).

In 2014, Land of Lincoln Health struggled with low enrollment, with just 3,461 members at the end of 2014 (only about 4 percent of their target).  But that changed dramatically in year two. For 2015, Land of Lincoln Health lowered their premiums by 20 to 30 percent, and in most areas of the state, they offered the lowest-priced silver plans.

As a result, their membership ballooned to 50,000 people by the end of the 2015 open enrollment period. Most of them – about 80 percent – had individual market plans, while the rest had small group plans that averaged about 8 to 10 employees each. By the end of 2015, the CO-OP had about 20 percent of the exchange market in Illinois, and about ten percent of the entire individual market in the state.

During the first six months of 2015, Land of Lincoln Health paid out $26 million more in claims than they collected in premiums. In October 2015, HHS announced that carriers across the country – including CO-OPs – would get only 12.6 percent of what they were owed under the risk corridors program. But the CO-OP had planned ahead for the possibility that they wouldn’t receive more than 10 percent of what they were owed under the risk corridors program, which meant they were able to weather the shortfall much better than CO-OPs that had budgeted for receiving the full risk corridor amount.

Over the next several weeks, eight CO-OPs announced that they would wind down their operations by the end of 2015, as a result of the risk corridor shortfall. Land of Lincoln Health was not among them, but the carrier did state that they would limit sales of small group plans during November and December, in order to focus on “responsible growth,” including “strategically managing [the CO-OP’s] performance” and “not surpassing [the CO-OP’s] enrollment targets.”

On December 1, the Chicago Tribune reported that Land of Lincoln has stopped accepting new small business enrollees for 2016 (although large group enrollment has continued and one of the CO-OP’s goals is to enroll more large businesses). Already-enrolled small businesses could still renew their coverage for 2016 (only off-exchange), but the carrier had stopped enrolling new small businesses. The CO-OP wants to end 2016 with about 10,000 people enrolled in small business plans; as of October 2015, they had about 8,000, so new growth had to be limited as part of their strategy to remain financially viable.

In mid-December, Land of Lincoln Health had indicated that they would cease individual enrollments “in the coming weeks.” By January 11, the Land of Lincoln website had the following message: “Land of Lincoln Health is proud to announce that we have met our membership goal for this year’s Open Enrollment period which means our individual and small group plans are no longer available for purchase.” Their target had been set at 70,000 members for 2016, and they met that goal well before the end of the 2016 open enrollment period. The CO-OP had acknowledged that setting an enrollment limit would mean that some people who want to purchase a plan through the CO-OP for 2016 will be turned away. Nonetheless, the target for 2016 still represented a growth of about 30 percent over 2015 enrollment.

Blue Cross Blue Shield dropped broad PPO

Blue Cross Blue Shield of Illinois insures about 80 percent of those who purchased coverage in the Illinois exchange in 2015. They had a total of about 329,000 people in ACA-compliant coverage, including off-exchange plans. BCBSIL’s average rates increased by almost 18 percent in 2016 and they announced in September 2015 that they would not offer their broad PPO (Blue PPO) network for ACA-compliant plans in 2016.

Grandmothered and grandfathered plans on the Blue PPO network were not impacted by the decision to end the broad network PPO, but there are about 173,000 people in Illinois who had ACA-compliant individual market Blue PPO plans in 2015. These insureds were auto-renewed into a Blue Choice PPO plan for 2016, unless they chose another policy instead during open enrollment. The Blue Choice PPO network is not as broad as the Blue PPO network, and some insureds were understandably upset about losing access to their healthcare provider, since the Blue PPO network was wider than most available in the individual market in Illinois.

But BCBSIL has noted that their broad network PPO was simply not sustainable at its current price, and that the rate increase that would have been necessary to make the broad PPO actuarially justified would have driven the carrier’s prices too high to be competitive in the market. Narrower networks are a trend nationwide; markets across the country have about 40 percent fewer PPOs in 2016 than they had in 2015.

In addition to higher prices and smaller networks, some of the BCBSIL plans will have increased costs for insureds in 2016, with fewer copays and more expenses being counted towards the deductible. The carrier noted that in the individual market, they paid out $280 million more in claims in 2014 than they collect in premiums.

2015 enrollment

As of February 2015, 349,487 Illinois residents had selected qualified health plans (QHPs) through HealthCare.gov.  50 percent were new to the exchange for 2015, and 78 percent qualified for premium subsidies. That put 2015 enrollment at about 160 percent of 2014 enrollment.

But some enrollees never paid their initial premiums, and some opted to cancel their coverage early in the year.  As of the end of March, 293,661 people had in-force private plan coverage through the Illinois exchange.  Nationwide, effectuated enrollment continued to decline slightly in the second quarter of 2015, as Healthcare.gov and the state-run exchanges stepped up their enforcement of documentation requirements for immigration and financial status.

But in Illinois, effectuated enrollment increased from March to June, with 297,406 people covered under in-force policies at the end of June.  78 percent are receiving premium subsidies, and 47 percent are receiving cost-sharing subsidies (only available with silver plans, for enrollees with incomes up to 250 percent of the poverty level).

So more than 231,000 people in Illinois are receiving premium subsidies, which were in jeopardy during the first half of 2015 when the King v. Burwell case was still undecided.  2016 rates were filed prior to the Court’s ruling in the King case, but the Illinois Department of Insurance had announced that if the subsidies were stuck down by the Supreme Court, carriers would have had two weeks from the date of the ruling to refile new – much higher – rates for 2016.

If that had happened, unsubsidized average premiums in Illinois would have increased from $336/month in 2015 to $504/month in 2016.  For Illinois exchange enrollees who receive subsidies, the result would have been much more significant:  Their premiums would have quadrupled from an average current (after-subsidy) premium of $125/month to $504/month next year.

No action on state-run exchange

Illinois runs its marketplace, Get Covered Illinois, as a partnership with the federal government. State residents use the federal marketplace, HealthCare.gov, to enroll.

Former Gov. Pat Quinn consistently supported a state-run exchange. A bill authorizing a state-run exchange passed the Illinois Senate in 2013, and there was hope the House might give its support during the 2014 fall veto session. However, sponsors did not have enough support to bring the bill to a vote.

Rep. Robyn Gabel had hoped the issue would gain traction in 2015, given that the U.S. Supreme Court was considering whether premium subsidies could be lawfully provided in states that don’t run their own health insurance exchange. By transitioning to a state-run exchange, Illinois would have secured ongoing subsidies for its residents regardless of how the Court ruled (ultimately, the Court deemed subsidies to be legal in every state, regardless of whether the federal government is running the exchange or not).

At this point, a state-run exchange is unlikely for the foreseeable future. The federal government is no longer providing new establishment grants, and Illinois would be challenged to fund startup costs on its own.

2015 rates up slightly on Get Covered Illinois

The Illinois Depart of Insurance summarized 2015 premium increases by metal level:

  • Lowest gold plan average: 3.7 percent increase
  • Lowest silver plan average: 2.6% increase
  • Lowest bronze plan average: 11% increase

More than half of 2014 enrollees in Illinois selected a silver plan.

Small business exchange

There are three carriers offering coverage through the Illinois SHOP exchange for 2016:

  • Health Alliance Medical Plan, Inc. (HAMP)
  • Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC, Blue Cross Blue Shield)
  • Land of Lincoln Mutual Health Insurance Company

Illinois is one of five states where small businesses (those with between 2 and 50 employees) had early access to the federal Small Business Health Options Program (SHOP) online portal in October 2014. Online enrollment functionality had been delayed so technical staff could work on fixing the marketplace used by individuals. Without the online function available, small businesses had been limited to working with a broker or by submitting a paper application to sign up for SHOP coverage.

Users in the early launch states experienced some problems with the SHOP according to The New York Times. Issues included some health plans not being displayed and glitches when using Firefox or Internet Explorer web browsers to access the site.

As of Nov. 15, 2014 the online SHOP was available in all states that use HealthCare.gov, but enrollment has been well below expectations nationwide.

Illinois delayed the launch of “employee choice” in the SHOP exchange until 2016. Employee choice allows employees of small businesses that use the SHOP to select from a range of plans rather than being limited to a single plan selected by their employer. The federal government let states that use the federal marketplace choose if they want to implement employee choice for 2015. Illinois is one of 18 states that opted to delay implementation of employee choice.

A recap of 2014 enrollment

About 217,500 Illinois residents enrolled in qualified health plans (QHPs) during 2014 open enrollment and 468,000 have signed up for Medicaid as of Sept. 30. Get Covered Illinois announced that the state exceeded the initial enrollment target set by the federal government by 52 percent.

Of those Illinois residents who selected a QHP, 77 percent qualified for financial assistance, compared to 85 percent nationally. An HHS report showed the average monthly premium, after tax credits, for Illinois consumers was $105. Twenty-five percent of enrollees pay $50 or less per month after subsidies.

Twenty-nine percent of Illinois residents selected a bronze plan (20 percent nationally), 56 percent selected a silver plan (65 percent nationally), 15 percent selected a gold plan (9 percent nationally), 1 percent selected a platinum plan (5 percent nationally) and 0 percent selected a catastrophic plan (2 percent nationally). Thirty-one percent of Illinois enrollees were between the ages of 18 and 34.

History of the Illinois exchange

Former Gov. Pat Quinn’s administration announced in July 2012 that the Illinois marketplace would operate as a state-federal partnership. Quinn had hoped to leverage the partnership model as an interim step toward a state-run marketplace for the 2015 coverage year. However, a state exchange bill passed in the Senate in 2013 didn’t get a vote in the House. As noted above, there was some hope that exchange legislation will be considered during the fall 2014 session. However, the House did not take up the issue, and Illinois continues to have a partnership exchange (as noted above, the state’s portion of the partnership was folded into the Department of Insurance in August 2015).

About 12 percent of state’s population remained uninsured after the first open enrollment period. In response, officials awarded nearly $26 million to 37 organizations to target groups that were hard to reach in 2014: Latinos, African Americans, and Millennials.  The efforts paid off, and Illinois’ uninsured rate dropped again from 2014 to 2015.

The uninsured rate in Illinois dropped from 15.5 percent in 2013 to 8.8 percent in the first half of 2015, according to a Gallup survey.  Medicaid expansion has no doubt played a significant role in the reduction in the uninsured rate, as total Medicaid/CHIP enrollment grew by half a million people from the fall of 2013 to June 2015 – a 19 percent increase.

Get Covered Illinois hired Onion Labs to build a campaign to reach Millennials. The campaign featured the fictional Luck Health Plan and the tagline: “You’ll be okay. Probably.”

In January 2015, Get Covered Illinois launched an ad targeting same-sex married couples. While the uninsured rate for low- and middle-income LGBT people dropped from 34 percent to 26 percent from 2013 to 2014, it is still much higher than the overall national average.

Illinois health insurance exchange resources

Get Covered Illinois
866-311-1119

HealthCare.gov
800-318-2596

Illinois Health Matters
Information resource on health care reform

Health Care Assistance
Office of the Attorney General
877-305-5145 (toll-free nationwide) TTY: 312-964-3013
Serves residents enrolled in private health insurance

Office Consumer Health Insurance and the Ombudsman for the Uninsured 
Illinois Department of Insurance
877-527-9431 (toll-free nationwide)
Serves residents who are uninsured as well as residents who have health insurance problems or questions.

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