UnitedHealthcare will exit exchange
At the end of 2016, UnitedHealthcare will exit the individual market in Louisiana, as will be the case in most states where United currently participates. United currently insures about 13 percent of the 214,000 people who enrolled in exchange plans in the state for 2016. In total, about 29,000 people will need to switch to a plan from another carrier during the open enrollment period for 2017 coverage, which begins on November 1.
But in good news for current UnitedHealthcare enrollees, the carrier reached an agreement with Ochsner Health System that will allow patients in the New Orleans area to continue to use Ochsner facilities until the end of 2016. Previously, the agreement between United and Ochsner was scheduled to end in mid-May, leaving United members in south Louisiana without any hospital access within an hour’s drive.
According to an analysis by Kaiser Family Foundation, United currently offers one of the two lowest-priced silver plans in the exchange in 50 of the state’s 64 counties. And United’s exit is expected to leave 59 of the state’s counties with just two carriers offering plans in the exchange.
The remaining carriers in the Louisiana exchange – not all of which offer plans in all areas of the state – are Blue Cross Blue Shield of Louisiana (BCBSLA has about 85,000 on-exchange enrollees), HMO Louisiana, Humana, and Vantage Health Plan. Humana is exiting the exchanges in at least a handful of states at the end of 2015, but regulators in Louisiana have not yet said whether the carrier will offer plans in Louisiana’s exchange in 2017.
Blue Cross Blue Shield of Louisiana has about 85,000 exchange enrollees in 2016. Although the carrier is also facing losses – more than $200 million by the end of 2016 – they have said that they’re committed to remaining in the state’s individual market.
214k enrolled for 2016
During the 2016 open enrollment period, 214,148 people enrolled in private health plans through the Louisiana exchange, including renewals and new enrollees. To put the total in perspective, enrollment was 186,277 by the end of the 2015 open enrollment period; Louisiana’s exchange enrolled 15 percent more people in 2016, despite the fact that this is the first year that HHS began subtracting unpaid and cancelled enrollments in real-time, while open enrollment was on-going. In prior years, they waited until open enrollment had ended to account for attrition.
And compared with enrollment as of mid-2015 (when 141,740 people had in-force coverage through the exchange), the enrollment count as of February 1, 2016 represented a 51 percent increase.
89 percent of Louisiana’s exchange enrollees qualified for premium subsidies in 2016. Their average pre-subsidy premium is $448 per month, but after subsidies, their average premium is just $86 per month.
Special options for enrolling
Open enrollment for 2016 ended on January 31. Coverage for 2016 is now only available under limited circumstances, including outside the exchange. But health plans are still available outside of open enrollment if:
- You experience a qualifying event. You have 60 days from the date of the event to sign up for insurance.
- You are a Native American. You can sign up for health insurance at any time during the year.
- You qualify for Medicaid. Medicaid accepts applications throughout the year. Medicaid expansion takes effect in Louisiana as of July 1, 2016, which means coverage will be newly-available to adults with household income up to 138 percent of the poverty level.
CO-OP closed at the end of 2015
In July 2015, the Louisiana Health Cooperative, an ACA-created CO-OP, announced that it would not participate in the 2016 period, and that existing policies would terminate at the end of 2015. Louisiana Health Cooperative was only the second CO-OP to fail (after CoOpportunity in Nebraska and Iowa), but ultimately ten more CO-OPs closed their doors by the end of 2015.
The CO-OP reassured its 16,000 members that they had enough capital on hand to fulfill obligations and pay claims incurred through the end of 2015. The Louisiana Department of Insurance posted an FAQ section regarding the CO-OP’s announcement, and reminded enrollees that they had to select a new plan between November 1 and December 15 (technically December 31 if they opted to enroll using a special enrollment period triggered by loss of coverage) in order to have continuous coverage with a new plan effective January 1.
2016 rates and carriers
There were six carriers that offered individual coverage in the Louisiana exchange in 2015, but the CO-OP’s exit reduced the number of participating carriers to five in 2016.
In the Louisiana exchange, two individual market carriers requested rate increases of ten percent or more for 2016: HMO Louisiana, and Louisiana Health Service & Indemnity (Blue Cross Blue Shield of Louisiana). For both carriers, the rates were finalized as-requested. But other carriers also proposed double digit rate hikes in the small group market and outside the exchange, and some were adjusted prior to final approval.
Louisiana Health Cooperative had requested rate increases of about 23 percent, but those no longer apply, since the CO-OP is not offering plans in 2016. Time Insurance Company’s requested 55 percent rate hike was eye-catching, but they only sold plans outside the exchange in 2015, and they exited the insurance market nationwide at the end of 2015.
The Louisiana Department of Insurance published proposed and final rate changes for all of the carriers in their individual and small group markets, including on and off-exchange carriers. The filings were separated based on whether the proposed rate change was greater than or less than ten percent, but individual and small group plans were not separated (you can tell whether a plan is individual or small group by viewing the rate filing on the far right side of the spreadsheet). Nearly all of the proposed rate hikes under ten percent were for small group plans (Healthcare.gov now also shows requested and approved rate changes for all plans, including those with proposed rate increases of less than 10 percent; those were not available prior to open enrollment).
Most of the filings were approved as-proposed or with very minor changes, but there were some significant changes for plans sold outside the exchange. Humana’s proposed rate increase of 14.8 percent was chopped down to 6.4 percent, and Aetna’s proposed 21 percent rate hike was increased to 29 percent.
At ACAsignups, Charles Gaba estimated the weighted average rate increase to be about 15.4 percent for the individual market in 2016, but that was before the rates had been approved. For plans sold in the exchange however, it didn’t matter, as the final rates were virtually all the same as the requested rates:
- Blue Cross Blue Shield of Louisiana: average rate increases ranged from 14.57 percent to 19.68 percent.
- HMO Louisiana: average rates increase of just under 12 percent
- Humana: average rate increase of 4.26 percent (slightly lower than the 5.79 percent increase Humana requested).
- UnitedHealthcare: I’m estimating 9 percent based on quotes I got for identical UnitedHealthcare plans in 2015 and 2016 using Healthcare.gov.
- Vantage Health Plan: 6.81 percent rate increase
HHS released a report in October detailing benchmark plan premium changes for 2016. The benchmark plan is the second-lowest-cost-Silver plan, but it’s not necessarily offered by the same carrier from one year to the next. In Louisiana, the average benchmark premium increase was 8.6 percent for 2016. Since subsidies are tied to the benchmark plan premium, a more expensive benchmark plan results in higher subsidies. But it was – as always – vitally important that enrollees shop around during open enrollment, as rate changes for 2016 varied significantly from one carrier to another.
Medicaid expansion by executive order
Former Governor Bobby Jindal staunchly opposed Medicaid expansion under the ACA, and refused to accept federal funding to expand coverage to adults with income up to 138 percent of the federal poverty level. As a result, Louisiana was among 20 states that were still refusing Medicaid expansion as of the end of 2015.
But in November 2015, John Bel Edwards was elected governor of Louisiana; he took office in January 2016. During the campaign, Edwards noted that one of his first priorities as governor would be Medicaid expansion, and true to his word, he signed an executive order on his second day in office, expanding Medicaid in Louisiana.
Louisiana passed House Concurrent Resolution 75 in 2015, which allows hospitals to generate revenue – via a new fee – to pay the state’s portion of the cost of expanding Medicaid. HCR75 gave Edwards until April 1, 2016 to propose a plan to expand Medicaid, but he did so much sooner than that.
The state expects about 375,000 people to gain coverage under expanded Medicaid, adding to the 1.07 million current Medicaid enrollees in Louisiana. Nearly 200,000 people in Louisiana are currently in the coverage gap – they have thus-far been locked out of Medicaid, and are also not eligible for subsidies in the exchange because their income is below the poverty level. That will change as of July 1, 2016, when Medicaid expansion takes effect in Louisiana (enrollment will begin June 1, but coverage won’t be effective until July 1).
Louisiana’s Department of Health and Hospitals will use SNAP (food stamp) data to auto-enroll an estimated 105,000 Louisiana residents in Medicaid once the new eligibility guidelines take effect. Several states have used SNAP data to automatically enroll people in expanded Medicaid, but Louisiana is the first state to obtain HHS approval to use SNAP data to verify eligibility for Medicaid automatically for both the initial enrollment and ongoing annual renewals (the other states have only used auto-enrollment for the initial enrollment).
As of May 2016, the state’s Medicaid program has been renamed “Healthy Louisiana.” Previously, Louisiana Medicaid was known as Bayou Health.
King v. Burwell – subsidies are safe
The Supreme Court ruled in June 2015 that subsidies are legal in every state, even if the federal government is running the exchange. The plaintiffs in King v. Burwell had argued that subsidies could only be provided by state-run exchanges, but the Court rejected that premise.
At ACAsignups, Charles Gaba estimated that if subsidies had been eliminated, unsubsidized average premiums in Louisiana would have climbed from $416/month in 2015 to $624/month in 2016. That was for people who pay full price for their coverage. Most enrollees in the Louisiana exchange have subsidies however, so the result for them would have been much more profound: Their rates would have jumped from an average 2015 (after-subsidy) premium of $93/month to $624/month in 2016.
The Louisiana Department of Insurance confirmed that if the subsidies had been stuck down by the Supreme Court, carriers would have had two weeks to refile new (presumably much higher) rates for 2016. Fortunately for the residents, insurers, and medical providers of Louisiana, that didn’t come to pass.
186,277 Louisiana residents selected qualified health plans (QHPs) through the marketplace during 2015 open enrollment, including the week-long extension that was added at the end of open enrollment. But not all of them paid their initial premiums, and some people cancelled their coverage in the early days of 2015. By the end of March, 149,954 people in Louisiana had in-force coverage through the exchange. Effectuated enrollments dropped again during the second quarter of 2015, to 141,740. Almost 91 percent of enrollees were receiving premium subsidies, and 58 percent were receiving cost-sharing subsidies.
Initial 2015 enrollment was about 83,000 higher than 2014 enrollment. However, Louisiana residents signed up at a slower rate than individuals across the nation. About 35 percent of eligible Louisiana residents signed up for coverage through the marketplace compared to about 41 percent nationally.
Rates and carriers for 2015
The number of insurance companies selling through the marketplace in Louisiana grew from five to six for 2015 coverage according to the U.S. Department of Health and Human Services. UnitedHealthcare, the nation’s largest health insurance company, joined the marketplace in Louisiana and about 20 other states. United took a very conservative approach in 2014, participating in just five states.
The Commonwealth Fund analyzed premiums and deductibles across all the metal tiers, differences in premiums between urban suburban and rural areas, and insurer participation in nearly all states. For Louisiana, the analysis showed premiums up 12 percent on average from 2014 to 2015. In contrast, the analysis showed a 0 percent change in premiums nationally. According to another study by the Commonwealth Fund, premiums in state individual insurance markets rose an average 10 percent or more each year from 2008 to 2010.
Small group plans
The SHOP exchange in Louisiana provides health insurance plans for businesses with up to 50 employees. Under the ACA, the definition of “small group” was scheduled to expand in 2016 to include businesses with up to 100 employees. But that changed in October 2015 when President Obama signed HR1624 (the PACE Act) into law, repealing the definition change for small groups. Under HR1624 States are free to independently define small groups as businesses with up to 100 employees, but most states have continued to define small groups as businesses with up to 50 employees in 2016.
In Louisiana, the state had already codified into law the definition change, mirroring what was in the ACA. But after HR 1624 was signed into law, the Louisiana Department of Insurance issued transitional relief, allowing carriers and businesses in the state to use the definitions in the PACE Act for 2016, rather than requiring businesses with 51 – 100 employees to become part of the small group market. It’s possible that the state could enact legislation to make that transitional relief permanent during the 2016 legislative session.
Paying more for NOT being covered
Penalties, like premiums, are rising. If you don’t qualify for exemption and don’t have health insurance in 2016, you’ll owe a penalty when you pay your 2016 taxes. 2016 penalties are the greater of:
- 2.5% of annual household income. The penalty can never exceed the national average cost for a bronze plan. The IRS announced in Revenue Procedure 2015-15 that the maximum 2015 penalty would be $2,484 for a single individual and $12,420 for a family of five or more. It will be a little higher in 2016, but the cap would only apply to very wealthy households.
- $695 per adult or $347.50 per child under 18. The maximum penalty under this method will be $2,085.
Although there were still 33 million uninsured people in the US in 2014, the IRS reported that just 7.5 million taxfilers were subject to the penalty in 2014 (out of more than 138 million returns). According to IRS data, 12 million filers qualified for an exemption (you can see a list of exemptions here).
2014 enrollment recap
During 2014 open enrollment, 101,778 Louisiana residents signed up for a qualified health plan (QHP). Eighty-eight percent of QHP enrollees received financial assistance, and their average monthly premium after subsidies was $83 according to a federal report.
More than 17 percent of Louisiana residents were without health insurance in 2014.
In early 2014, the Urban Institute estimated that Louisiana’s enrollment in the marketplace would reach 305,000 in 2016. That appears to be on the high side however, as enrollment stood just shy of 215,000 at the end of the 2016 open enrollment period. Enrollment in the exchanges is lower nationwide than had been predicted, partially due to the fact that the anticipated drop in employer-sponsored coverage has not materialized.
ACA and exchange implementation in Louisiana
Louisiana is among the 26 states that left all responsibility for its health insurance marketplace to the federal government. Former Gov. Bobby Jindal repeatedly rejected a state-run exchange and even returned a $1 million federal planning grant. He also refused to expand Medicaid under the ACA, although newly-elected Governor John Bel Edwards has reversed Jindal’s position on Medicaid expansion, and eligibility is expected to be expanded in mid-2016.
Jindal’s decision against Medicaid expansion in 2014 and 2015 affected not only uninsured individuals, but also Louisiana healthcare providers and its overall economy. The state provided $18 million in stopgap funding in late August 2014 when Baton Rouge General Mid City Hospital announced it would close its emergency room due to the expense of providing uncompensated care for the uninsured. Despite the infusion, the emergency room shut down in March 2015. An Urban Institute study says Louisiana would lose out on $15.8 billion in funding between 2013 and 2022 by not expanding Medicaid, while contributing $5.7 billion in taxes over the same period that will be used states that have expanded.
With Governor Edwards’ executive order to expand Medicaid, the state will begin receiving federal funding to cover the cost of expansion.
Louisiana health insurance exchange links
State Exchange Profile: Louisiana
The Henry J. Kaiser Family Foundation overview of Louisiana’s progress toward creating a state health insurance exchange.
Louisiana Department of Insurance, Office of Health Insurance
Assists consumers who have purchased insurance on the individual market or who have insurance through an employer who only does business in Louisiana.
(225) 219-4770 / Toll Free: (800) 259-5301