58,114 people enrolled in private plans through the Montana exchange during the 2016 open enrollment period, including renewals and new enrollees. That’s up 7 percent over the 54,266 people who enrolled during the 2015 open enrollment period, but the 2016 enrollment already accounts for early attrition, which the 2015 enrollment total did not.
2016 is the first year that HHS began subtracting unpaid and cancelled enrollments in real-time, while open enrollment was ongoing. In prior years, they waited until later in the year to report effectuated enrollment (by the end of June 2015, effectuated enrollment had fallen to 48,591 people; there will still be attrition in 2016, but some of it has already been accounted for in the enrollment total as of February 1.
Open enrollment ended on January 31. The next open enrollment begins on November 1, for plans effective January 1, 2017. Between now and then, plans can only be purchased (including outside the exchange) if you have a qualifying event. And Healthcare.gov will begin requiring proof of qualifying events in 2016. There are some exceptions though: Native Americans can enroll in a health plan through the exchange year-round, and enrollment in Medicaid/CHIP also continues year-round.
Montana has three carriers offering individual plans in the exchange for 2016. Rates are considerably higher than they were in 2015, with average rate increases ranging from 22 percent to 34 percent. But premium subsidies offset all or most of the premium increase for enrollees who are eligible for subsidies.
In September 2015, Montana Insurance Commissioner Monica Lindeen announced that rates had been finalized in Montana for 2016. Her office had an outside actuary review proposed rates, in an effort to get final rates as low as possible. But the Commissioner’s office doesn’t have the authority to deny rate requests the way regulators in some states can.
2015’s individual market premium increase in Montana was “historically low” at an average of just 1.6 percent. But 2016 is a different story. Rates increased between 22 and 34 percent across the individual market in Montana, very much in line with the rates that were submitted earlier in the year by each carrier.
- Blue Cross Blue Shield of Montana had requested rate increases averaging 20 percent to 22 percent for their individual plans.
- PacificSource had proposed a 32 percent average rate increase.
- Montana Health Cooperative requested an average rate increase of 34 percent, and the CO-OP eliminated their platinum plan option for 2016, as the rich benefits of the plan attracted insureds with significant healthcare needs and resulted in losses for the CO-OP. Out of 14,000 enrollees, just 120 insureds generated about half of the CO-OP’s claims expenses last year.
- A fourth carrier, Time, also proposed steep increases for 2016, but their parent company, Assurant, subsequently announced that they would exit the insurance market nationwide, and would no longer offer coverage in 2016. As of June 2015, there were 7,283 Montana residents who had individual coverage from Time; all of them had to select replacement policies for 2016.
Of the 37 states that used Healthcare.gov in 2015, Montana had the highest average benchmark premium increase for 2016, at 34.5 percent. Benchmark plans are the second lowest-cost silver plan in each area, and their price is used to determine subsidy amounts. So the steep increase in benchmark premiums in Montana means that subsidies will generally keep pace with the overall rate hikes in the state.
But as always, it was vitally important for people to shop around during open enrollment, since different plans had different rate increases. Montana’s notice about the 22 to 34 percent rate increases stated that it only applied to people who weren’t receiving subsidies (ie, either on-exchange but ineligible for subsidies, or off-exchange). They noted that the total unsubsidized population in the individual market in 2015 was about 41,000 people, versus 42,000 who were receiving premium subsidies in the exchange.
CMS approves Medicaid expansion proposal
Until April 2015, Montana had opted out of expanding Medicaid. Unfortunately, it was an accidental “no” vote that doomed the expansion effort, but there’s no way to undo such a vote after it happens.
The governor’s office was supportive of some aspects of Medicaid expansion, but the legislature only meets every other year in Montana, so the issue couldn’t be re-addressed from a legislative standpoint until 2015.
But Montana made headlines in the spring of 2015, becoming the 29th state to approve Medicaid expansion. Governor Steve Bullock signed Senate Bill 405 into law on April 29, paving the way for Medicaid expansion in the Big Sky Country.
In September 2015, Montana submitted their Medicaid expansion waiver to CMS for review. The proposal had several deviations from straight Medicaid expansion, including premiums and copays for some enrollees. On November 2, CMS approved Montana’s Medicaid expansion waiver, and enrollment commenced immediately for coverage effective January 1, 2016. As of November 3, Healthcare.gov’s system had already been updated with the new Medicaid eligibility guidelines in Montana for applicants enrolling in 2016 coverage.
In December, Blue Cross Blue Shield of Montana entered into a contract with the state and is administering the expanded Medicaid program in Montana. By December 31, enrollment in Montana’s expanded Medicaid program had reached 20,000 people, and their coverage took effect January 1. The state had predicted that 23,000 people would enroll by June 2016, and had reached roughly that amount by early March.
Uninsured rate down to 14.4%
It’s still above the national average though, and above even the average across all states that either haven’t expanded Medicaid, haven’t established their own exchanges, or have done neither of those things. Montana does not run its own exchange. But the 23,000 people who are newly-insured by Medicaid should help to put a dent in the state’ uninsured rate (23,000 people is more than 2 percent of Montana’s population), as will the several thousand additional people who purchased private plans through the Montana exchange for 2016.
Two organizations in Montana received a total of $535,000 in September 2015 to fund their navigator and enrollment assistance efforts for 2016. Planned Parenthood and the Montana Health Network are serving as navigator organizations in the state.
Navigators in Montana are focusing on outreach targeted at uninsured populations within the state, particularly Native Americans. Native Americans are exempt from the ACA’s individual mandate, and they have access to Indian Health Service care. But Native American leaders caution that relying solely on IHS can mean foregoing some care, and there are excellent plans available through the ACA that provide enhanced benefits for Native Americans.
There’s also monthly enrollment year-round for Native Americans; the normal open enrollment deadline does not apply. But despite the enhanced benefits and extended enrollment, an April 2015 report indicated that there’s still a significant disparity in terms of access to healthcare, and that many Native Americans in Montana lack adequate access to healthcare. There’s hope that the progress being made on Medicaid expansion will help to address the disparity.
2015 enrollment in Montana’s exchange
54,266 people enrolled in private plans through the Montana exchange during the 2015 open enrollment period (through February 22, including the week-long extension). HHS had projected 47,000 enrollees, and Charles Gaba of ACAsignups projected 57,000 enrollees in Montana by the end of open enrollment. Ultimately, the final total was in the middle, but closer to the higher number that Gaba had predicted.
As expected, some enrollees never paid their initial premiums (meaning their coverage never became effective), and some cancelled their coverage soon after it began. By the end of June, 48,591 Montana residents had in-force private coverage through the exchange. 83 percent are receiving premium subsidies and 51 percent are receiving cost-sharing subsidies.
Of the people who selected a plan during the 2015 open enrollment period, 41 percent were new to the exchange for 2015.
An additional 2,683 people enrolleed in Medicaid or CHIP through the exchange between November 15, 2014 and February 22, 2015, qualifying under the state’s pre-ACA guidelines.
Healthcare reform in the legislature – 2015
Montana’s legislature only has regularly-scheduled sessions in odd-numbered years, so there’s no session in 2016. But several healthcare reform bills were introduced in the 2015 session.
In addition to signing SB 405, Governor Bullock vetoed another healthcare bill on April 29, 2015. Senate Bill 349 would have required health insurance carriers that offer elective abortion coverage to also offer plans without elective abortion coverage. It passed the House and Senate, but was not supported by any health insurance carriers in the state, and was ultimately vetoed.
Two other ACA-related – but very disparate – bills were introduced in the 2015 legislative session in Montana. HB 249, the “Healthy Montana Act” would have expanded Medicaid and enhanced access to healthcare and health insurance under the ACA. But on the other end of the spectrum, HB 256, introduced by Republican Representative Matthew Monforton of Bozeman, would require legislative approval for any further implementation of Obamacare in Montana, including the expansion or Medicaid or the creation of a state-run exchange.
HB 249 stalled in the House in March 2015, but Medicaid expansion was approved by the legislature using SB 405. HB 256 passed the House and moved to the Senate in February 2015, but was indefinitely postponed by the Senate in late March.
2015 rate increase “historically low”
Across all carriers, the lowest cost bronze plan in the Montana exchange averaged $251/month in 2014, which was very close to the national average of $249.
And 2015’s rate increase was historically low, with rates only increasing an average of 1.6 percent for individuals (when combined with small group premiums, the average increase was even smaller, at 1.35 percent). Insurance Commissioner Monica Lindeen described the 2015 rate hike as “historically low”
In all rating areas in Montana, the benchmark plan (second-lowest-cost silver plan) was less expensive for 2015 than it was in 2014. But in order to get the lower rates, consumers needed to shop around in the exchange during open enrollment. People who had the benchmark plan in 2014 and let it automatically renew saw higher premiums state-wide for 2015. And because the benchmark plans were less expensive in 2015, subsidies were lower too, highlighting the importance of shopping around during open enrollment.
2014 enrollment numbers
As of mid-April 2014, private plan Obamacare enrollments had been completed for 36,584 Montana residents. Another 4,638 people had qualified for Medicaid (this was under the pre-expansion guidelines).
In addition to the people who purchased plans through the exchange, nearly 35,000 people enrolled in Obamacare-compliant plans outside the exchange by mid-April. One of the provisions of the ACA requires that carriers use a single risk pool for all of their individual plans in a state, so each carrier’s off-exchange enrollments are merged with its on-exchange enrollments for risk purposes – meaning that the additional off-exchange enrollments are helpful in stabilizing rates.
By mid-July, the number of uninsured residents in Montana was about 30,000 lower than it had been in 2013 – more than a 15% drop in the uninsured rate in the state. This was achieved with both on and off-exchange enrollments of previously uninsured folks, as well as the “woodwork” effect that increased Medicaid enrollment even in states like Montana that didn’t initially expand Medicaid under the ACA.
Exchange history in Montana
Montana’s legislature not only failed to authorize a state-run exchange, it also passed a bill in 2011 to prohibit the creation of an insurance exchange in Montana.
While Democratic Gov. Brian Schweitzer vetoed that bill, neither he nor Monica Lindeen, the state auditor and insurance commissioner, were able to generate legislative or public support for an exchange.
Consequently, the federal government is operating the exchange in Montana at Healthcare.gov. Montana is also one of nineteen states that has passed laws making it more difficult for people to serve as navigators for the exchange.
Under the federal model, most aspects of the exchange are managed by the federal government. However, states can retain control of “plan management” functions, and Montana opted to do so. Lindeen’s office released final exchange rates for the first round of open enrollment in mid-August 2013, nothing that the premiums were similar to what they would have been without the ACA. Her office regulates plans that operate on the exchange, as it does for plans sold outside the exchange.
HHS is also running the SHOP exchange in Montana, providing health insurance for small businesses. Montana is one of 18 states where the employee-choice feature of the SHOP exchange was delayed until 2016 – meaning that instead of allowing employees to select from among a variety of options, there was only one plan for each group in 2015.
Three organizations in Montana received federal grants in 2013 to serve as navigators and assist residents with the enrollment process during the first open enrollment period: Planned Parenthood, Montana Primary Care Association, and the Montana Health Network.
On November 25, 2013 Lindeen announced that Montana would allow health insurance carriers to extend 2013 policies that had been scheduled to terminate at the end of the year, but it was left up to each carrier to decide how to proceed. Insureds with a policy that was eligible for renewal into 2014 also had the option of switching to an exchange plan.
Ultimately, none of the insurance carriers in Montana’s individual market opted to keep transitional plans in place, and all non-grandfathered plans in the individual market in Montana are now ACA-compliant.
Montana health insurance exchange links
State Exchange Profile: Montana
The Henry J. Kaiser Family Foundation overview of Montana’s progress toward creating a state health insurance exchange.
Montana Consumer Assistance Program, Office of the Commissioner of Securities and Insurance
Serves as the state government watchdog for citizens of Montana in the insurance industry
Health Insurance Exchange Page from Montana Commission of Securities and Insurance
Details about how the exchange works, along with legislative history in Montana regarding the exchange creation process.