Highlights and updates
- Open enrollment for 2019 coverage in New Hampshire ended on December 15.
- Enrollment is still open for New Hampshire residents with qualifying events.
- Short-term health plans are available in New Hampshire with initial plan terms up to six months.
- 2019 rates an average of 14 percent lower, but would have decreased even more without mandate penalty repeal
- New Hampshire is switching from PAP to Medicaid managed care as of January 2019
- Just under 50k enrolled for 2018, down about 6.5% from 2017.
New Hampshire exchange overview
New Hampshire is one of seven states that operates a partnership exchange with the federal government. These exchanges are considered federally facilitated, and they use Healthcare.gov’s enrollment platform and call center.
But the state also takes an active role, and operates Covering New Hampshire, a resource site for residents to learn about the exchange and the plans that are available.
New Hampshire’s exchange had four carriers offering coverage for 2017, down from five in 2016. And Minuteman Health exited the market at the end of 2017, leaving three insurers offering plans for 2018. All three are continuing to offer exchange plans in 2019.
Rates decreased for 2019
Open enrollment for 2019 health coverage began on November 1, 2018, and ended on December 15, 2018 (though New Hampshire residents with qualifying events can still enroll in 2019 plans). All plans selected during open enrollment will take effect January 1. In the first five weeks of open enrollment, 15,255 people in New Hampshire selected plans through the exchange for 2019 (that includes new enrollees as well as active renewals, but people who are relying on automatic renewal won’t be counted until after open enrollment ends). The enrollment total after five weeks was nearly 22 percent lower than it had been at the same point the year before.
The lower enrollment could be due to a variety of factors, including the impending repeal of the individual mandate penalty (ie, people will no longer be penalized by the IRS for being uninsured in 2019), as well as the reduced federal funding for marketing and enrollment assistance. New Hampshire did not receive any federal navigator funding in 2018, whereas two organizations received more than $450,000 in 2017 (both are continuing to provide enrollment assistance, but without federal navigator funding in 2018).
Insurers in New Hampshire had to submit rate filings for 2019 by June 30, 2018. Redacted filing data was published on ratereview.healthcare.gov on August 1. In good news for New Hampshire residents, the average proposed rates were lower for 2019 than they were for 2018, likely due in part to the state’s plan to stop buying private coverage for Medicaid expansion enrollees and switch to Medicaid managed care instead. Once rate filings were approved, New Hampshire’s individual market ended up with an average rate decrease of 14.4 percent.
The New Hampshire Insurance Department has a summary page that shows the various plans available in the individual market for 2019 and how they compare with one another in terms of the coverage provided.
The three insurers that offer plans in New Hampshire’s exchange have implemented the following average rate decreases:
- Ambetter/Celtic: Average decrease of 15.2 percent. Ambetter’s rate filing notes that they expect “risk pool deterioration” as a result of the elimination of the individual mandate penalty after 2018.
- Anthem (Matthew Thornton): Average decrease of 13.5 percent (and an even larger average decrease of 20 percent of off-exchange plans). Anthem’s rate filing also notes that they expect market deterioration “to continue in part because of the elimination of the individual market penalty… and potential movement into other markets.” This is likely a reference to the fact that access to short-term health plans and association health plans has been expanded by the Trump Administration, although New Hampshire limits short-term plans to six months and prohibits their renewal.
- Harvard Pilgrim: Average decrease of 14.1 percent (Harvard Pilgrim had initially proposed an average decrease of 7.4 percent, but a revised filing, submitted in August, called for a 14.1 percent average decrease). Harvard Pilgrim’s initial rate filing indicated that the proposed rates were 12 percentage points higher than they would have been without the impending mandate penalty repeal, meaning that the average rate decrease would have been almost 20 percent if the mandate penalty had been maintained for 2019.
So although rates are dropping in New Hampshire, they would have been declining even more if the individual mandate penalty wasn’t being repealed.
The cost of cost-sharing reductions (CSR) has been added to silver plan rates in New Hampshire. As was the case in 2018, this results in disproportionately large premium subsidies, and after-subsidy rates on bronze and gold plans that are lower than they would have been if the federal government had continued to directly reimburse insurers for the cost of CSR.
Medicaid expansion enrollees used private exchange plans through 2018, but NH is switching to Medicaid managed care starting in 2019; this is likely a big part of the reason for the rate decreases for 2019
The rate decreases for 2019 are likely due in large part to the fact that the state is changing the way Medicaid expansion is handled. Through the end of 2018, New Hampshire uses Medicaid funds to purchases private plans (qualified health plans, or QHPs) in the exchange for Medicaid expansion enrollees, via the state’s Premium Assistance Program (PAP).
However, New Hampshire enacted legislation in 2018 that directs the state to seek federal approval to abandon the PAP system and switch to regular Medicaid managed care instead. New Hampshire submitted a waiver proposal to this effect to CMS in July 2018. Approval was granted by CSM in late November, but that appeared to be just a formality, as the state had already sent notices to enrollees in October, and the QHP insurers had mentioned the impending transition from PAP to Medicaid managed care in their filings that were submitted over the summer.
[Separately, a Medicaid work requirement was already approved by CMS, and will take effect in New Hampshire in January 2019.]
There is a correlation between lower income and poorer health, so if the Medicaid expansion population is moved out of the QHP risk pool, the overall health of the pool will improve. This reduced morbidity will translate into lower premiums for everyone who remains in the QHP pool.
Exchange grew from one carrier to five in 2015, dropped to three by 2018
For 2014, only one health insurance carrier — Anthem Blue Cross Blue Shield — applied to participate in the state-federal partnership exchange in New Hampshire, offering 14 health plan options. But that changed significantly for 2015, when the New Hampshire exchange grew to include policies from five carriers. Not all carriers offered plans in all counties, but there were an average of 38 plans available in each county, up from 10 in 2014.
Two of the new carriers that joined the New Hampshire exchange in 2015 are ACA-created CO-OPs: Minuteman Health, based in Boston, and Community Health Options (formerly Maine Community Health Options, or MCHO) that garnered 83 percent of the market share in neighboring Maine during the 2014 open enrollment. CHO had a limited presence in New Hampshire 2015, offering coverage in four NH counties: Coos, Carroll, Rockingham, and Strafford.
Harvard Pilgrim Health Care and Assurant also joined the New Hampshire exchange in 2015, although Assurant announced in mid-2015 that they would exit the entire market nationwide, and they no longer had any enrollees in the New Hampshire exchange as of September 2015.
For 2017, Community Health Options was no longer offering coverage in the exchange, but plans continued to be available from Anthem, Ambetter, Minuteman Health, and Harvard Pilgrim.
But Minuteman Health was ultimately placed in receivership, and was not allowed to offer coverage past the end of 2017. So for 2018, plans are available in the New Hampshire exchange from Anthem, Ambetter, and Harvard Pilgrim. All three insurers have filed plans to continue to participate in the exchange in 2019, with significant rate decreases.
49,573 people enrolled in coverage through New Hampshire’s exchange during the open enrollment period for 2018 coverage. 53,024 people enrolled the year before, so enrollment was down about 6.5 percent for 2018. Across all the states that use HealthCare.gov, enrollment dropped about 5 percent in 2018.
Lower enrollment in 2018 was due to multiple factors, including a much shorter enrollment period (just over six weeks, instead of three months), sharply reduced federal funding for enrollment assistance and exchange marketing, uncertainty about the future of the ACA and the individual mandate (the mandate penalty was repealed in the GOP tax bill, after the end of open enrollment, but that won’t take effect until 2019), much higher premiums for people who don’t get premium subsidies, and insurer exits from the marketplace.
Minuteman Health in receivership, did not offer plans for 2018
Minuteman Health was a Massachusetts-based CO-OP that expanded to offer plans in New Hampshire starting in 2015. Amid financial struggles (due in part to the ACA’s risk adjustment programs, described below), Minuteman announced in June 2017 that they would stop offering plans at the end of 2017, but indicated their intention to reopen as a new, for-profit insurer in 2018.
In August 2017, however, it became apparent that Minuteman would not be able to reopen as a for-profit insurer in 2018, because they had not raised enough capital by the deadline for seeking regulatory approval to sell plans in the exchanges in Massachusetts and New Hampshire (they needed to be licensed as a new insurer by August 16, and were not able to do that due to lack of capital). As a result, Minuteman Health enrollees had to switch to new plans for 2018, and residents did not have an opportunity to buy a for-profit version of Minuteman coverage (the New Hampshire Insurance Department published a list of FAQs about Minuteman’s departure from the market).
As of December 2017, New Hampshire’s exchange had 81,962 total enrollees, 39,899 of whom had PAP coverage. Of the total enrollees, 21,583 had coverage with Minuteman Health (3,189 of those had PAP coverage). All of those individuals (including the PAP enrollees) needed to switch to new plans during open enrollment, which ran from November 1, 2017 through December 15, 2017. Minuteman members also qualified for a special enrollment period — which continued until March 1, 2018 — triggered by loss of coverage, during which they could select a new plan.
The other three insurers in New Hampshire’s exchange — Ambetter, Anthem (Matthew Thornton), and Harvard Pilgrim — all remained in the exchange in 2018.
2018 rate changes: Cost of CSR added to premiums
Amid uncertainty about the future of the ACA and the ACA’s cost-sharing subsidies, New Hampshire extended the deadline by which insurers had to file rates and plans for 2018. It was previously April 24, but was pushed out to June 2.
The proposed rates became available on ratereview.healthcare.gov in August. At that point, the three remaining exchange insurers in New Hampshire had proposed rates based on the assumption that cost-sharing reductions (CSR) would continue to be funded by the federal government. But later in the summer, they all filed revised rates, based on the assumption that CSR funding would not continue, and those rates were ultimately deemed justified by state regulators. In mid-October, the Trump Administration announced that CSR funding would end immediately. But by that point, all of New Hampshire’s insurers had already added the cost of CSR to their 2018 premiums.
The following average rate increases have been implemented in New Hampshire for 2018 coverage:
- Ambetter: 18.4 percent. Ambetter’s initial rate filing was for an average increase of just 0.37 percent, but the revised filing (which was deemed reasonable) calls for substantially higher rate increases, presumably to account for the lack of CSR funding (this is not specifically stated in the publically available filing, but presumably, the cost of CSR has been added to silver plans for 2018). The filing indicates that the rate change applies to approximately 16,804 members. New Hampshire’s exchange has 18,109 Ambetter enrollees as of May 2017. Virtually all of them have coverage via PAP though, with Medicaid paying the premiums; only 102 have non-PAP coverage.
- Anthem (Matthew Thornton): 48.9 percent. This was a revised filing (deemed reasonable), based on the assumption that CSR funding would not continue, with the cost of CSR added to silver plan premiums. The initial proposed rate increase had assumed that CSR funding would continue, but the initial proposed rate change had been only slightly lower, at 45.3 percent; filing indicates 29,000 members (27,238 have coverage in the exchange)
- Harvard Pilgrim: 45.7 percent. This was a revised filing (deemed reasonable), based on assumption that CSR funding would not continue in 2018, and with the cost of CSR added to silver plan premiums. But Harvard Pilgrim’s initial proposed rate increase, which had assumed that CSR funding would continue, was only slightly lower, at 42.5 percent. The filing indicates that 6,483 members would be affected, but according to the New Hampshire Insurance Department, Harvard Pilgrim has more than 20,000 enrollees (across two networks) in the exchange, including PAP and non-PAP.
At first glance, the initial rate filings seemed odd, since Ambetter was requesting a minuscule rate hike, while Anthem and Harvard Pilgrim proposed premium increases of more than 40 percent. But a look at the 2017 rates helps to explain the difference. I used HealthCare.gov’s quote tool to get 2017 prices for a 38-year-old non-smoker in Concord, NH. It returned 32 quotes, including plans from all three insurers (Minuteman rates were also shown, and were by far the lowest-priced plans available in each metal level).
Ambetter’s lowest-priced plan was a silver plan for $400/month. In the ranking of plans from lowest-price to highest-price, it was listed 26th out of 32 plans. In comparison, Anthem’s lowest-priced silver plan was $307/month, and Harvard Pilgrim’s lowest-priced silver plan was $316/month (Minuteman had a silver plan for $261/month, but Minuteman plans are not available for 2018). At least in Concord, it’s obvious that Ambetter charged substantially more than Anthem or Harvard Pilgrim in 2017. If the initially proposed rate changes had been implemented, Anthem and Harvard Pilgrim would have ended up more expensive than Ambetter in 2018, but the difference would have been much less pronounced than the current difference.
The dramatically higher premiums for Ambetter in 2017 also explain why virtually all of Ambetter’s 2017 enrollees were in Medicaid-funded PAP plans. People who aren’t in PAP were likely to find one of the other three insurers to be a better value with the 2017 rates (regardless of whether they receive premium subsidies).
Ultimately, the revised rates have less spread among the carriers than the initially proposed rates, but Ambetter’s average percentage rate increase was still much smaller than the other two insurers. Ambetter’s proposed average rate increase went from less than half a percent to more than 18 percent when the filings were revised, while both Anthem and Harvard Pilgrim made only modest increases to their proposals.
Cost of CSR added to silver plans, so premium subsidies are much larger than they were in 2017
CSR benefits are only available on silver plans, so insurers in most states added the cost of CSR to silver plan premiums for 2018 (either initially, or in revised filings once it became evident that CSR funding was not going to continue). CSR benefits are still available to all eligible enrollees for 2018, if they select silver plans. But premium subsidies are also still available to all eligible enrollees, and premium subsidies are based on the cost of the second-lowest-cost silver plan in each area. So as silver plan premiums increase, so do premium subsidies (in New Hampshire in 2018, premium subsidies are available to individuals with income between $16,642 and $48,240, and to a family of four with income between $33,948 and $98,400).
And while premium subsidies are designed to keep the price of the second-lowest-cost silver plan at a consistent level from one year to the next, they can also be applied to plans at other metal levels. Since the other metal levels have smaller premium increases for 2018 than the silver plans, the premium subsidies are making non-silver plans more affordable for enrollees who are subsidy eligible.
As an example, consider a 50-year-old couple living in Manchester, earning $45,000 (keeping their age the same from one year to the next for comparison’s sake). In 2017, the least expensive plan available to them was $212/month in premiums after their $404/month premium subsidy. But for 2018, they can get a plan for $99/month, after a $993/month premium subsidy is applied. The premiums for the bronze plans have increased, but the premium subsidies have grown by an even larger margin, making the bronze plan more affordable than it was in 2017.
There’s no one-size-fits-all when it comes to health insurance, and each enrollee should carefully comparison shop to ensure that they’re getting the plan for 2018 that represents the best value. But because the cost of CSR has been added to silver plans, there are some pricing anomalies in some areas of the country, making it more important than ever for enrollees to consider all of their options before picking a plan, and to avoid simply auto-renewing their 2017 plan. Particularly for people who don’t qualify for premium subsidies — and are thus subject to the full brunt of the rate hikes — comparison shopping is important, and non-silver plans might end up being a better choice for 2018.
53,024 people enrolled in private QHPs through New Hampshire’s exchange during the 2017 open enrollment period. Their average unsubsidized premiums are $399/month (lower than the $476/month average across all states that use the federally-facilitated exchange). But 63 percent of New Hampshire’s exchange enrollees are receiving premium subsidies that reduce their average premiums to $242/month.
Some enrollees don’t pay their initial premiums, and others cancel their coverage early in the year. By May 2017, in-force enrollment in QHPs (not counting PAP enrollments) stood at 49,534. In addition, there were 43,308 PAP enrollees in Medicaid-funded QHPs.
As of May 2017, there were 761 people enrolled in small group (SHOP) plans through the New Hampshire exchange. They were employees and dependents of 130 small businesses.
2017 rates and carriers: Remaining CO-OP had significant market share, but exited market at the end of 2017
There were two ACA-created CO-OPs operating in New Hampshire in 2016, but Community Health Options (CHO) exited the New Hampshire market at the end of 2016, to focus solely on Maine (details below). That left four carriers offering plans in New Hampshire’s exchange for 2017.
But despite the exit, the state reports that there are still the same number of individual market plans (32) available in 2017, and every hospital in the state is included in at least one exchange carrier’s network (all but two of the 26 hospitals are included in at least two networks, and all but three are included on more than two networks). The state has created summaries of the 32 plans for 2017, available here.
These four carriers are offering individual market QHPs in the New Hampshire exchange for 2017, and implemented the following average rate increases (on-exchange membership counts are as of May 2017):
- Ambetter by Celtic: (May 2017: 102 non-PAP enrollees, plus 18,007 PAP enrollees) 1.35 percent
- Anthem Blue Cross Blue Shield of New Hampshire (Matthew Thornton Health Plan): 13.9 percent (May 2017: 16,910 non-PAP enrollees, plus 10,328 PAP enrollees).
- Harvard Pilgrim Health Care of New England: 11.1 percent (May 2017: 9,099 non-PAP enrollees, plus 11,580 PAP enrollees)
- Minuteman Health (an ACA-created CO-OP): In April 2016, Minuteman had announced that their average rate increase would be 45.2 percent for 2017 (details below), and initial rate increase proposals ranged from 18 percent to 60 percent, depending on the plan. But the final approved rate increases ranged from 2.22 percent, to 9.89 percent, with an average of 4.2 percent, resulting in the lowest-priced plans in the exchange at all metal levels. As of May 2017, Minuteman had 23,423 non-PAP enrollees, plus 3,393 PAP enrollees.
Of the non-PAP enrollments, Minuteman Health had the largest market share in the exchange in 2017, with 44 percent of the enrollments. Anthem was in second place, with 36 percent of the enrollments (including PAP enrollees, Anthem’s membership is slightly higher than Minuteman’s). But as noted above, Minuteman Health enrollees will need to select new plans for 2018, as their coverage will no longer be available after the end of 2017.
Two carriers—Anthem and Delta Dental—are offering dental plans through the New Hampshire exchange in 2017. There were four dental carriers in 2016, but two of them—Dentegra and Guardian Life Insurance Company—are no longer offering dental plans in the exchange after the end of 2016.
Community Health Options exited New Hampshire at the end of 2016
Community Health Options, a Maine-based CO-OP that expanded into New Hampshire in 2015, is among the more successful CO-OPs in the country (one of only five that are still operational for 2017), although they’ve struggled with financial losses recently. They were the only CO-OP to make a profit in 2014, but they experienced higher-than-expected losses in 2015 (they lost $31 million in 2015, and also set aside $43 million in reserves to cover anticipated losses for 2016; about 85 percent of their membership was in Maine).
As a result, they ceased new individual plan enrollments for 2016 on December 15, 2015 through their website, and December 26 through Healthcare.gov. The carrier continued to offer new group plans, and all individual plans that were in force in December 2015 were eligible for renewal into 2016 if insureds didn’t select coverage with a different carrier instead.
But in September 2016, Community Health Options announced that they would exit the New Hampshire market at the end of 2016 in order to focus entirely on Maine. New Hampshire still has a CO-OP in the exchange in 2017, as Minuteman Health has remained in the market. But that will no longer be the case in 2018 — Minuteman Health has been placed in receivership by the Massachusetts Division of Insurance (the CO-OP is domiciled in Massachusetts), and will not offer coverage in 2018.
The bulk of CHO’s enrollees — about 85 percent — were already in Maine, but they had 11,438 members in New Hampshire as of July 2016 (as of September, CHO’s total enrollment in the New Hampshire exchange stood at 4,649 in the individual market, including PAP members, along with 524 in the small group exchange; their off-exchange enrollees in New Hampshire —which included the bulk of their small business enrollments — also had to find new coverage for 2017).
New Hampshire businesses that were enrolled in CHO’s small group plans can keep their coverage until their renewal date in 2017, but the carrier stopped renewing New Hampshire small group plans in October 2016, and is not selling small-group plans in the state for 2017.
The impact in New Hampshire if the ACA is repealed
According to an HHS report released in December 2016, the number of people in New Hampshire with health insurance increased by 63,000 from 2010 to 2015 as a result of the ACA. This includes young adults who have been able to remain on a parent’s plan, people who enrolled in through the exchange (including those enrolled via PAP), as well as people who have gained coverage through other avenues.
The New Hampshire Insurance Department reported that the uninsured rate in the state was 11 percent in 2013, and had dropped to just 6 percent by 2015. This decrease is mostly due to the ACA.
The majority (63 percent) of the people who enrolled in non-PAP coverage through the New Hampshire exchange in 2017 are receiving premium subsidies to make their coverage affordable, and everyone in the PAP system is receiving subsidized coverage.
Republican leadership in the House has supported the American Health Care Act (AHCA) since early March, although the bill failed to gain enough support in the early weeks of debate and was pulled prior to a full vote in the House. The legislation was back under consideration in April. Although it does call for some premium subsidies, they’re generally smaller than the subsidies provided by the ACA.
In New Hampshire, however, average premiums for exchange enrollees would tend to be significantly lower under the AHCA than they are under the ACA. This is likely due to the relatively large percentage of New Hampshire exchange enrollees who currently pay full price for their coverage, without any ACA premium assistance. The AHCA’s premium assistance would be smaller for people with lower incomes, but it would extend much higher into the middle class and upper-middle class than the ACA’s subsidies do.
However, that analysis of average net premium changes does not account for PAP enrollees, whose coverage is funded with Medicaid dollars. The AHCA would end new Medicaid expansion enrollments after 2019, and would also convert Medicaid to a per-capita allotment system, reducing the total amount of federal money that states have to spend on Medicaid as time goes by.
There is little doubt that many of the tens of thousands of current lower-income exchange enrollees and those with PAP assistance would find coverage much less affordable under the AHCA or similar proposals that Republican lawmakers have introduced over the last few years.
There are also worries that pre-existing conditions could once again become an obstacle for people enrolling in coverage in the individual market. In an effort to garner support from the ultra-conservative House Freedom Caucus, Republican leaders have considered the possibility of allowing insurers to charge higher premiums when applicants have pre-existing conditions, which is a practice that the ACA banned.
Because so much is still up in the air, there is considerable uncertainty surrounding the future of the ACA under the Trump Administration. For now, however, nothing has changed. Subsidies are still available to offset premiums and out-of-pocket costs in the exchange. And although open enrollment ended on January 31, coverage is still available if you experience a qualifying event, regardless of pre-existing medical conditions. HealthCare.gov is implementing pre-enrollment eligibility verification for special enrollment periods beginning in June 2017, so be prepared to provide proof of your qualifying event, as it will be required in order to complete the enrollment.
By October 2016, total enrollment in qualified health plans (QHPs, which are private plans) through the exchange stood at 47,976.
In addition, there were 41,714 people enrolled in New Hampshire’s Premium Assistance Program (PAP – the state uses Medicaid funding to purchase QHPs through the exchange for Medicaid-eligible individuals).
Here’s how the individual QHP market share in the exchange was distributed across the five New Hampshire exchange carriers as of October 2016:
- Anthem Blue Cross Blue Shield: 20,876 QHP enrollees (down from about 26,000 in March), plus an additional 8,550 PAP enrollees
- Minuteman: 16,004 QHP enrollees (about half are on Bronze plans), plus an additional 2,955 PAP enrollees.
- Harvard Pilgrim: 9,442 QHP enrollees, plus an additional 10,196 PAP enrollees
- Community Health Options: 1,631 QHP enrollees, plus an additional 1,389 PAP enrollees (enrollment in QHPs ceased as of December 26, 2015, and CHO is exiting the state altogether at the end of 2016).
- Ambetter: 23 QHP enrollees, plus an additional 18,624 PAP enrollees (New Hampshire Healthy Families enrollees were automatically enrolled in Ambetter through the PAP, although they had the option to pick a different health plan).
According to the New Hampshire Insurance Department, the enrollment drop-off for Community Health Options from March to April 2016 was partially a result of a reporting glitch in previous months: Rather than reporting just on-exchange numbers to the Insurance Department (used for the monthly QHP membership report that the Insurance Department publishes), Community Health Options had been reporting both on and off-exchange numbers combined. So starting in April, the enrollment report includes only on-exchange enrollments.
PAP enrollments for Medicaid-eligible enrollees are QHPs, and are in the same risk pool as regular QHP enrollments. PAP simply uses Medicaid funding to pay the premiums and any cost-sharing above Medicaid levels, and adds in any additional benefits that must be covered under Medicaid.
Enrollment in QHPs during the 2015 open enrollment period reached 53,005, so the 55,183 people who enrolled in QHPs for 2016 (by February 1) represented a 4 percent increase. And the 49,114 effectuated enrollment total as of March 2016 was an 8 percent increase over the 45,607 effectuated enrollment number from the same time the previous year.
Of the 2016 enrollees, 32 percent were new to the exchange for 2016, and 63.4 percent were receiving premium subsidies as of March 2016. This was the lowest percentage of subsidy-eligible enrollees in any of the states where HHS is running the exchange, and quite a bit lower than the 85 percent average across all the states that use the federally-facilitate exchange.
763 people enrolled in small business exchange as of April 2017
The October 2016 enrollment report indicated that there were 817 people enrolled in small business (SHOP) plans through the New Hampshire exchange, representing a total of 153 small businesses. There was a sharp drop-off from March to April; the March report had indicated that there were 825 groups and 7,615 enrollees.
The drop-off was due to Community Health Options’ enrollment tally, which went from 766 groups with 7,265 insured members, to just 81 groups with 499 insured members. According to the New Hampshire Insurance Department, the April numbers (and the subsequent months) are correct, and the prior numbers had included off-exchange enrollments along with SHOP enrollments. The vast majority of Community Health Options’ small business enrollments were off-exchange (those small businesses will have to find new coverage as of their 2017 renewal, as CHO has exited New Hampshire altogether, including the off-exchange market).
As of April 2017, there were 138 small businesses enrolled in SHOP plans, covering 763 people.
Minuteman Health contends that risk adjustment program is badly flawed
Minuteman Health had roughly 26,500 members as of November 2016 — well above their goal of 22,500 members. The CO-OP filed a lawsuit in August 2016 over the risk adjustment payments they owed to CMS (more than $16 million for the 2015 benefit year alone, accounting for 90 percent of the state’s total risk adjustment payments, despite having just 19 percent of the on-exchange market share), and has warned that significant changes are necessary in order to stabilize the individual market (risk adjustment is a permanent program, unlike the other two “Rs” which sunset at the end of 2016).
Blue Cross Blue Shield of Massachusetts, however, is happy with the way the risk adjustment program was structured, as they’re receiving $40 million from their competitors under the program.
In April 2016, Minuteman Health announced that they were requesting a 45.2 percent rate increase for 2017. But the final average rate increase for Minuteman plans in 2017 was just 4.2 percent (the lowest of any of the exchange carriers in New Hampshire, and resulting in the lowest overall prices in the exchange as well). For perspective, Minuteman Health requested rate hikes of 42 to 51 percent for their individual market plans heading into 2016, but regulators ended up approving average rate increases that ranged from 2.75 percent to 9.63 percent.
Minuteman is the only carrier in the New Hampshire exchange that offers platinum plans, and they continue to have two zero-deductible platinum plans available for 2017. But their most popular plans are bronze and silver; 6,323 of their 16,004 on-exchange (non-PAP) members had bronze plans as of September 2016, and 7,691 had silver plans. As noted above, however, Minuteman Health has been placed in receivership by the Massachusetts Division of Insurance, and their plans will not be available in 2018.
2016 rates and carriers
In 2015, New Hampshire’s exchange had five carriers, up from just one in 2014. There were still five carriers offering plans for 2016, although there was one swap: Assurant/Time exited the market (nationwide), but Ambetter (offered by Celtic) joined the exchange in New Hampshire (Assurant had 189 enrollees in the New Hampshire exchange as of January 2015, but enrollment had dropped to zero by September 2015, in anticipation of their market exit).
In 2015, there were 42 individual plans available in the state, and that increased to 51 for 2016. Dentegra also joined the exchange, bringing the total number of dental carriers from three to four (Dentegra only participated in the exchange for 2016, and is not offering plans for 2017)
Two carriers in the exchange – Minuteman Health and Community Health Options – requested double digit rate increases for 2016. Both carriers were CO-OPs created under the ACA, and both expanded into New Hampshire at the start of 2015, so their claims data for the state was very limited. But they both noted in their rate justifications that the transition of the NH Health Protection Program population (those newly eligible for Medicaid under the ACA’s Medicaid expansion) to private plans in 2016 was a driving force in the higher rates they requested for 2016 (the state is using Medicaid funds to subsidize premiums for the transitioning enrollees). Minuteman requested an average rate increase of nearly 50 percent, although they proposed a rate reduction of nearly 27 percent for their catastrophic plan.
2016 approved rate hikes modest
Ultimately, regulators approved Community Health Options’ 2016 rates as proposed. But the final approved rate increases for Minuteman Health were much smaller than the carrier had requested. The rate decrease for the catastrophic plan was approved with only minor changes. But for Minuteman’s other individual market plans – on which the CO-OP had requested rate increases of nearly 50 percent – regulators approved average rate increases ranging from 2.75 percent to 9.63 percent.
Anthem and Harvard Pilgrim Health Care both had average approved rate increases of less than 6 percent. The New Hampshire exchange provides market share data that’s updated monthly; 44,670 people had in-force private plan coverage in the New Hampshire exchange as of December 2015.
Here’s market share and rate change data for each carrier offering individual plans in the New Hampshire exchange in 2016:
- Ambetter (Celtic) – new to New Hampshire exchange for 2016.
- Anthem: Average approved rate changes were a 0.29 percent decrease, and a 5.7 percent increase. Anthem had 24,567 in force enrollees as of December 2015
- Community Health Options (previously known as Maine Community Health Options): Average rate increases of 13.8 percent to 16.7 percent, approved as-proposed. 4,013 in-force enrollees as of November 2015 (new individual plan enrollments will cease December 26).
- Harvard Pilgrim Health Care: 4.36 percent increase for the NH Network plans, and a 2.09 percent decrease for the Elevate Health plans. 6,568 in force enrollees as of December 2015; nearly three quarters of Harvard Pilgrim’s enrollees are in the Elevate Health plans.
- Minuteman Health: Approved average rate increases range from 2.75 percent to 9.63 percent for individual market plans (much lower than the proposed rate increases of 42 percent to 51 percent). Catastrophic plan rates will decrease by more than 27 percent in 2016, which is very close to what Minuteman Health requested for this plan. Minuteman had 8,360 in force enrollees as of November 2015.
Before rates were finalized in New Hampshire, the worst-case scenario rate increase based on proposed rates was 18.5 percent. This was based on using the highest proposed rate increases for Community Health options and Minuteman (assuming the majority of their enrollees were in the plans with the highest proposed rate hikes), and the possibility of 9.9 percent rate increases for Anthem and Harvard Pilgrim. Despite the fact that Minuteman had proposed rate hikes of nearly 50 percent, their enrollment accounted for less than 20 percent of the exchange total. And the dominant carrier in the exchange – Anthem – had requested a rate hike of less than 10 percent, so the overall proposed weighted average rate hike was still under 20 percent.
But once the rate review process was finalized, the overall weighted average rate hike was just over 6 percent – even if we assume that the majority of Community Health Options, Anthem, and Minuteman enrollees were in plans with the highest rate hikes. According to HHS data, the average benchmark premium (second lowest-cost Silver plan, which isn’t necessarily the same plan from one year to the next) in New Hampshire is 5.1 percent more expensive in 2016 than it was in 2015. In the Manchester area, a Kaiser Family Foundation analysis determined that the average benchmark premium increased by 5.7 percent for 2016.
Higher benchmark premiums mean that average subsidies are higher in 2016 than they were in 2015. But it was still important for enrollees to shop around during open enrollment, as the increase in subsidies didn’t apply consistently in every area, and wasn’t enough to offset the rate hikes that some plans experienced in 2016.
Increased network options in 2016
All 26 hospitals in the state are contracted with at least two of the five carriers in 2016, and most of the hospitals are on three, four, or five of the networks. Network issues plagued the New Hampshire exchange in 2014, as Anthem only contracted with 16 of the state’s 26 hospitals in efforts to keep premiums as low as possible.
As a result, even though the exchange had just one carrier in 2014, premiums in New Hampshire were comparable to rates in states that had many carriers offering policies. But Anthem’s restrictions on its hospital and physician networks drew fire, despite the low premiums that the narrow network allowed.
Provider access in New Hampshire had already expanded considerably for 2015. In November 2014, the New Hampshire Department of Insurance published a detailed explanation of 2015 network size and scope based on county and carrier for all of the carriers offering plans in the exchange. Provider network details are also available on each carrier’s website.
There was a mix of broad and narrow networks available in New Hampshire for 2015, and that continues to be the case in 2016; shoppers can find the price and network combination that most appeals to them.
The same four carriers are offering individual policies outside the exchange in 2017, and there are no additional carriers in the state that only sell off-exchange products. But the state does not track market share outside the exchange, so the weighted average rate increase could be different when considering the entire individual market in New Hampshire, including both on and off-exchange.
But it’s worth considering that in their rate justification for 2016, Community Health Options noted that the size of the individual market in New Hampshire was about 50,000 people in 2015 (total enrollment in private plans through the exchange in December 2015 was 43,508). Given that risk pools for on and off-exchange plans are unified, that would seem to indicate a relatively small ACA-compliant individual market outside the exchange.
That hypothesis is further bolstered by the fact that less than 63 percent of New Hampshire exchange enrollees were receiving premium subsidies in 2015 and again in 2016 — far lower than the national average of about 85 percent. If a significant number of non-subsidy-eligible enrollees are getting coverage through the exchange (this is the population most likely to shop outside the exchange), it makes sense that the off-exchange population might be quite small.
A hands-on state
The New Hampshire Department of Insurance is an active participant in overall functionality of the New Hampshire exchange, which operates as a partnership between the state and HHS. The Department of Insurance has published an inclusive overview of exchange information on their website to serve as a resource for state residents.
Although New Hampshire residents use Healthcare.gov to enroll in health plans, the state also has a website called Covering New Hampshire that serves as an excellent resource for residents. The site provides extensive information about health insurance options in New Hampshire, and can also connect residents with local in-person assistance.
The state’s efforts to get people enrolled in health insurance – both expanded Medicaid and private coverage – are evident in the reduction in the uninsured rate. According to Gallup data, 13.8 percent of New Hampshire residents were uninsured in 2013. By the first half of 2015 – after Medicaid expansion had been in effect for several months – the uninsured rate had fallen to 8.7 percent.
2015 enrollment totals
53,005 people in New Hampshire had enrolled in private plans through the exchange by February 22, 2015, when the second open enrollment period – and its extension – ended. Only 71 percent of them were receiving premium subsidies – the lowest percentage of any state where HHS was running the exchange (that figure has dropped to 67 percent for 2016).
The official HHS target for New Hampshire was 50,000 enrollees during the 2015 open enrollment period, so the exchange exceeded that target by more than three thousand people. However, by April 1, only 45,504 people had in-force policies in the New Hampshire exchange, as some enrollees didn’t pay their initial premiums, and others cancelled their coverage shortly after enrolling. All in all, the effectuation rate matches up with the national averages.
The effectuated enrollment report from CMS showed 44,727 people in New Hampshire with in-force private plan coverage through the exchange as of June 30, and the state’s own report pegged the number at 44,305 by November. There’s some fluctuation from one month to another, especially given that subsidized plans don’t terminate for non-payment until premiums are three months past-due.
An additional 9,294 people in New Hampshire enrolled in Medicaid or CHIP through the exchange between November 15 and February 22. Medicaid enrollment continues year-round.
King v. Burwell – subsidies upheld
Democratic Representative Ed Butler introduced a bill to create a state-run exchange in New Hampshire in 2015 (the state currently has a partnership exchange), but it was defeated by the Republican dominated legislature in March. Since the state still uses the federally-run exchange, 28,000 people in New Hampshire would have lost their subsidies if the Supreme Court had ruled that subsidies could only be issued by state-run exchanges. But in June 2015, the Supreme Court ruled that subsidies are legal in every state, even those that rely on the federally-run exchange.
Benefits extend beyond those receiving subsidies
This was obviously a huge win for the people of New Hampshire who have subsidized coverage through the exchange; the Kaiser Family Foundation had estimated that their premiums would have increased by 218 percent if the subsidies had been eliminated. But it’s also a win for everyone who buys individual insurance in the state, including those who don’t receive subsidies. The American Academy of Actuaries had projected market-wide rate increases of at least 35 percent if subsidies had been eliminated, and the overall size of the individual market pool would have dropped by about 70 percent.
As well as the citizens of New Hampsire, the King ruling was also a win for health insurers – their market is no longer in danger of imminent destabilization – and for medical providers, since their patients will still have insurance and be able to afford care.
In addition, New Hampshire expanded Medicaid under the ACA, but with a waiver that allowed the state to start using Medicaid funds to subsidize private plans in the exchange for the newly eligible population in 2016, rather than continuing to cover them in the state’s Medicaid managed care program. Those funds would still have been available in 2016 regardless of the outcome of the King case, but state leaders had expressed concern that the program could have been jeopardized by the upheaval that would have been created in the exchange if subsidies had been eliminated.
Lower premiums in 2015
One result of the increased competition in 2015 was a sharp reduction in average premiums. The benchmark plan (second-lowest-cost silver plan) changed as a result of the influx of carriers to the exchange, and the new benchmark plan in 2015 was about 17 percent less expensive than the benchmark plan in 2014. This was among the sharpest drops in the country, and highlights the importance of competition in holding down premiums.
Avalere Health found that the average lowest-cost bronze plan in New Hampshire was 17 percent less expensive in 2015, and that the average lowest-cost silver plan was 18 percent less expensive. The silver drop is the largest in the nation, and the bronze drop is second only to Mississippi.
2014 enrollment numbers
40,262 people had completed their private plan Obamacare enrollments in the New Hampshire exchange by mid-April 2014. Another 7,235 exchange applicants were eligible for the state’s existing Medicaid coverage during the first open enrollment (Medicaid enrollment continues year-round, but tends to peak during open enrollment due to increased outreach).
For private plan enrollments, New Hampshire greatly exceeded CMS projections in 2014. The original projection for the New Hampshire exchange was 19,000 enrollees during the 2014 open enrollment; the final total is more than double that amount.
Anthem Blue Cross Blue Shield had 90 percent of the individual market share in New Hampshire prior to 2014, so it’s not especially unusual that they were the only carrier that opted to participate in the exchange the first year.
Anthem reported that more than 35,000 of the exchange enrollees were new customers for them in 2014. Given the carrier’s long-term dominance in the market, we can assume that a significant majority of the first-year Obamacare enrollments in New Hampshire were for people who were previously uninsured. Anthem also reported that almost 90 percent of their enrollees paid their initial premiums in 2014.
Unique Medicaid expansion began mid-2014
Residents were able to begin enrolling in New Hampshire’s expanded Medicaid program as of July 1, 2014, with policies effective August 15 (Medicaid enrollment during the winter and spring was only possible for people who qualified under the state’s pre-expansion guidelines).
The state estimated that roughly 50,000 people would be eligible for coverage under the expanded Medicaid program. By the end of September, three months after enrollment began for expanded Medicaid, 18,500 people had already enrolled, and that had grown to nearly 24 thousand people by November 19.
Medicaid expansion in New Hampshire was a contentious issue, but ultimately Governor Maggie Hassan prevailed in her efforts to expand Medicaid, albeit in a privatized fashion. Gov Hassan signed Senate Bill 413 into law on March 27, 2014, paving the way for New Hampshire to become the 26th state to accept Medicaid expansion.
For the first couple years, the program has looked much the same as Medicaid expansion looks in the other 25 states. The state uses federal Medicaid funds to provide New Hampshire Health Protection Program coverage to residents with incomes below 138 percent of poverty.
But starting in January 2016, the state transitioned the NH Health Protection Program’s participants to subsidized, private coverage (Premium Assistance Program), following the “private option” Medicaid expansion path that has been popular in several other states. As of March 2016, PAP enrollment through the New Hampshire exchange stood at 43,732.
Risk pool and grandmothered plans
In November 2013, New Hampshire’s Insurance Commissioner Roger Sevigny announced that the state-run high risk pool (New Hampshire Health Plan) would remain in effect “until the federal marketplace is fully available (the risk pool had previously been scheduled to cease operations on December 31). The risk pool ceased operations on June 30, 2014.
In 2016, CMS issued another extension for transitional (grandmothered) plans, allowing them to renew as late as October 2017, and remain in force until as late as December 31, 2017. But the final decision regarding transitional plans was left to the states. New Hampshire opted to go along with the provision allowing transitional plans to remain in force until the end of 2017, but only if the plans are renewed by January 1, 2017. This is different from the requirements in most states, since transitional plans will not be allowed to renew in New Hampshire through October 2017; instead, the renewals will have to be complete by January 1, 2017. A transitional plan that’s up for renewal in March 2017 will have to be replaced with an ACA-compliant plan at that point instead of being renewed.
But residents also have the option to cancel their existing plan and switch to a new ACA-compliant policy instead, during open enrollment or when their grandfathered/grandmothered plan renews (renewal outside of open enrollment is considered a qualifying event that allows people to purchase an ACA-compliant plan instead). Anthem Blue Cross Blue Shield announced in May 2014 that they would accept the government’s offer to further extend pre-ACA policies that were carried over from 2013.
The New Hampshire Health Plan, which runs the state’s high-risk insurance pool, was approved in September 2013 for a federal grant to help facilitate education and outreach for the exchange. In addition, Planned Parenthood and Bi-State Primary Care were both awarded grants to serve as navigators during the first open enrollment period, for NH residents who had questions or needed personal assistance with the enrollment process.
Covering New Hampshire, an organization dedicated to educating consumers in New Hampshire and helping them enroll in coverage, focused additional efforts on targeting young men during the 2015 open enrollment, since they were under-represented during the 2014 open enrollment period.
In September 2015, CMS announced navigator grants for two New Hampshire organizations: Bi-State Primary Care received almost $355,000, and Bhutanese Community of New Hampshire received more than $245,000.
Legislation and exchange history
The exchange creation process in New Hampshire has been a legislative battle. In February 2013, Gov. Hassan announced that New Hampshire would operate its health insurance marketplace as a partnership with the federal government.
Prior to the 2012 elections, New Hampshire seemed firmly on a path to relying on the federally facilitated exchange. Former Democratic Gov. John Lynch had no effective means to push back against a Republican-dominated state Legislature that was united against a state-run exchange.
And in 2011, lawmakers passed a bill (enacted into law without Lynch’s signature) that prohibited any sort of penalties for New Hampshire residents who fail to obtain health insurance – in direct conflict with the ACA’s individual mandate and shared responsibility penalty. The law has no real impact however, because the IRS (a federal agency, not under state control) is responsible for assessing the ACA’s penalties, and because the ACA is a federal law that cannot be superseded by state law.
But the 2012 elections gave control of the state House to Democrats, put more Democrats in the Senate, and kept the governor’s office in Democratic hands. The political shift and a law that allowed the state to take on specific exchange functions enabled the state to adopt a partnership model.
New Hampshire is responsible for plan management and consumer assistance, and the federal government is managing all other marketplace functions. The NH Health Exchange Advisory Board holds monthly meetings, the minutes of which are available here.
New Hampshire health insurance exchange links
New Hampshire Department of Insurance: Health Benefit Partnership Exchange Advisory Board
Includes meeting agendas and documents from November 2012 until the present.
State Exchange Profile: New Hampshire
The Henry J. Kaiser Family Foundation overview of New Hampshire’s progress toward creating a state health insurance exchange.
New Hampshire Consumer Assistance Program
Assists consumers who have purchased insurance on the individual market or who have insurance through an employer who only does business in New Hampshire.
(800) 852-3416 / firstname.lastname@example.org
Covering New Hampshire – a statewide effort by the New Hampshire Health Plan to inform residents of their coverage options in the exchange and the resources that are available for those who need assistance.
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.