Highlights and updates
- Open enrollment for 2020 coverage in New Hampshire has ended, although residents who experience qualifying events can still enroll or make plans changes for 2020. The next open enrollment period begins November 1, 2020, for plans effective in 2021.
- Short-term health plans are available in New Hampshire with initial plan terms up to six months.
- New Hampshire plans to seek federal pass-through funding for a reinsurance program that could result in a rate decrease in 2021.
- 2020 rates declining slightly, on the heels of a 14 percent decrease in 2019.
- New Hampshire switched from PAP to Medicaid managed care as of January 2019.
- Enrollment in New Hampshire’s exchange dropped again in 2019.
- Five insurers offered plans in New Hampshire’s exchange in 2015 (up from one in 2014), but that has since dropped to three.
- New Hampshire is allowing grandmothered/transitional plans to renew for 2020, but will not allow renewal after that, even if CMS grants additional extensions.
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. The Department of Insurance has an inclusive overview of exchange information on their website to serve as a resource for state residents, and maintains a monthly enrollment report that shows how many people have plans purchased through the exchange from each participating insurer.
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 2020.
Open enrollment for 2020 coverage has ended, although residents who experience qualifying events can still enroll or make plans changes for 2020. The next open enrollment period begins November 1, 2020, for plans effective in 2021.
Federal funding for exchange marketing and enrollment assistance has been cut sharply during the Trump Administration. New Hampshire did not receive any federal navigator funding in 2018, whereas two organizations received more than $450,000 in 2017. But in 2019, First Choice Services in New Hampshire received $100,000 in navigator funding.
New Hampshire plans to seek federal approval for a reinsurance program
New Hampshire is planning to follow a dozen other states that have implemented reinsurance programs to stabilize their individual insurance markets. Reinsurance works by taking on some of the risk that the health insurers would otherwise have to bear, and the result is lower premiums in the individual market. That translates to smaller premium subsidies, which reduces federal spending. By using a 1332 waiver, a state can recoup the savings (instead of having the federal government keep the money) and use the money to fund the reinsurance program.
New Hampshire will seek public input this spring, and submit a waiver proposal to the federal government later this year. The state’s projection is that the planned reinsurance program will result in 2021 individual market premiums that are 15 percent lower than they would otherwise have been.
It’s important to understand, however, that this direct reduction in premiums generally only applies to people who pay full price for their coverage. In New Hampshire, that’s about 10,000 exchange enrollees (the rest get premium subsidies) plus another 10,000 people who buy their coverage outside the exchange. For people who get premium subsidies, the subsidies will shrink as premiums decline, and after-subsidy premiums can end up decreasing, staying the same, or increasing, depending on how the benchmark premiums change.
But assuming the reinsurance program is approved (and it almost certainly will be, as numerous other states have already established reinsurance programs with 1332 waivers), overall individual market rates could decrease again in New Hampshire next year, for the third year in a row.
Slight rate decrease for 2020, on the heels of another rate decrease in 2019
State law prevents the New Hampshire Insurance Department from publishing health insurance rate information until open enrollment begins on November 1. But the Department is proactive in sharing the information that the federal government publishes at the beginning of August in terms of proposed rates for the coming year.
The finalized rate changes are available on ratereview.healthcare.gov. Anthem’s approved rate change is the same as the insurer initially proposed, but final rates ended up lower for both of the other insurers. The following average rate changes are being implemented for full-price premiums in New Hampshire’s individual market for 2020 (keeping in mind that most exchange enrollees get premium subsidies, and the after-subsidy rate changes can be much different):
- Ambetter/Celtic: Average increase of 4.53 percent (the initially proposed rate increase was 8.56 percent)
- Anthem (Matthew Thornton): Average decrease of 2.39 percent (the initially proposed rate change was a 2.5 percent increase)
- Harvard Pilgrim: Average decrease of 4.32 percent
At ACA Signups, Charles Gaba calculated a weighted average rate decrease of 0.8 percent for 2020 in New Hampshire’s individual market (again, keeping in mind that this applies to full-price premiums; net rate changes for people who get premium subsidies can be much different).
The New Hampshire Insurance Department created an at-a-glance resource showing which hospitals are in-network with each of the insurers that offer plans in the exchange for 2020, as well as a side-by-side comparison of the benefits offered by each plan.
The cost of cost-sharing reductions (CSR) has been added to silver plan rates in New Hampshire, as was the case in 2018 and 2019. 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.
For perspective, here’s a look at how average premiums have changed in New Hampshire’s exchange over the years:
- In 2014, premiums were essentially actuaries’ best guesses, since there was no market experience on which to base them. The ACA had drastically reformed the individual market, enhancing coverage requirements and eliminating medical underwriting, which was previously the most significant factor in keeping premiums fairly low in the individual market.
- For 2015, average premiums decreased in New Hampshire, due in large part to the fact that the exchange went from having just one insurer in 2014 to having five in 2015. 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. 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 was the largest in the nation, and the bronze drop was second only to Mississippi.
- For 2016, there were still five insurers, although Ambetter (Celtic) was new to the exchange and Time/Assurant exited the market. Average rate changes were fairly modest, ranging from a decrease of about 2 percent for some of Harvard Pilgrim’s plans to an increase of more than 16 percent for some Community Health Options plans. Before rates were finalized in New Hampshire, the worst-case scenario rate increase based on proposed rates was 18.5 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 was 5.1 percent more expensive in 2016 than it was in 2015.
- For 2017, there were four insurers offering plans in New Hampshire’s exchanges. Average rates increased by 8.8 percent in 2017, ranging from an average of just 1.35 percent for Ambetter/Celtic, to an average increase of nearly 14 percent for Anthem (Matthew Thornton Health Plan). Minuteman Health (an ACA-created CO-OP) had initially proposed rate hikes that ranged from 18 to 60 percent, but ended up with an average rate hike of just 4.2 percent, resulting in the lowest-priced plans in the exchange at all metal levels.
- In 2018, Minuteman Health was no longer offering coverage in New Hampshire. The three remaining insurers implemented significant rate increases, but that was due in large part to the fact that the Trump Administration had stopped reimbursing insurers for the cost of cost-sharing reductions (CSR), so insurers added that cost to silver plan rates starting in 2018 (details below). Ambetter’s average rate increase for 2018 was 18.4 percent, Anthem’s was nearly 49 percent, and Harvard Pilgrim’s was nearly 46 percent.
- For 2019, insurers in New Hampshire proposed average rate decreases, 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.But all three insurers indicated in their filings that they expected the health of their risk pools to deteriorate as a result of the repeal of the individual mandate penalty. Anthem’s filing also noted that the risk pool was expected to deteriorate due to “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; their expansion is not as robust in New Hampshire as it has been in some other states). So although rates dropped in New Hampshire in 2019, they would have declined even more if the individual mandate penalty hadn’t been repealed, and if the Trump Administration hadn’t expanded access to short-term plans and association health plans.
Medicaid expansion enrollees used private exchange plans through 2018, but NH switched 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 were likely due in large part to the fact that the state changed the way Medicaid expansion is handled. Through the end of 2018, New Hampshire used 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 directed 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.
The new Medicaid expansion program in New Hampshire is called the Granite Advantage Health Care Program, and it took effect in January 2019. [The Granite Advantage program has a Medicaid work requirement, which was already approved by CMS under the terms of a separate waiver, and also took effect in January 2019. The work requirement was challenged in court and overturned in July 2019, the same month that the state enacted legislation to modify the work requirement. The work requirement is currently not in effect, pending appeal of the court’s ruling.]
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.
Enrollment in New Hampshire’s exchange increased from 2014 to 2016, but has since declined
During the open enrollment period for 2019 coverage, 44,581 people enrolled in private plans through the New Hampshire exchange. That was about 10 percent lower than the 49,573 people who enrolled in coverage during open enrollment the year before, for 2018 plans.
By February 2019, New Hampshire’s monthly enrollment report indicated that just over 43,000 people had coverage in individual market plans through the state’s exchange. In addition, 1,257 people had coverage under small business (SHOP) plans offered by Anthem in New Hampshire (New Hampshire is one of just 12 states that use HealthCare.gov where there are still SHOP-certified plans available in 2019; HealthCare.gov no longer operates a SHOP enrollment platform, so small businesses in New Hampshire enroll directly with Anthem).
As is the case in many states that use HealthCare.gov, enrollment in New Hampshire’s exchange peaked in 2016, and has declined each year since then. For 2020, enrollment is higher than it was in 2014, but lower than it’s been in any other year since then — although the decline from 2019 to 2020 was minuscule, with enrollment essentially holding steady in 2020. Here’s an overview of enrollment since the exchange began operating in 2014:
- 40,262 people enrolled for 2014 (this greatly exceeded CMS projections).
- 53,005 people enrolled for 2015.
- 55,183 people enrolled for 2016.
- 53,024 people enrolled for 2017.
- 49,573 people enrolled for 2018.
- 44,581 people enrolled for 2019.
- 44,412 people enrolled for 2020.
[These numbers do not include Medicaid members who were enrolled in private plans via New Hampshire’s Premium Assistance Program (PAP) prior to 2019; PAP enrollees were in the same qualified health plans as other enrollees, but the policies were funded by Medicaid.]
Enrollment in states that use HealthCare.gov has dropped for a variety of reasons since 2016:
- The Trump Administration has sharply reduced funding for exchange marketing and enrollment assistance.
- The individual mandate penalty has been eliminated.
- The rules have been relaxed for short-term plans and association health plans, making them more attractive as an alternative for healthy enrollees.
- Premiums have grown considerably, making coverage less affordable for those who don’t get premium subsidies (much of the rate increases can be attributed to GOP efforts to sabotage the ACA and the fact that the Trump Administration cut off funding for cost-sharing reductions in 2017 — although that has also resulted in larger premium subsidies, which benefit the majority of enrollees).
Enrollment outside the exchange is not tracked as closely as exchange enrollment. But 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.
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 were 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 (they opted to focus entirely on Maine instead, and exited the New Hampshire market at the end of 2016), 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. They had intended to reopen as a new, for-profit insurer in 2018, but did not raise enough capital to make that possible. 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).
So for 2018, plans were available in the New Hampshire exchange from Anthem, Ambetter, and Harvard Pilgrim. All three insurers are continuing to participate in the exchange in 2019, with significant rate decreases.
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), and continued to do so for 2019. CSR benefits are still available to all eligible enrollees 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.
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 made non-silver plans more affordable for enrollees who are subsidy eligible. And although there was an overall rate decrease in New Hampshire in 2019, silver plan rates are still disproportionately expensive, making after-subsidy premiums more affordable than they were in 2017.
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 could get a plan for $99/month, after a $993/month premium subsidy is applied. The premiums for the bronze plans had increased, but the premium subsidies grew by an even larger margin, making the bronze plan more affordable than it was in 2017. And although average premiums dropped in 2019, this couple would still qualify for a premium subsidy of $785/month, and could get an even lower-priced plan, with an after-subsidy premium of just $62 for the lowest-cost bronze plan in 2019 (this illustrates the interaction between unsubsidized premiums and subsidies; although the total subsidy amount is lower in 2019, there’s a lower-priced plan available for sale and it ends up with a lower net premium despite the smaller subsidy amount).
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 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 gold plans less expensive than silver plans, and resulting in some bargains on both bronze and gold plans after premium subsidies are applied.
Unique Medicaid expansion began mid-2014, but transitioned to Medicaid managed care (with a work requirement) as of 2019
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).
Medicaid expansion in New Hampshire was a contentious issue, but ultimately then-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 of years, the program operated in much the same fashion as it did in other Medicaid expansion states, with the state using federal Medicaid funds to provide New Hampshire Health Protection Program coverage to residents with incomes below 139 percent of poverty.
But starting in January 2016, the state transitioned the NH Health Protection Program’s participants to subsidized, private coverage (dubbed the Premium Assistance Program). As described above, New Hampshire abandoned that plan at the end of 2018, and switched to a Medicaid managed care model (the Granite Advantage Health Care Program) with a work requirement.
Grandmothered plans can exist only until the end of 2020 in New Hampshire (regardless of future federal extensions)
In 2019, CMS issued yet another extension for transitional (grandmothered) plans, allowing them to renew as late as October 2020, and remain in force until as late as December 31, 2020. 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 2020, but only if the plans are renewed by January 1, 2020. This is different from the requirements in most states, since transitional plans will not be allowed to renew in New Hampshire through October 2020; instead, the renewals will have to be complete by January 1, 2020 (New Hampshire adopted this approach a few years ago, so it’s likely that the remaining grandmothered plans in the state are already on a calendar-year schedule).
And after several years of going along with annual extensions from CMS, New Hampshire has drawn a line in the sand. The Insurance Department clarified in April 2019 (see page 21) that they would allow grandmothered plans to renew again for 2020, but not after that — even if CMS grants additional renewal allowances for future years. The guidance from the NH Insurance Department notes that when grandmothered plans renew for 2020, insurers must inform policyholder that renewal will not be available for 2021, and that transition to an ACA-compliant plan will be necessary in order to maintain coverage after the end of 2021.
People who have grandmothered health plans were healthy enough to qualify for medically underwritten coverage between 2010 and 2013, and have opted to keep that coverage ever since. There have long been concerns that segmenting this population in a separate risk pool (ie, plans that are not fully compliant with the ACA) harms the ACA-compliant risk pool, since the grandmothered plan population was fairly healthy. That may still be the case, although the underwriting on those policies is several years old now. Some states opted to not allow grandmothered plans in the first place, and a few states only allowed them for a year or two. But there has also been a natural decline in enrollment in grandmothered plans, since people have been able to leave those plans over the years, but no new enrollees have been able to purchase coverage under those plans since 2013.
Legislation and exchange history
The exchange creation process in New Hampshire was a legislative battle. In February 2013, then-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 had no real impact however, because the IRS (a federal agency, not under state control) was responsible for assessing the ACA’s penalties, and because the ACA is a federal law that cannot be superseded by state law (the federal penalty was eliminated after the end of 2018; people who are uninsured in 2019 and beyond are no longer subject to a penalty).
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 held monthly meetings from 2012 through 2015, 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.