Highlights and updates
- Presbyterian files to re-join exchange in 2019
- Proposed average rate changes for 2019
- Molina may exit individual market due to loss of Medicaid managed care contract
- Rates were lower than average in 2017, but increased sharply for 2018
- 2018 enrollment almost 9% lower than 2017
- Insurance market stability task force is considering auto-enrollment
- Lawmakers request data on potential cost of Medicaid buy-in program in NM
- Cost of CSR added to silver plans
- BCBSNM added cost of Native American CSR to all plans
- For most enrollees, larger premium subsidies offset the rate hikes
- In some areas, 2018 subsidies were larger for people who enrolled early
- NM Health Connections CO-OP partners with Evolent for group insurance
New Mexico exchange overview
New Mexico has a state-run exchange, beWellnm (also referred to as NMHIX, or the New Mexico Health Insurance Exchange), but they use the federal enrollment platform at HealthCare.gov for individual enrollments. For small businesses, New Mexico has its own SHOP exchange enrollment platform.
In August 2016, the New Mexico Health Insurance Exchange appointed Linda Wedeen as interim CEO to replace Amy Doud, who resigned after two years as CEO to take a position with Molina Healthcare. After conducting a search for a new permanent CEO, the exchange hired Cheryl Smith Gardner, who took over as CEO in March 2017. Gardner was formerly the director of the exchange in Arkansas.
Looking ahead to 2019: Average proposed rate changes, and Presbyterian planning to rejoin the exchange
Rate filings were due in New Mexico by June 10, 2018, for insurers that wish to offer individual market plans in 2019. Insurers that offer on-exchange coverage have been instructed by the New Mexico Office of the Superintendent of Insurance (NMOSI) to add the cost of cost-sharing reductions (CSR) only to on-exchange silver plans and the identical versions of those plans offered off-exchange (different silver plans offered only off-exchange will not have the cost of CSR added to their premiums).
All four insurers that currently offer exchange plans in New Mexico have filed rates and forms for continued on-exchange plans in 2019. In addition, Presbyterian Health Plan, which exited the New Mexico exchange after the end of 2016 (details below), has filed rates for on-exchange plans in 2019. Presbyterian plans were only available off-exchange in New Mexico in 2017 and 2018, but the insurer anticipates having both on- and off-exchange plans available in 2019.
As noted below, Molina has threatened a possible exit of the individual market in New Mexico due to the impending loss of their Medicaid managed care contract. I spoke with the NMOSI about this issue, and although they said that they do expect Molina to participate in the exchange for 2019, the situation is still up in the air (Molina has protested their loss in the Medicaid bidding process, but the state has rejected that protest). Molina has filed on- and off-exchange plans — with a proposed reduction in rates — for 2019. But that does not bind them to participate in the individual market next year, as they could opt to withdraw those filings later in the summer.
Insurers have filed the following proposed average rate changes, which are now being reviewed by the New Mexico Office of the Superintendent of Insurance:
- Molina: decrease of 0.4 percent (25,045 members)
- Christus: 14.9 percent (2,298 members). Of that rate increase, 6 percentage points are due to “less tangible items, including non-enforcement of the individual mandate and reduced advertising and outreach.” In other words, the rate increase proposal would be single-digit if the individual mandate penalty weren’t going away, and if the Trump Administration hadn’t sharply reduced funding for exchange outreach and marketing.
- New Mexico Health Connections: 14.54 percent (17,884 members)
- Blue Cross Blue Shield of New Mexico (part of Illinois-based non-profit Health Care Service Corporation): 9.2 percent (3,582 members)
- Presbyterian Health Plan: 18.5 percent (20,288 members, all off-exchange in 2018). Presbyterian’s rate filing notes that part of the proposed rate increase is an adjustment to account for the fact that they’ll be “serving a significantly different population” in 2019 (ie, on-exchange) in addition to their current off-exchange members. When Presbyterian pulled out of the exchange at the end of 2016, they noted that their on-exchange enrollees had been incurring claims costs that were 30 percent higher than their off-exchange members.
Molina has threatened to leave at year-end over Medicaid contract non-renewal
There are four insurers offering individual market plans statewide in the New Mexico exchange for 2018 — all four also offered coverage in 2017 — which makes the exchange more robust than those in many other states (although there are states with far more than four participating insurers, participation in generally localized rather than state-wide, so some areas of those states end up with very limited choice of plans).
This is a direct result of New Mexico’s decision to require participating insurers to offer at least one plan statewide at each metal level where the insurer wants to offer plans (silver and gold plans are required by the ACA; insurers can choose to offer more metal levels than that if they wish, but in New Mexico, insurers must ensure that there’s at least one statewide plan at each metal level). New Mexico also requires all exchange plans to be offered off-exchange.
And for 2019, five insurers have filed rates and plans for exchange participation.
But one of them might still be on the fence. Molina has threatened to exit New Mexico altogether at the end of 2018, including the exchange market. Molina is one of the four insurers that currently provides Medicaid managed care services in New Mexico — and is currently the largest Medicaid managed care plan in the state — but their contract was not renewed for 2019 (UnitedHealthcare’s contract also was not renewed, but they don’t offer exchange plans in New Mexico). Molina and United filed a lawsuit when the contract wasn’t renewed, alleging that there was a conflict of interest in the selection process for new Medicaid managed care insurers, but the suit was thrown out the following week.
All four of the insurers that lost the bidding process — Molina, UnitedHealthcare, WellCare of New Mexico, and AmeriHealth Caritas New Mexico — appealed the state’s decision to deny them Medicaid managed care contracts, alleging a conflict of interest in the contracting process and the state’s failure to justify reducing the number of Medicaid managed care insurers from four to three. The state rejected the insurers’ protest in May 2018, opening the door for the insurers to take the matter to district court.
Molina noted that their Medicaid managed care business in New Mexico is the “most significant portion” of their overall business in the state, and indicated that without the Medicaid managed care contract, they would have little incentive to continue to offer private plans in New Mexico. But they have filed
Subsidies differ depending on when people enrolled for 2018
In November 2017, for the first 18 days of open enrollment for 2018 coverage, CHRISTUS plans didn’t show up on HealthCare.gov. This was apparently due to the fact that the final rates didn’t account for the lack of CSR funding, and were thus suppressed by the federal exchange (the situation is outlined here, but as noted below, the revised rate filing that CHRISTUS submitted in September included the cost of CSR added to premiums and the assumption that CSR funding would not continue in 2018, so it’s unclear why there was a problem with the rates).
CHRISTUS plans became available on HealthCare.gov on November 18, more than two weeks after the start of open enrollment. And in some areas of the state, the newly-available CHRISTUS plans took over the second-lowest-cost silver (benchmark) spot, with lower prices than the plan that had held the benchmark spot for the first couple weeks of open enrollment. This was important, because premium subsidies are based on the cost of the benchmark plan, and are designed to make that plan affordable — if the benchmark plan suddenly becomes less expensive, the subsidies for everyone in that area (regardless of what plan they choose) will decline commensurately.
People who enrolled in early November while the CHRISTUS plans were suppressed were able to keep the premium subsidies that they qualified for when they enrolled, and that’s what will show up on their Form 1095-A for 2018 (which they’ll receive in early 2019). People who enrolled after the CHRISTUS plans were unsuppressed are getting smaller premium subsidies in some areas (since the benchmark plan in some areas is now less expensive) and those lower subsidy amounts will show up on their Forms 1095-A. So two people in the same area could have different subsidy amounts, depending on when they enrolled, and those subsidy amounts will remain in effect throughout the year.
CMS confirmed that this bulletin (see question 7) from 2016 is still applicable to this situation. They also confirmed that New Mexico is the only HealthCare.gov state that had suppressed plans at the start of the current enrollment period, with only CHRISTUS plans suppressed.
2018 enrollment, and a task force to address market stability
49,792 people enrolled in individual market plans through the New Mexico exchange during the open enrollment period for 2018 coverage, which lasted just over six weeks (November 1, 2017 to December 15, 2017). This was half the length of previous open enrollment periods, and enrollment was almost 9 percent lower than the 54,653 people who had signed up the year before.
Senate Memorial 7 received unanimous support in the New Mexico Senate in early 2018, and directed the state to establish a Health Insurance Market Stability Task Force. The task force is being jointly run by Health Action NM and the NM Office of the Superintendent of Insurance, and will report to the legislature by November 1, 2018.
SM7 notes that the NM Office of the Superintendent of Insurance has estimated that for every 1 percent increase in premiums, 200 people will drop out of the individual market in the state (and it’s noted that this is a conservative estimate). SM7 directs the task force to consider alternatives to the ACA’s individual mandate (which will be eliminated after 2018, under the terms of the GOP tax bill that was enacted in late 2017), including the possibility of auto-enrolling subsidy-eligible uninsured residents into zero-cost or low-cost plans.
Lawmakers request cost analysis of Medicaid buy-in program
Lawmakers in New Mexico passed two legislative memorials in February 2018 (SM3 and HM9) that call for a cost analysis of a Medicaid buy-in program in New Mexico. The idea is to determine the costs, along with pros and cons, of allowing New Mexico residents who aren’t eligible for Medicaid to purchase Medicaid if they choose to do so.
Nevada lawmakers passed a bill in 2017 that would have allowed for Medicaid buy-in, but Governor Brian Sandoval vetoed it. So far, there are no states that have established Medicaid buy-in programs, but U.S. Representative, Ben Ray Lujan, who represents New Mexico’s 3rd Congressional District in the U.S. House, believes New Mexico should be a trailblazer in terms of implementing a Medicaid buy-in program. And Representative Michelle Lujan Grisham, who also represents New Mexico in the U.S. House and who is leading the state’s Gubernatorial race in 2018, introduced legislation at the federal level in 2017 that would have allowed people to buy into Medicaid.
The New Mexico legislature has only just begun the process of compiling data about a potential Medicaid buy-in program. If lawmakers were to ultimately decide to open up Medicaid in New Mexico for purchase by anyone in the state, a federal waiver would also be required. But New Mexico is a state to watch in terms of new innovations in the health care reform sphere.
2018 rates and plans: CSR cost added to silver plans; BCBS also added Native American CSR cost to all plans
All four insurers in the New Mexico exchange continued to offer plans for 2018. New Mexico is one of very few states where there are three or more insurers offering exchange plans in every county for 2018.
Insurers in New Mexico were allowed to file two sets of 2018 rates, to accommodate the uncertainty that the Trump Administration created in the individual market. Of great concern to insurers — and playing a significant role in rate increases for 2018 — was the long-term funding for the ACA’s cost-sharing reductions (CSR).
The rate filings were made public in July 2017 on New Mexico’s Office of the Superintendent of Insurance (NM OSI) website and on SERFF. By September, the insurers in New Mexico had all assumed that CSR funding would end, and had officially added the cost of CSR to silver plan premiums for 2018. The Trump Administration ultimately did terminate CSR funding on October 12.
The cost of CSR was added to premiums for silver exchange plans and the mirrored off-exchange versions of those silver plans, but NM OSI confirmed that there are also silver plans available in New Mexico for 2018 that are only sold outside the exchange, and thus do not have the cost of CSR added to their premiums. The off-exchange-only plans would be a suitable choice for an enrollee who wants a silver plan but whose income is too high to qualify for premium subsidies in the exchange (the cut-off for subsidy eligibility is $48,240 for a single person in 2018, and $98,400 for a family of four). And the fact that the cost of CSR was added to silver plans resulted in larger premium subsidies for all subsidy-eligible enrollees in 2018, since the subsidies are based on the cost of silver plans.
Although the cost of CSR was added only to silver plan premiums, NM OSI also confirmed that Blue Cross Blue Shield of New Mexico also added the cost of Native American cost-sharing reductions to all plans for 2018 (Native Americans can purchase $0 cost-sharing plans if their income doesn’t exceed 300 percent of the poverty level). NM OSI noted that the cost of Native American CSR only added about 0.5 percent to 2 percent to the overall premiums for 2018, and the other three insurers didn’t account for it in their rate filings. Essentially, BCBSNM was concerned that the potential elimination of CSR funding would include elimination of Native American CSR funding, so they added that cost to their 2018 premiums as well.
I’m not aware of insurers in other states that added this cost of Native American CSR to their rates for 2018 either, but CMS confirmed in November that all CSR funding had ended, including funding for the enhanced benefits for Native Americans. Although it’s a much smaller total cost to insurers than regular CSR, insurers that didn’t add the cost of Native American CSR to their 2018 premiums are having to absorb the cost of enhanced benefits for Native Americans, while BCBSNM baked that cost into their premiums.
The following average rate increases were approved by New Mexico regulators (the approved average increases are in bold font, with previously-proposed average increases crossed out):
- Blue Cross Blue Shield of New Mexico (part of Illinois-based non-profit Health Care Service Corporation):
26.5 percent26.1 percent (2,114 members as of 2017)
- New Mexico Health Connections (a non-profit ACA-created CO-OP):
30.1 percent28.2 percent. According to a filing submitted in early September, NMHC proposed a 28.2 percent overall average increase, but 48 percent for the Care Connect Silver plan, which is NMHC’s only silver plan offered on the exchange. The larger increase for the silver plan is due to the assumption that CSR funding will not continue in 2018. This proposed rate increase is substantially lower than the 84 percent increase that New Mexico Health Connections initially filed, and that one was based on the assumption that CSR funding would continue. New Mexico Health Connections explained that once they found out that all of the state’s insurers would be remaining in the marketplace, they were able to refile with a smaller proposed rate increase.
- Molina (a for-profit insurer)
21.2 percent56.6 percent (29,928 members). The earlier rate filing was based on the assumption that CSR funding would continue, whereas the much larger average increase (ultimately approved for 2018) was based on the assumption that CSR funding would end. In the revised filing, Molina notes that the average rate increase for bronze plans is 25.6 percent, and for gold plans, is 21.4 percent. But for silver plans, it’s a whopping 69.6 percent, driving the overall average increase sharply higher.
- Christus (a Texas-based non-profit): 49.2 percent (revised filing submitted in early September was based on the assumption that CSR funding would not continue in 2018. The initial rate filing for Christus did not mention CSR funding, but noted, however, that 9 percentage points of the proposed increase were due to “less tangible items, including non-enforcement of the individual mandate, and reduced advertising and outreach”)
When considering New Mexico insurers’ rate changes for 2018, it’s important to keep in mind that New Mexico’s 2017 premiums were well below the national average. Across the 34 states that use the federally-facilitated exchange, average pre-subsidy premiums were $476/month in 2017. In contrast, New Mexico’s average pre-subsidy premiums were just $366/month. So it would have taken a 30 percent average rate increase in New Mexico — with all other states seeing no rate change at all, which is definitely not what happened — just for New Mexico to catch up with the national average.
It’s also important to keep in mind that premium subsidies under the ACA grow to keep pace with rate increases. 73 percent of New Mexico exchange enrollees were receiving premium subsidies in 2017, and those subsidies are larger in 2018 to offset the higher premiums, protecting enrollees from the brunt of the rate hikes.
Robert Hickey, CEO of New Mexico Health Connections, noted in February 2017 that premium increases for 2018 were very much up in the air, and would depend in large part on regulations and legislation handed down by the federal government. At that point, he gave a ballpark range of 7 percent to 40 percent in terms of how much premiums could increase, with the lower end being possible only if measures to stabilize the markets are implemented. HHS did finalize new rules intended to stabilize the markets in April 2017, but the lack of commitment for CSR funding (and the eventual elimination of that funding altogether) and the Trump Administration’s relentless focus on repealing — as opposed to improving — the ACA both had a deleterious effect on the stability of the individual health insurance market. The result was sharply higher premiums for 2018, but also much large premium subsidies that keep coverage affordable for most exchange enrollees.
NM Health Connections CO-OP partners with Evolent Health for employer-sponsored plans
New Mexico Health Connections (NMHC), one of the four carriers offering plans for 2018 in the New Mexico exchange, is a CO-OP (consumer oriented and operated plan) established with funding provided by the ACA. Of the 23 CO-OPs that began selling plans in the fall of 2013, only four are still operational as of 2018 — New Mexico Health Connections is among them.
But the CO-OP has struggled with losses: Axios reports that NMHC lost $23 million in 2015, and $17.9 million in 2017.
In September 2017, NMHC announced that pending regulatory approval, they were entering a partnership with Virginia-based Evolent Health. Evolent announced in early January 2018 that the partnership had been finalized. Evolent has created a new for-profit subsidiary, True Health New Mexico, which is covering the roughly 20,000 enrollees who previously had coverage under NMHC’s employer-sponsored plans. NMHC continues to be a non-profit, and is now focused entirely on the individual market, where they had about 18,000 enrollees in 2017.
The partnership will allow the new insurer to offer coverage in market segments — including Medicare Advantage and Medicaid — where CO-OPs aren’t allowed to operate. NMHC CEO, Martin Hickey, and the rest of the NMHC employees transitioned to True Health New Mexico at the start of 2018. Hickey is now the CEO of True Health New Mexico.
Evolent paid $10.25 million to acquire NMHC’s commercial insurance membership, and True Health New Mexico — the subsidiary of Evolent that was created in New Mexico — will establish an administrative services agreement that will allow them to support NMHC’s ongoing operations in the individual market, while letting NMHC continue to be an independent non-profit.
A significant factor in NHMC’s losses has been the ACA’s risk adjustment program, which many insurers have alleged is designed in a way that benefits large insurers and harms smaller and newer insurers.
In June 2016, HHS announced the results of the 2015 risk adjustment program; NMHC had to pay $14.6 million to HHS. Shortly after the risk adjustment numbers were published, the CO-OPs in Connecticut and Oregon announced their impending closures due to the financial peril that the risk adjustment payments would impose. New Mexico Health Connections is one of several health insurers that have filed lawsuits against the federal government over the risk adjustment program, and the CO-OP has noted that changes to the program would be needed going forward in order for NM Health Connections to continue to be profitable.
For the 2016 risk adjustment program, NMHC expected to receive $7 million, according to Axios, but ended up having to pay $8.8 million instead (based on the CMS report in mid-2017). And this was after they only had $14 million in capital as of March 2017.
By March 2015, total enrollment in NM Health Connections had reached nearly 40,000, including on and off-exchange enrollments. And by February 2016, enrollment had grown to more than 50,000 members, and the CO-OP had added several big-name employers, including Goodwill Industries of New Mexico, Youth Development Inc., and Heritage Hotels & Resorts.
In 2014, New Mexico Health Connections had a medical loss ratio of 78 percent (the portion of premiums that are spent on medical claims). The ACA requires insurers in the individual and small group markets to spend at least 80 percent of premiums on medical expenses, but the CO-OPs have three years to reach that target. Once admin expenses were included, the CO-OP ended up with a net loss of $4.2 million in 2014. All but three other CO-OPs had significantly higher losses in 2014.
At the start of the 2016 open enrollment period, Hickey described how NM Health Connections was “in excellent shape” financially.
But Hickey also noted in 2015 that healthcare cost increases are far outpacing inflation, and that premiums and out-of-pocket costs will continue to increase (for all carriers) until we get a handle on healthcare costs. For 2016, New Mexico Health Connections opted to drop their PPO plans in order to focus on HMO plans that allow the carrier to better control costs. Hickey has pointed out that NM Health Connections is the only CO-OP that has contracted directly with providers from the get-go, avoiding the need to rent another carrier’s network.
Another key aspect of NM Health Connection’s ability to stay afloat in 2016 was that they weren’t counting on significant risk corridor payments from the federal government at the end of 2015. Eight CO-OPs (in Colorado, Kentucky, Tennessee, Oregon, Arizona, South Carolina, Utah, and Michigan) failed in the wake of the 2014 risk corridor shortfall.
A technical glitch delayed the inclusion of New Mexico Health Connection’s plans on Healthcare.gov for the first two weeks of the 2016 open enrollment period. Consumers were able to begin purchasing 2016 coverage on November 1, 2015, but NM Health Connections plans didn’t show up on the exchange until November 15. During the first two weeks of November, 2016 coverage could be purchased directly from NM Health Connections — but subsidies are not available when plans are purchased outside the exchange.
Despite the delayed quoting, NM Health Connections expected to grow their membership significantly during the 2016 open enrollment period, and noted that they were poised to enroll many of BCBSNM’s insureds whose plans terminated at the end of 2015 (see details below). Total enrollment by February 2016 had grown to more than 50,000 members, including individual, small group, and large group membership. By that point, there were about 1,300 employer groups — both large and small — in New Mexico that had coverage through the exchange. A total of about 15,000 people were covered under those employer group plans.
As of the end of the first quarter of 2016, total actual enrollment in New Mexico Health Connections stood at 46,135, including both individual and group enrollees. NPR reported in early 2017 that the CO-OP’s enrollment stood at around 45,000.
54,653 people enrolled in coverage through the New Mexico exchange during the 2017 open enrollment period. That was just slightly lower than the 54,865 people who had enrolled the year before.
Across all states that use HealthCare.gov, there was a more substantial decrease in enrollment year over year, due in part to rising premiums, uncertainty about the future of the law under the Trump Administration, and the Administration’s choice to cut back on advertising and outreach in the final week of open enrollment.
HHS has estimated that there are 8,000 people with off-exchange coverage in New Mexico (ie, purchased directly from the insurance companies, rather than through the exchange) who would be eligible for subsidies if they switched to the exchange instead.
Open enrollment for 2017 has ended, but people can still enroll if they experience a qualifying event. HHS has proposed tighter rules around special enrollment periods, so applicants should be prepared to provide proof of qualifying events at the time of enrollment.
Legislation to move people from high-risk pool to exchange; didn’t pass in 2017
There are still 2,771 people in New Mexico enrolled in the state’s high-risk pool. Most of them are eligible for coverage in the exchange, but the high-risk pool has remained operational (unlike those in many other states that closed after guaranteed-issue coverage became available in the exchanges). The high-risk pool, called New Mexico Medical Insurance Pool, includes discounted rates for people with low incomes.
New Mexico H.B.316, introduced in January 2017, would end eligibility for anyone who could otherwise purchase subsidized coverage in the New Mexico exchange. However, the bill did not move forward during the 2017 legislative session, which ended in mid-March.
Under the MacArthur Amendment to the ACHA (the late-April amendment that garnered support from the House Freedom Caucus), medical underwriting in the individual market could be reintroduce in states that request it via waiver, although the states would have to take steps to ensure that there would be adequate coverage available for people with pre-existing conditions. This could involve maintaining a high-risk pool, although there are other alternatives as well. In states like New Mexico that have maintained their high-risk pools, it would be a workable option. However, some states — particularly those that have embraced the ACA — would be less likely to seek waivers to roll back ACA protections.
2017: Presbyterian exited exchange, BCBS returned (Presbyterian will return in 2019)
Presbyterian Health Plan was one of the four carriers that offered plans in the New Mexico exchange in 2016. They filed rates in May 2016 for 2017 coverage, but announced in July that they would transition to only offering off-exchange coverage in 2017. The carrier noted that their on-exchange enrollees were incurring 30 percent more claims than their off-exchange enrollees. Since the pricing has to be the same for the same plan sold on and off-exchange, Presbyterian determined that their on-exchange business was not sustainable.
There were about 10,000 on-exchange Presbyterian enrollees in New Mexico in 2016, and about 80 percent of them were receiving subsidies. In order to keep their subsidies in 2017, they needed to switch to a different carrier during open enrollment. HealthCare.gov used automatic re-enrollment for the first time for 2017 coverage for enrollees whose carriers exited the exchange at the end of 2016. But enrollees were able to log back onto HealthCare.gov during open enrollment to select a plan other than the one that the exchange picked on their behalf.
Blue Cross Blue Shield of New Mexico returned to the exchange after not participating in 2016. BCBS of NM continued to offer one off-exchange HMO plan in 2016, thus avoiding a full market exit and making it possible to rejoin the exchange for 2017. BCBS of NM requested an average rate increase of 83.1 percent for their HMO product, but later revised it to 93.2 percent and regulators approved the requested rate hike (the reason they exited the exchange at the end of 2015 was that state regulators would not approve their requested 51 percent rate increase; more details below).
BCBS of NM did not raise the rates on their remaining off-exchange HMO product for 2016, so the 93.2 percent rate increase is in relation to the 2015 rates. (small group plans have an average proposed rate increase of 20.6 percent).
Presbyterian only offered off-exchange plans in 2017 and 2018, but they have filed rates and plans to once again participate in the exchange starting in 2019. If approved by NMOSI, Presbyterian’s plans will be available when open enrollment starts on November 1, 2018.
2017 rates and plans
- Blue Cross Blue Shield of New Mexico (part of Illinois-based non-profit Health Care Service Corporation): 93.2 percent
- New Mexico Health Connections (a non-profit ACA-created CO-OP): 33.07 percent (31.7 percent average for Care Connect HMO, and 36.3 percent average for Health Connect HMO; CO-OPTIONS Connect HMO is a new product for 2017)
- Molina (a for-profit insurer) 24 percent
- Christus (a Texas-based non-profit): 15.7 percent
There were no PPO options in the New Mexico exchange in 2016, and that is still the case in 2017. But the Santa Fe New Mexican reports that there were only two health insurance companies offering individual coverage in New Mexico pre-ACA, so competition has increased in the state under the ACA. John Franchini, New Mexico Superintendent of Insurance, explains that in terms of access to coverage and plan choice, New Mexico is “in a much better place than we were four years ago. It’s getting better and better,”
Indeed, New Mexico is one of just nine states in the U.S. where residents in every county have at least three exchange carriers from which to choose in 2017.
The second-lowest-cost silver plan in each area is called the benchmark plan. Premiums for those plans are used to determine subsidies, so as benchmark premiums increase, subsidies also grow. In New Mexico, the average benchmark plan is 29 percent more expensive in 2017 than it was in 2016 (compared to an average of 22 percent across all 38 states that used HealthCare.gov in 2016).
But to keep that data in context, we have to note that New Mexico’s average benchmark premium was the lowest of all those 38 states in 2016, and even with the 29 percent average increase, New Mexico’s benchmark premiums are still among the lowest-priced in 2017. They average $224/month for a 27-year-old, versus an average of $296/month across all the states that use HealthCare.gov.
On May 31, 2016, the New Mexico Office of the Superintendent of Insurance opened up a public comment period for the rate filings that had been submitted for 2017. It ran through August. Consumers can view the proposed and approved rate changes here. (click on the “ready to begin, start here” link, and then use the default setting to see all plans; limit by date (April through September 2016) to see the filings for 2017.
Molina’s exchange enrollment grew from 3,300 in 2015 to 18,000 in 2016, and the carrier is expanding their workforce in Albuquerque to meet the growing demand (including off-exchange enrollments, Molina had more than 19,000 enrollees as of March 2016).
54,865 people enrolled in private plans through the New Mexico exchange during the 2016 open enrollment period, including renewals and new enrollees. That’s an increase of nearly five percent over the 52,358 people who enrolled during the 2015 open enrollment period, but it’s slightly short of HHS’ projection of 56,000 for the 2016 open enrollment period.
The New Mexico exchange enrollment growth for 2016 is more impressive when we consider the fact that half of the people who were enrolled through the exchange as of late 2015 were on Blue Cross Blue Shield of New Mexico plans that were discontinued at the end of the year (see details below). Some undoubtedly opted to go without insurance in 2016, and others might have purchased coverage outside the exchange or switched to the one remaining BCBSNM product still available (an off-exchange HMO). But clearly, a significant number of them opted to remain with the exchange and switch to a different carrier.
Effectuated enrollment in the New Mexico exchange stood at 47,497 as of March 31.
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 is 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.
60% of uninsured eligible for financial assistance in 2016
In New Mexico, there were still 233,000 uninsured residents in 2015. According to Kaiser Family Foundation data, 47 percent of them were eligible for Medicaid (New Mexico expanded Medicaid under the ACA, and coverage is available for people with household income up to 138 percent of the poverty level). And 13 percent were eligible for premium subsidies in the exchange. As of mid-2015, the New Mexico exchange had just 44,307 people enrolled in private plans, and enrollment grew to nearly 55,000 by the end of the 2016 open enrollment period, thanks in part to the exchange’s outreach efforts to enroll a significant number of the remaining uninsured population.
According to Gallup data, New Mexico’s uninsured rate in 2013 was 20.2 percent, and had declined to 13.1 percent by the first half of 2015. This is quite a bit higher than the average for all states that established their own exchanges and expanded Medicaid (New Mexico did both, although their exchange is now operating as a federally-supported state-based exchange).
BCBS didn’t offer plans in the exchange in 2016, but returned for 2017
In the summer of 2015, Blue Cross and Blue Shield of New Mexico filed a proposal to increase premiums for 2016 by an average of 51.6 percent. The announcement generated headlines nationwide, standing out even among some of the relatively steep rate increases proposed in other states. BCBS garnered about a third of the market share in the New Mexico exchange in 2015, so their proposed rate increase would have had a significant impact on the market.
But in early August, the New Mexico Office of the Superintendent of Insurance (OSI) denied the proposed rate hike, stating that the data submitted with the rate proposal didn’t justify a rate increase of more than 24 percent. BCBS rejected the rate change offered by the state, but came back in the following days and submitted new rates that they claimed had an average rate increase of 11.3 percent. But the OSI has said that they don’t consider the secondary proposal to be a “real offer or realistic offer” and it was not accepted.
Including off-exchange business, BCBS insured about 35,000 people in 2015 in the individual market in New Mexico, and the carrier confirmed in late August that they would not be offering individual plans in the New Mexico exchange in 2016. BCBS has kept one individual off-exchange plan – a bronze level HMO – with rates unchanged from 2015. This avoided a full market exit, meaning that BCBS preserved their option to return to the individual market with additional plans in 2017, which they have decided to do. But the off-exchange bronze HMO plan had very few enrollees in 2015, so the vast majority of BCBS’s individual market insureds had to switch to new coverage for 2016 (it’s likely that many of them would have opted to find new coverage anyway, if the 51 percent rate increase had been approved, because the coverage would have become much less affordable). The carrier’s rate filing for 2017 indicates that they have 1,319 people enrolled in their HMO plan in 2016.
The individual market only comprised about ten percent of BCBS’s 2015 book of business in New Mexico. They proposed much smaller rate increases for their group market plans, and those were approved by OSI.
Lisa Reid, OSI’s director of life and health insurance, explained that BCBS had the lowest rates in the exchange in 2015, but they weren’t dramatically lower than their competitors. So their proposed 51 percent rate hike would have put their prices significantly above many of the other plans, most of which only imposed single-digit rate increases for 2016. For 2014, BCBS proposed rates so low that OSI required an increase before the plans could be approved for sale (similar to what Oregon regulators required for some plans going into 2016). And then in 2015, BCBS didn’t increase their overall weighted average rates at all (note that there were variations from one plan to another however; BCBS of NM had rate changes that varied from a 12.8 percent increase for their HMO plans to a 2.37 percent decrease for their MSPP).
Ultimately, they did end up with significant claims costs that would have justified the 24 percent average rate hike that OSI proposed – but OSI determined that the data presented by BCBS wasn’t sufficient to justify a 51 percent rate increase.
BCBS of NM did receive far more in reinsurance and risk adjustment payments than the other New Mexico carriers, based on 2014 claims. BCBS got nearly $25 million, while three other carriers – Presbyterian, Molina, and NM Health Connections – received a combined total of $11 million.
Whether or not OSI will approve BCBS of NM’s proposed rates for 2017 remains to be seen. Numerous carriers around the country have requested very significant rate increases for 2017, as reinsurance and risk corridors will end at the end of 2016, and providing coverage to the newly-insured population has proven to be more expensive than expected.
Average benchmark premium up 7%, NOT 25.8%
Overall, the average benchmark (second-lowest-cost Silver) plan in the New Mexico exchange is 7 percent more expensive in 2016 than in 2015. When HHS released a report in late October detailing average benchmark premiums in each of the states that use Healthcare.gov, they indicated that the average benchmark increase in New Mexico would be 25.8 percent. But because New Mexico Health Connections plans weren’t appearing in the quote system (due to the technical glitch that prevented their plans from displaying until mid-November), their rates weren’t taken into consideration when HHS analyzed the change in second-lowest-cost premium.
New Mexico was one of eight states where the HHS report indicated that the average benchmark premium would increase by more than 20 percent; the corrected change (just 7 percent) helps to make a small reduction in the national average benchmark premium increase. It also means that the average subsidy increases in 2016 were much more modest than they would have been if the original report had been correct, since subsidy amounts are based on the benchmark premiums.
Modest price hikes, but no PPOs available in 2016
The four remaining carriers in the exchange all said that they were ready to accept an influx of new enrollees switching off of BCBS plans. And all four of them proposed much smaller rate increases than BCBS for 2016:
- Presbyterian had asked for a 6 percent rate hike, and the approved rate change was between 3 and 6 percent.
- New Mexico Health Connections (an ACA-created CO-OP) rates increased between 4 and 17 percent, depending on the plan. The CO-OP ceased offering PPO plans in the individual market at the end of 2015, and is only offering HMO plans for 2016 (they are continuing to offer PPO plans in the group market). As explanation for their commitment to HMO’s, New Mexico Health Connections has noted that HMOs are lower-cost and make health insurance more affordable for more people. NM Health Connections had 1,900 members on PPO plans in 2015 (1,230 of them bought coverage through the exchange), and they had to switch to a different plan for 2016.
- Christus – no rate change for 2016.
- Molina didn’t ask for rate increases in their preliminary proposals; regulators ultimately approved a rate decrease of 2 percent.
None of the carriers in New Mexico’s exchange are offering any PPO options in the individual market for 2016. This is a trend nationwide, in an effort to keep premiums affordable. But it does mean that some insureds will have to switch doctors. In 2015, there were 22,000 BCBS of NM insureds who had a PPO option through the exchange; all of them had to select coverage from another insurer for 2016 in order to continue receiving coverage through the exchange (BCBS is keeping one off-exchange plan available, but it’s an HMO). And the CO-OP has also dropped its PPO plans for 2016.
Celtic entered New Mexico’s individual market for 2016, but is only selling off-exchange plans. Celtic is the only carrier in the state’s individual market that has a PPO option, but it’s only available off-exchange.
NM opts to stay with Healthcare.gov
New Mexico has a unique exchange; the state runs the small business portion, and while the individual exchange is also technically state-run, Healthcare.gov is used to enroll people in individual insurance (ie, a federally-supported state-based marketplace). Initially, the state had planned to establish a state-run website for individual enrollments, and that was still in the works until early spring 2015. But in April, the exchange board voted to continue to use Healthcare.gov, as that was viewed as the less-costly alternative.
New Mexico’s exchange had completed about 75 percent of their enrollment website when HHS changed the design guidelines in the fall of 2014. The exchange then applied for a $97 million federal grant to help pay for the website changes as well as other costs, but the grant was denied. Ultimately, it was decided that continuing to use Healthcare.gov would be the most fiscally responsible option.
But will fees make them reconsider that decision?
In the proposed Benefit and Payment Parameters for 2017 that HHS published in December 2015, HHS proposed a fee of 3 percent of premiums for states that run their own exchanges but use the Healthcare.gov enrollment platform starting in 2017 (the fee is 3.5 percent of premiums in states that have a federally-run exchange or a partnership exchange). Until 2017, these states have been using the Healthcare.gov platform for free, while funding and operating the rest of their exchange functions themselves.
Oregon and Nevada are both considering the possibility of switching back to being fully state-run exchanges in order to avoid the additional fees. Along with Oregon and Nevada, Hawaii and New Mexico are state-run exchanges that use Healthcare.gov’s enrollment technology.
When the final Benefit and Payment Parameters for 2017 were released in February 2016, HHS had agreed to cut the exchange user fee in half for the first year for state-based exchanges that use Healthcare.gov. For 2017 only, the user fee in those states will be 1.5 percent of premiums. After that, starting with the 2018 plan year, the user fee will be 3 percent for state-based exchanges that use Healthcare.gov.
2015 New Mexico exchange enrollment
By February 22, 2015, after the 2015 open enrollment period and extension had ended, 52,358 people in New Mexico had completed their private plan enrollments through the exchange, including 25,398 people who renewed 2014 coverage (4,542 of those individuals opted to switch to a new plan for 2015 rather than simply renewing their existing coverage). Of the 52,358 people who enrolled in private plans in the New Mexico exchange during open enrollment, 76 percent qualified for premium subsidies.
HHS had projected 43,000 enrollees in the New Mexico exchange by the end of open enrollment, but the state had already surpassed their official goal early in January (admittedly, the goals published by HHS were probably set on the low side for 2015, to avoid all of the hoopla we saw the year before in terms of reaching the stated target). Ultimately, the exchange ended up enrolling nearly 122 percent of their target amount.
Carriers in the NM exchange were predicting total 2015 enrollment of around 50,000 to 55,000 people, which ended up being very accurate. But the exchange itself avoided making any hard predictions for 2015 after falling far short of their goal in 2014. The exchange thought they’d enroll about 80,000 people for 2014, and ended up enrolling only about 34,000 – less than half of their target. Some of that was due to technical failures, but the predictions from carriers for 2015 indicates that perhaps the exchange set an unrealistic goal in 2014.
By the end of March 2015, effectuated enrollment in private plans stood at 44,085 people, as some enrollees didn’t pay their initial premiums, and others cancelled their coverage early in the year for one reason or another. Although attrition is to be expected, special enrollment periods mean that people can continue to enroll throughout the year if they have a qualifying event. Between February 23 and June 30, another 5,758 people enrolled in private plans through the New Mexico exchange. 458 of them enrolled during the tax season special enrollment period for people who were previously unaware of the tax penalty for being uninsured. By the end of June, in-force enrollments had grown slightly, to 44,307 people (nationwide, during the second quarter of the year, the trend was a decline in the number of people with in-force coverage, but New Mexico had a small increase instead).
Another 15,522 exchange enrollees in New Mexico were eligible for expanded Medicaid or CHIP between November 15, 2014 and February 22, 2015. Medicaid/CHIP enrollment continues year-round.
Lower 2015 rates and a new carrier
Sticker shock wasn’t a problem in New Mexico in 2015. Across the four carriers that participated in the exchange in 2014, the state announced in September 2014 that the weighted average premium change for 2015 would be a decrease of 1.65 percent. This was especially good news given that in 2014, the lowest cost bronze plan in the NM exchange averaged $217 a month, quite a bit lower than the national average of $249.
PricewaterhouseCoopers LLC conducted rate analysis across the entire individual market, including on and off-exchange plans. For New Mexico, the weighted average they found for all six carriers was an increase of 1.4 percent. But a Commonwealth Fund analysis of just the plans in the exchange found an average rate decrease of 1 percent. And for people who had the benchmark plan (second lowest-cost silver plan) in 2014, the price decrease for 2015 was even more pronounced.
Christus Health Plan also joined the exchange in 2015, bringing the total number of carriers to five. Christus joined Health Care Service Corporation (Blue Cross and Blue Shield of New Mexico), Molina Healthcare of New Mexico, New Mexico Health Connections and Presbyterian Health Plan. There were a total of more than 40 plans available through BeWellNM for 2015.
New leadership and marketing
The New Mexico exchange (NMHIX) is continuing to operate as a federally-supported state based marketplace, and is utilizing HealthCare.gov for individual plan enrollments. Small businesses use the state-run exchange portal.
In late August 2014, NMHIX hired CEO Amy Doud, who came to them from the Idaho exchange that she had run for 15 months (Idaho was a federally-supported state-based exchange in 2014, but became a fully state-run exchange in time for the 2015 open enrollment). Doud’s focus is on working with agents and brokers and promoting one-on-one assistance to drive up enrollment numbers, as much of Idaho’s success during the first open enrollment was attributed to their strong partnership with agents and brokers.
Just a few weeks before the start of the 2015 open enrollment period, NMHIX hired a new Director of Communications and Outreach. Linda Wedeen has three decades of experience in marketing and communications in New Mexico.
The exchange also hired additional enrollment counselors leading up to the 2015 open enrollment, and was particularly focused on recruiting enrollment counselors who would be able to reach out to the Native American population in the state.
New marketing and PR team
In the summer of 2013, NMHIX began working with Milwaukee-based marketing firm BVK to market and promote the exchange throughout the state. In July 2014, the exchange board unanimously voted to renew the BVK contract for $6.2 million. But in September, NMHIX Chair Dr. J.R. Damron expressed dissatisfaction with the marketing approach, and highlighted recent survey numbers that found the majority of uninsured adults in NM were unaware of the services the exchange provides, and even more had not heard about the exchange on various media sources.
The agreement with BVK was terminated and the marketing contract was put out for bidding in September 2014. In October, 18 firms submitted bids; 12 were local New Mexico companies. BVK did not bid for the new contract, but said it was committed to working with the new contractor for a smooth hand-off. The contract was ultimately awarded to Garrity Group PR in November 2014, along with K2MD.
The ACA’s subsidies
According to a report released by HHS in June 2014, the average after-subsidy premium in the New Mexico exchange was $120/month in 2014, significantly higher than the $82/month average across the 36 federally-facilitated marketplaces (FFM). And only 78% of New Mexico exchange enrollees received subsidies, compared with 87% across all of the FFMs.
The average after-subsidy premium in New Mexico was the fifth highest among the 36 FFMs, but NM Superintendent of Insurance John Franchini attributed that to one of the four carriers in the exchange charging premiums that were 20 to 25 percent higher than the other three carriers. He didn’t say which carrier it was, but noted that it was a carrier with which people were already familiar, and about a third of the enrollees picked that carrier’s plans, despite the higher premiums.
Since the tax credit subsidies are based on the cost of the second-lowest-price Silver plan, an outlier plan on the high end will mean higher average after-subsidy premiums if a significant number of people choose to apply their subsidy towards the high cost plan instead of selecting a less expensive policy. Franchini notes that even though $120/month is higher than the average in most of the other FFM states, it’s still far less expensive than people would have been paying prior to the implementation of Obamacare and the premium tax credits.
As of mid-2015, the average subsidy in the New Mexico exchange was $196/month – significantly smaller than the $270 national average. But the average pre-subsidy premiums were also lower in New Mexico: $323/month, as opposed to $364/month nationwide (as of the end of open enrollment; attrition throughout the year changes the averages). In March, the after-subsidy average premium in New Mexico was $127/month. Nationwide, it was $101/month.
Be Well New Mexico’s 2014 enrollment
By April 15, 2014, 34,966 people had completed their private plan selections through the New Mexico Exchange. This was roughly 11 percent of the eligible population, and was significantly lower than the state had projected.
An additional 30,147 exchange applicants were eligible for the state’s expanded Medicaid program during open enrollment. But Medicaid enrollment is year-round, and most eligible residents in New Mexico have enrolled directly with the state’s Medicaid program rather than going through the exchange. By November 2014, the total new enrollment in Medicaid had reached 170,000. That’s more than 76 percent of the total eligible population, making New Mexico one of the most successful states for Medicaid enrollment. By the end of 2015, New Mexico’s Medicaid enrollment had grown by about 200,000 people since the end of 2013, but three quarters of them had enrolled directly through the New Mexico Medicaid program.
New Mexico had the ninth-highest drop in uninsured rate during the first half of 2014. According to a Gallup poll released in August, the state’s uninsured rate was 20.2 percent in 2013, and had dropped to 15.2 percent by mid-2014.
An expensive exchange
New Mexico’s exchange had the seventh highest cost per enrollee in the nation in 2014, coming in at about $6,181 per enrollee when total start-up and operating expenses were divided among the 32,062 people who had selected a private plan by the end of March 2014.
However, nearly three thousand more New Mexicans completed their Obamacare enrollment in the first half of April, which brought the total cost per enrollee down to about $5,668. This was still far higher than the national average of $922 though. In 2014, the exchange was still working out the details of how to become financially self-sustaining by 2016, but ultimately they ended up switching to the Healthcare.gov platform starting with the 2015 open enrollment period.
The state-run SHOP exchange
By March 2014, the state-run SHOP exchange had enrolled 524 people, including 345 employees and 179 of their dependents. Nearly 1500 small businesses had started their applications in the SHOP exchange by the end of 2013, and several thousand employee names had been entered into the system. But by December 2014, total enrollment was still only around 800 people. SHOP enrollment runs year-round, so businesses can continue to apply throughout the year.
The SHOP exchange needed $1.5 million in annual funding starting in 2015 when it had to begin operating without financing from the federal government. In December 2014, the exchange board voted to impose a fee on all health insurance policies sold in the state of New Mexico, in order to raise the funds needed for Be Well New Mexico’s SHOP exchange in 2015 and beyond.
Establishing the exchange
New Mexico’s path to establishing an exchange was atypical. New Mexico Gov. Susana Martinez, a Republican who opposes the federal health reform law, has been the driving force in establishing an exchange and advocating for the state-run model.
Martinez designated that the Health Insurance Alliance develop the state exchange. The Health Insurance Alliance is a nonprofit association of health plans created by the state Legislature in 1994 to offer health insurance coverage to small employers. Later, the Senate and House both approved a state-run exchange.
New Mexico health insurance exchange links
Guide to the New Mexico Health Insurance Exchange
Includes details about carriers, important dates, eligibility and enrollment information
New Mexico Health Insurance Exchange
Administrative and start-up information
State Exchange Profile: New Mexico
The Henry J. Kaiser Family Foundation overview of New Mexico’s progress toward creating a state health insurance exchange.