Open enrollment for 2016 is underway, and enrollees have until December 15 to select a plan with a January 1 effective date. Open enrollment will continue until January 31. After that point, most applicants will only be able to purchase a 2016 plan – on or off the exchange – if they have a qualifying event (Native Americans can enroll year-round, as can applicants who are eligible for Medicaid/CHIP). Open enrollment won’t begin again until November 1,2016, for coverage effective January 1, 2017.
2016 rates and carriers
In 2015, New Hampshire’s exchange had five carriers, up from just one in 2014. There are still five carriers offering plans for 2016, although there’s one swap: Assurant/Time is exiting the market (nationwide), but Ambetter (offered by Celtic) has 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).
In 2015, there were 42 individual plans available in the state, and that has increased to 51 for 2016. Dentegra has also joined the exchange, bringing the total number of dental carriers from three to four.
Two carriers in the exchange – Minuteman Health and Community Health Options – requested double digit rate increases for 2016. Both carriers are CO-OPs created under the ACA, and both expanded into New Hampshire at the start of 2015, so their claims data for the state is 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 is a driving force in the higher rates they requested for the coming year (the state will use 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.
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.s
Anthem and Harvard Pilgrim Health Care both have average approved rate increases of less than 6 percent. The New Hampshire exchange provides market share data that’s updated monthly; 44,305 people had in-force private plan coverage in the New Hampshire exchange as of November 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 are a 0.29 percent decrease, and a 5.7 percent increase. Anthem had 25,039 in force enrollees as of November 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.
- Harvard Pilgrim Health Care: 4.36 percent increase for the NH Network plans, and a 2.09 percent decrease for the Elevate Health plans. 6,690 in force enrollees as of November 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 8,563 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 accounts 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 is just over 6 percent – even if we assume that the majority of Community Health Options, Anthem, and Minuteman enrollees are 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 is increasing by 5.7 percent for 2016.
Higher benchmark premiums mean that average subsidies will be higher in 2016 than they were in 2015. But it’s still important for enrollees to shop around during open enrollment, as the increase in subsidies won’t apply consistently in every area, and won’t be enough to offset the rate hikes that some plans will experience in 2016.
The same five carriers are offering individual policies outside the exchange in 2016, 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 noting that in their rate justification, Community Health Options noted that the size of the current individual market in New Hampshire is about 50,000 people. 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 are receiving premium subsidies – far lower than the national average of nearly 84 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, when the second open enrollment period – and its extension – ended. Only 71 percent of them are receiving premium subsidies – the lowest percentage of any state where HHS is running the exchange.
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 released this summer by 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 on June 25, 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 is 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 allows 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 be available in 2016 regardless of the outcome of the King case, but state leaders had expressed concern that the program could be jeopardized by the upheaval that would have been created in the exchange if subsidies had been eliminated.
Exchange grows from one carrier to five
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 offer 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.
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.
Healthcare legislation in the 2015 session
A variety of healthcare reform bills were introduced in the 2015 legislative session in New Hampshire. They ran the gamut from establishing a state-based single payer healthcare system to allowing individuals and small businesses to buy coverage from outside the state.
There was also a possibility that lawmakers would revisit the question of Medicaid expansion (Medicaid is currently expanded in New Hampshire under the ACA), although the current expansion law doesn’t sunset until 2016. Ultimately, the issue of reauthorizing Medicaid expansion was postponed until the 2016 session, and will be a priority for lawmakers when they reconvene.
Increased network options
All 26 hospitals in the state will accept coverage from 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 have 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 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 will continue to be the case in 2016; shoppers can find the price and network combination that most appeals to them.
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-year
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 by 2016, the state plans to transition the program’s insureds to subsidized, private coverage, following the “private option” Medicaid expansion path that has been popular in several other states.
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.
New Hampshire allowed existing 2013 health plans to continue to renew until October 2016 and remain in force as late as September 2017, following guidance issued by CMS in early 2014. But residents also have the option to cancel their existing plan and switch to a new ACA-compliant policy instead. Anthem Blue Cross Blue Shield announced in May 2014 that they will 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 that are working to enroll people during the 2016 open enrollment period: 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.