By March 2016, total enrollment in qualified health plans (QHPs, which are private plans) through the exchange stood at 55,212 (up slightly from the 55,183 that CMS reported as of February 1). In addition, there were 43,732 people enrolled in New Hampshire’s Premium Assistance Program (PAP – the state uses Medicaid funding to purchase QHPs through the exchange for Medicaid-eligible individuals).
But by the beginning of April, only 48,704 had paid-up coverage in force through the New Hampshire exchange. Platinum plan enrollment increased from March to April, but the other three metal levels – as well as catastrophic plans – saw a decline in enrollment. PAP enrollment also declined in April, to 41,831.
The bulk of the QHP enrollment drop is from Community Health Options (a drop of more than 4,000 enrollees) and Anthem (a drop of more than 2,500 enrollees). But according to the New Hampshire Insurance Department, the drop-off for Community Health Options is partially a result of a reporting glitch in previous months: Rather than reporting just on-exchange numbers to the Insurance Department (used for the monthly QHP membership report that the Insurance Department publishes), Community Health Options had been reporting both on and off-exchange numbers combined. So for April – unlike prior months – the enrollment report includes only on-exchange enrollments.
Here’s how the individual QHP market share in the exchange was distributed across the five New Hampshire exchange carriers as of April:
- Anthem Blue Cross Blue Shield: 23,392 QHP enrollees (down from about 26,000 in March), plus an additional 7,185 PAP enrollees
- Minuteman: 13,571 QHP enrollees (about half are on Bronze plans), plus an additional 2,874 PAP enrollees.
- Harvard Pilgrim: 9,685 QHP enrollees, plus an additional 8,670 PAP enrollees
- Community Health Options: 2,032 QHP enrollees (a drop of about 68 percent since March, partially due of the reporting change described above; the 2,032 enrollees are all on-exchange), plus an additional 2,054 PAP enrollees (enrollment in QHPs ceased as of December 26 – more details below).
- Ambetter: 24 QHP enrollees, plus an additional 20,801 PAP enrollees (New Hampshire Healthy Families enrollees were automatically enrolled in Ambetter through the PAP, although they had the option to pick a different health plan).
PAP enrollments for Medicaid-eligible enrollees are QHPs, and are in the same risk pool as regular QHP enrollments. PAP simply uses Medicaid funding to pay the premiums and any cost-sharing above Medicaid levels, and adds in any additional benefits that must be covered under Medicaid.
Enrollment in QHPs during the 2015 open enrollment period reached 53,005, so the 55,183 people who enrolled in QHPs for 2016 (by February 1) represented a four percent increase. And the 2016 total had already been adjusted to account for attrition as of February 1 (in prior years, HHS waited until after open enrollment was over to begin subtracting cancelled and unpaid enrollments).
Of the 2016 enrollees, 32 percent are new to the exchange for 2016, and 67 percent are receiving premium subsidies. This is the lowest percentage of subsidy-eligible enrollees in any of the states where HHS is running the exchange, and quite a bit lower than the 85 percent average across all the states that use the federally-facilitate exchange.
Open enrollment for 2016 ended on January 31. The next open enrollment period – for coverage effective in 2017 – will begin on November first. Between now and then, most applicants will only be able to purchase coverage – 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).
847 people enrolled in small business exchange
The April enrollment report indicated that there are 847 people enrolled in small business (SHOP) plans through the New Hampshire exchange, representing a total of 145 small businesses. This was a sharp drop-off from the March total, which said that there were 825 groups and 7,615 enrollees.
The drop-off was due to Community Health Options’ enrollment tally, which went from 766 groups with 7,265 insured members, to just 81 groups with 499 insured members. According to the New Hampshire Insurance Department, the April numbers are correct, and the prior numbers had included off-exchange enrollments along with SHOP enrollments. The vast majority of Community Health Options’ small business enrollments are off-exchange.
Minuteman Health rate request
In April 2016, Minuteman Health announced that they’re requesting a 45.2 percent rate increase for 2017. It’s unclear whether such a request will be approved by the New Hampshire Insurance Department. For 2016, Minuteman Health requested rate hikes of 42 to 51 percent for their individual market plans, but regulators ended up approving average rate increases that ranged from 2.75 percent to 9.63 percent.
The same thing might happen again for 2017, and Minuteman Health has acknowledged that they’re being very conservative with their initial rate request for 2017. They also said they’ll update their rate request in July based on the 2015 results of the risk adjustment program, which HHS will report on June 30.
Minuteman is the only carrier in the New Hampshire exchange that offers platinum plans. But their most popular plans are bronze; 6,902 of their 13,571 enrollments as of April were in bronze plans.
Competitor Harvard Pilgrim is optimistic about their exchange business, noting that they planned for significant utilization in the early years of ACA implementation.
Community Health Options ceased enrollments; membership down but finances improving
Community Health Options, a Maine-based CO-OP that expanded into New Hampshire in 2015, is among the more successful CO-OPs in the country, although they’ve struggled with financial losses recently. They were the only CO-OP to make a profit in 2014, but they experienced higher-than-expected losses in 2015 (they lost $31 million in 2015, and also set aside $43 million in reserves to cover anticipated losses for 2016; most of their membership is in Maine).
As a result, they ceased new individual plan enrollments on December 15 through their website, and December 26 through Healthcare.gov. The carrier is continuing to offer new group plans, and all individual plans that were in force in December were eligible for renewal if insureds didn’t select coverage with a different carrier instead.
Community Health Options has said that they hope to resume offering new individual plans in the “not-so-distant future” although it’s doubtful that they’ll have plans for sale before the 2017 open enrollment period begins, since regulators and the CO-OP have determined that the rates for 2016 (which cannot be changed until 2017) are too low to be sustainable.
Community Health Options is under increased oversight from the Maine Bureau of Insurance (about 85 percent of the CO-OP’s enrollees are in Maine, the rest are in New Hampshire). In April 2016, the Maine Bureau of Insurance released their second monthly report on the CO-OP’s performance, indicating that the carrier’s finances are improving. Community Health CEO Kevin Lewis said that the CO-OP is “extremely bullish about 2016 and beyond,” and Maine Bureau of Insurance superintendent Eric Cioppa described the April report a “certainly good, there’s no question about it” but noted that it’s still difficult to predict from one month to the next how things will go.
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 exited the market (nationwide), but Ambetter (offered by Celtic) joined the exchange in New Hampshire (Assurant had 189 enrollees in the New Hampshire exchange as of January 2015, but enrollment had dropped to zero by September).
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 2016 (the state is using Medicaid funds to subsidize premiums for the transitioning enrollees). Minuteman requested an average rate increase of nearly 50 percent, although they proposed a rate reduction of nearly 27 percent for their catastrophic plan.
Approved rate hikes modest
Ultimately, regulators approved Community Health Options’ 2016 rates as-proposed. But the final approved rate increases for Minuteman Health were much smaller than the carrier had requested. The rate decrease for the catastrophic plan was approved with only minor changes. But for Minuteman’s other individual market plans – on which the CO-OP had requested rate increases of nearly 50 percent – regulators approved average rate increases ranging from 2.75 percent to 9.63 percent.
Anthem and Harvard Pilgrim Health Care both had average approved rate increases of less than 6 percent. The New Hampshire exchange provides market share data that’s updated monthly; 44,670 people had in-force private plan coverage in the New Hampshire exchange as of December 2015.
Here’s market share and rate change data for each carrier offering individual plans in the New Hampshire exchange in 2016:
- Ambetter (Celtic) – new to New Hampshire exchange for 2016.
- Anthem: Average approved rate changes are a 0.29 percent decrease, and a 5.7 percent increase. Anthem had 24,567 in force enrollees as of December 2015
- Community Health Options (previously known as Maine Community Health Options): Average rate increases of 13.8 percent to 16.7 percent, approved as-proposed. 4,013 in-force enrollees as of November 2015 (new individual plan enrollments will cease December 26).
- Harvard Pilgrim Health Care: 4.36 percent increase for the NH Network plans, and a 2.09 percent decrease for the Elevate Health plans. 6,568 in force enrollees as of December 2015; nearly three quarters of Harvard Pilgrim’s enrollees are in the Elevate Health plans.
- Minuteman Health: Approved average rate increases range from 2.75 percent to 9.63 percent for individual market plans (much lower than the proposed rate increases of 42 percent to 51 percent). Catastrophic plan rates will decrease by more than 27 percent in 2016, which is very close to what Minuteman Health requested for this plan. Minuteman had 8,360 in force enrollees as of November 2015.
Before rates were finalized in New Hampshire, the worst-case scenario rate increase based on proposed rates was 18.5 percent. This was based on using the highest proposed rate increases for Community Health options and Minuteman (assuming the majority of their enrollees were in the plans with the highest proposed rate hikes), and the possibility of 9.9 percent rate increases for Anthem and Harvard Pilgrim. Despite the fact that Minuteman had proposed rate hikes of nearly 50 percent, their enrollment accounted for less than 20 percent of the exchange total. And the dominant carrier in the exchange – Anthem – had requested a rate hike of less than 10 percent, so the overall proposed weighted average rate hike was still under 20 percent.
But once the rate review process was finalized, the overall weighted average rate hike was just over 6 percent – even if we assume that the majority of Community Health Options, Anthem, and Minuteman enrollees were in plans with the highest rate hikes. According to HHS data, the average benchmark premium (second lowest-cost Silver plan, which isn’t necessarily the same plan from one year to the next) in New Hampshire is 5.1 percent more expensive in 2016 than it was in 2015. In the Manchester area, a Kaiser Family Foundation analysis determined that the average benchmark premium increased by 5.7 percent for 2016.
Higher benchmark premiums mean that average subsidies are higher in 2016 than they were in 2015. But it was still important for enrollees to shop around during open enrollment, as the increase in subsidies didn’t apply consistently in every area, and wasn’t enough to offset the rate hikes that some plans experienced in 2016.
Increased network options
All 26 hospitals in the state are contracted with at least two of the five carriers in 2016, and most of the hospitals are on three, four, or five of the networks. Network issues plagued the New Hampshire exchange in 2014, as Anthem only contracted with 16 of the state’s 26 hospitals in efforts to keep premiums as low as possible.
As a result, even though the exchange had just one carrier in 2014, premiums in New Hampshire were comparable to rates in states that had many carriers offering policies. But Anthem’s restrictions on its hospital and physician networks drew fire, despite the low premiums that the narrow network allowed.
Provider access in New Hampshire had already expanded considerably for 2015. In November 2014, the New Hampshire Department of Insurance published a detailed explanation of 2015 network size and scope based on county and carrier for all of the carriers offering plans in the exchange. Provider network details are also available on each carrier’s website.
There was a mix of broad and narrow networks available in New Hampshire for 2015, and that continues to be the case in 2016; shoppers can find the price and network combination that most appeals to them.
The same 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 considering that in their rate justification, Community Health Options noted that the size of the individual market in New Hampshire was about 50,000 people in 2015 (total enrollment in private plans through the exchange in December 2015 was 43,508). Given that risk pools for on and off-exchange plans are unified, that would seem to indicate a relatively small ACA-compliant individual market outside the exchange.
That hypothesis is further bolstered by the fact that less than 63 percent of New Hampshire exchange enrollees were receiving premium subsidies in 2015 – 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, 2015, when the second open enrollment period – and its extension – ended. Only 71 percent of them were receiving premium subsidies – the lowest percentage of any state where HHS was running the exchange (that figure has dropped to 67 percent for 2016).
The official HHS target for New Hampshire was 50,000 enrollees during the 2015 open enrollment period, so the exchange exceeded that target by more than three thousand people. However, by April 1, only 45,504 people had in-force policies in the New Hampshire exchange, as some enrollees didn’t pay their initial premiums, and others cancelled their coverage shortly after enrolling. All in all, the effectuation rate matches up with the national averages.
The effectuated enrollment report from CMS showed 44,727 people in New Hampshire with in-force private plan coverage through the exchange as of June 30, and the state’s own report pegged the number at 44,305 by November. There’s some fluctuation from one month to another, especially given that subsidized plans don’t terminate for non-payment until premiums are three months past-due.
An additional 9,294 people in New Hampshire enrolled in Medicaid or CHIP through the exchange between November 15 and February 22. Medicaid enrollment continues year-round.
King v. Burwell – subsidies upheld
Democratic Representative Ed Butler introduced a bill to create a state-run exchange in New Hampshire in 2015 (the state currently has a partnership exchange), but it was defeated by the Republican dominated legislature in March. Since the state still uses the federally-run exchange, 28,000 people in New Hampshire would have lost their subsidies if the Supreme Court had ruled that subsidies could only be issued by state-run exchanges. But in June 2015, the Supreme Court ruled that subsidies are legal in every state, even those that rely on the federally-run exchange.
Benefits extend beyond those receiving subsidies
This was obviously a huge win for the people of New Hampshire who have subsidized coverage through the exchange; the Kaiser Family Foundation had estimated that their premiums would have increased by 218 percent if the subsidies had been eliminated. But it’s also a win for everyone who buys individual insurance in the state, including those who don’t receive subsidies. The American Academy of Actuaries had projected market-wide rate increases of at least 35 percent if subsidies had been eliminated, and the overall size of the individual market pool would have dropped by about 70 percent.
As well as the citizens of New Hampsire, the King ruling was also a win for health insurers – their market is no longer in danger of imminent destabilization – and for medical providers, since their patients will still have insurance and be able to afford care.
In addition, New Hampshire expanded Medicaid under the ACA, but with a waiver that allowed the state to start using Medicaid funds to subsidize private plans in the exchange for the newly eligible population in 2016, rather than continuing to cover them in the state’s Medicaid managed care program. Those funds would still have been available in 2016 regardless of the outcome of the King case, but state leaders had expressed concern that the program could have been jeopardized by the upheaval that would have been created in the exchange if subsidies had been eliminated.
Exchange grew from one carrier to five in 2015
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.
2014 enrollment numbers
40,262 people had completed their private plan Obamacare enrollments in the New Hampshire exchange by mid-April 2014. Another 7,235 exchange applicants were eligible for the state’s existing Medicaid coverage during the first open enrollment (Medicaid enrollment continues year-round, but tends to peak during open enrollment due to increased outreach).
For private plan enrollments, New Hampshire greatly exceeded CMS projections in 2014. The original projection for the New Hampshire exchange was 19,000 enrollees during the 2014 open enrollment; the final total is more than double that amount.
Anthem Blue Cross Blue Shield had 90 percent of the individual market share in New Hampshire prior to 2014, so it’s not especially unusual that they were the only carrier that opted to participate in the exchange the first year.
Anthem reported that more than 35,000 of the exchange enrollees were new customers for them in 2014. Given the carrier’s long-term dominance in the market, we can assume that a significant majority of the first-year Obamacare enrollments in New Hampshire were for people who were previously uninsured. Anthem also reported that almost 90 percent of their enrollees paid their initial premiums in 2014.
Unique Medicaid expansion began mid-2014
Residents were able to begin enrolling in New Hampshire’s expanded Medicaid program as of July 1, 2014, with policies effective August 15 (Medicaid enrollment during the winter and spring was only possible for people who qualified under the state’s pre-expansion guidelines).
The state estimated that roughly 50,000 people would be eligible for coverage under the expanded Medicaid program. By the end of September, three months after enrollment began for expanded Medicaid, 18,500 people had already enrolled, and that had grown to nearly 24 thousand people by November 19.
Medicaid expansion in New Hampshire was a contentious issue, but ultimately Governor Maggie Hassan prevailed in her efforts to expand Medicaid, albeit in a privatized fashion. Gov Hassan signed Senate Bill 413 into law on March 27, 2014, paving the way for New Hampshire to become the 26th state to accept Medicaid expansion.
For the first couple years, the program has looked much the same as Medicaid expansion looks in the other 25 states. The state uses federal Medicaid funds to provide New Hampshire Health Protection Program coverage to residents with incomes below 138 percent of poverty.
But starting in January 2016, the state transitioned the NH Health Protection Program’s participants to subsidized, private coverage (Premium Assistance Program), following the “private option” Medicaid expansion path that has been popular in several other states. As of March 2016, PAP enrollment through the New Hampshire exchange stood at 43,732.
Risk pool and grandmothered plans
In November 2013, New Hampshire’s Insurance Commissioner Roger Sevigny announced that the state-run high risk pool (New Hampshire Health Plan) would remain in effect “until the federal marketplace is fully available (the risk pool had previously been scheduled to cease operations on December 31). The risk pool ceased operations on June 30, 2014.
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 (CMS has since announced another extension, allowing transitional plans to remain in force until as late as December 31, 2017, at the discretion of the states; it’s not yet clear whether New Hampshire will go along with the latest extension).
But residents also have the option to cancel their existing plan and switch to a new ACA-compliant policy instead, during open enrollment or when their grandfathered/grandmothered plan renews (renewal outside of open enrollment is considered a qualifying event that allows people to purchase an ACA-compliant plan instead). Anthem Blue Cross Blue Shield announced in May 2014 that they would accept the government’s offer to further extend pre-ACA policies that were carried over from 2013.
The New Hampshire Health Plan, which runs the state’s high-risk insurance pool, was approved in September 2013 for a federal grant to help facilitate education and outreach for the exchange. In addition, Planned Parenthood and Bi-State Primary Care were both awarded grants to serve as navigators during the first open enrollment period, for NH residents who had questions or needed personal assistance with the enrollment process.
Covering New Hampshire, an organization dedicated to educating consumers in New Hampshire and helping them enroll in coverage, focused additional efforts on targeting young men during the 2015 open enrollment, since they were under-represented during the 2014 open enrollment period.
In September 2015, CMS announced navigator grants for two New Hampshire organizations: Bi-State Primary Care received almost $355,000, and Bhutanese Community of New Hampshire received more than $245,000.
Legislation and exchange history
The exchange creation process in New Hampshire has been a legislative battle. In February 2013, Gov. Hassan announced that New Hampshire would operate its health insurance marketplace as a partnership with the federal government.
Prior to the 2012 elections, New Hampshire seemed firmly on a path to relying on the federally facilitated exchange. Former Democratic Gov. John Lynch had no effective means to push back against a Republican-dominated state Legislature that was united against a state-run exchange.
And in 2011, lawmakers passed a bill (enacted into law without Lynch’s signature) that prohibited any sort of penalties for New Hampshire residents who fail to obtain health insurance – in direct conflict with the ACA’s individual mandate and shared responsibility penalty. The law has no real impact however, because the IRS (a federal agency, not under state control) is responsible for assessing the ACA’s penalties, and because the ACA is a federal law that cannot be superseded by state law.
But the 2012 elections gave control of the state House to Democrats, put more Democrats in the Senate, and kept the governor’s office in Democratic hands. The political shift and a law that allowed the state to take on specific exchange functions enabled the state to adopt a partnership model.
New Hampshire is responsible for plan management and consumer assistance, and the federal government is managing all other marketplace functions. The NH Health Exchange Advisory Board holds monthly meetings, the minutes of which are available here.
New Hampshire health insurance exchange links
New Hampshire Department of Insurance: Health Benefit Partnership Exchange Advisory Board
Includes meeting agendas and documents from November 2012 until the present.
State Exchange Profile: New Hampshire
The Henry J. Kaiser Family Foundation overview of New Hampshire’s progress toward creating a state health insurance exchange.
New Hampshire Consumer Assistance Program
Assists consumers who have purchased insurance on the individual market or who have insurance through an employer who only does business in New Hampshire.
(800) 852-3416 / firstname.lastname@example.org
Covering New Hampshire – a statewide effort by the New Hampshire Health Plan to inform residents of their coverage options in the exchange and the resources that are available for those who need assistance.