Highlights and updates
- 2018 enrollment: down about 3.6% from 2017
- Ohio seeks to eliminate the individual mandate — not just the penalty
- All counties have plans available for 2018; bare spots were filled
- Humana, Anthem, and Premier exited, seven insurers stayed for 2018
- Five insurers expanded to cover 20 otherwise bare counties
- Approved 2018 rate increases much larger than insurers originally proposed
- Revised (much higher) rate filings were due to lack of federal funding for CSR
- Cost of CSR added to silver plan premiums, subsidies offset for most enrollees
- 16 counties have no gold plans available for 2018
Ohio exchange overview
Ohio has a federally facilitated exchange, which means residents in Ohio use Healthcare.gov to enroll in exchange plans. But Ohio is one of seven states that participates in plan management and the qualified health plan (QHP) certification process.
Ohio expanded Medicaid under the ACA, due in large part to Republican Governor John Kasich’s efforts. Ohio residents can enroll in QHPs or Medicaid via the exchange, with eligibility dependent on income. Enrollment in Medicaid runs year-round.
Open enrollment for 2018 individual market coverage (on and off-exchange) began on November 1, 2017, and ended on December 15, 2017. This was much shorter than previous open enrollment periods, and marks the first time that open enrollment ended before the start of the coming year, with all plans effective January 1. This same November 1 – December 15 enrollment schedule will continue to be used in future years.
Outside of open enrollment, most people are only able to sign up for a private plan (on or off-exchange) if they have a qualifying event, although Native Americans can enroll year-round, as can anyone eligible for Medicaid or CHIP.
Ohio wants to eliminate the individual and employer mandates
Ohio passed legislation in 2015 that requires the state to propose a 1332 waiver that would, if federal permission is granted, allow the state to eliminate the ACA’s individual and employer mandates. In March 2018, the state submitted a 1332 waiver to HHS, requesting the elimination of the individual mandate in Ohio as of January 1, 2019.
The federal government has already eliminated the individual mandate penalty as of January 1, 2019, but not the mandate itself (this was done via the Tax Cuts and Jobs Act that GOP lawmakers passed in December 2017). So under federal law, people will still technically be required to maintain coverage after 2018, but the penalty, if they fail to do so, will be $0. Ohio went ahead and submitted their 1332 waiver proposal to HHS, requesting elimination of the mandate itself in Ohio, as of 2019. But the waiver proposal notes that the impact will be negligible since the penalty will be $0 in 2019 and beyond.
Ohio has not yet submitted a proposal to eliminate the employer mandate in the state. That change, if proposed and approved, would certainly have an impact on federal revenue, since nothing has changed about the employer mandate penalty, and the federal government will still be collecting it in 2019 and beyond. In order to receive federal approval for the elimination of the employer mandate in Ohio, the state would have to demonstrate a way to do so that would be budget-neutral for the federal government. That’s unlikely, given the reduction in employer mandate revenue that would result, along with the likely uptick in the number of people seeking subsidized individual market coverage if their employers were to stop offering coverage.
It’s noteworthy that there are several states that are taking the opposite approach when it comes to the individual mandate, and are considering state-based individual mandates — with state-based penalties — to replace the federal individual mandate penalty that will be eliminated after the end of 2018. Those states are driven by the understanding that an insured population is a healthier population, and that a stable risk pool requires as many healthy enrollees as possible.
2018 enrollment: down about 3.6% from 2017
230,127 people enrolled in individual market plans through Ohio’s exchange during open enrollment for 2018 coverage. That was about 3.6 percent lower than the 238,843 people who enrolled the year before, but open enrollment was half as long for 2018 coverage, and the Trump Administration sharply reduced funding for exchange marketing and enrollment assistance just before the start of open enrollment for 2018 coverage.
Enrollment for 2018 is down about 5.6 percent from a high of 243,715 people in 2016. This mirrors the general trend that we’ve seen in states that use HealthCare.gov, with enrollment declining from 2016 to 2017, and again from 2017 to 2018. States that run their own exchanges have been much more likely to see increased enrollment during at least one of those years.
Humana, Anthem, and Premier exited at the end of 2017; seven other insurers offering 2018 coverage
For individual and small group major medical plans (on and off-exchange), insurers had until June 5 to file 2018 rates in Ohio.This was an extension of the original deadline, which was May 26. Humana and Anthem exited the exchange at the end of 2017, but the other eight insurers in Ohio’s exchange continued to offer coverage in 2018.
Humana announced in early 2017 that they would exit the individual market altogether, nationwide, at the end of 2017. Humana was one of the insurers that offered plans in the Ohio exchange in 2017. But at the end of 2016, Humana sharply reduced their individual market footprint, nationwide. They remained in 11 states (down from 19 in 2016), but only offered plans in a total of 156 counties across those 11 states (for reference, there are 88 counties in Ohio alone).
Anthem also pulled out of the exchange in Ohio, and their individual market offerings in 2018 consist of a single off-exchange plan in Pike County (this prevented a full market exit in Ohio, allowing them to re-enter the rest of the state in 2019 or later, which Anthem noted that they hope to do; a full statewide exit would prevent them from returning to Ohio’s individual market for five years, under long-standing HIPAA rules).
Anthem’s grandfathered and grandmothered individual market plans were allowed to remain in force, and were not impacted by the exit from most of the state’s ACA-compliant market.
Anthem noted that “planning and pricing for ACA-compliant health plans has become increasingly difficult due to the shrinking individual market as well as continual changes in federal operations, rules and guidance.” Their exit had a lot to do with the general instability in the individual insurance markets, which has been exacerbated by the Trump Administration’s loosening of the individual mandate (the penalty will be repealed altogether as of 2019, but enrollees’ perception of whether the mandate is being enforced is important for market stability, and the Trump Administration’s public commitment to rolling back the mandate has led to a perception that it’s not well enforced) and refusal to commit to funding cost-sharing reductions (CSRs). Trump indicated on more than one occasion in 2017 that he might withhold CSR funding in an effort to get Democrats to negotiate on health care reform, and he announced in mid-October that CSR funding would end immediately. By that point, however, Anthem had long-since decided to exit Ohio’s exchange at the end of 2017.
There were 67,000 people in Ohio with Anthem coverage who needed to select new plans for 2018. Eleven insurers offered plans in Ohio’s exchange in 2017, but their participation was localized. And in 20 of Ohio’s 88 counties, Anthem was the only participating exchange insurer in 2017 (Anthem was the only insurer in Ohio that offered exchange coverage in every county in 2017).
Premier Health Plan also exited the Ohio exchange at the end of 2017. They continued to offer one bronze plan outside the exchange (in the same 16 western Ohio counties where they offered coverage for 2017), but coverage under that plan ended on March 31, 2018. The rate filing indicated that only 40 members were expected to have coverage under Premier in 2018. Average rates for the remaining bronze off-exchange plan increased by an average of 34.63 percent in 2018, and anyone who had that plan in the first quarter of 2018 needed to purchase a new plan with coverage effective April 1, 2018. Premier noted in their rate filing that “members who choose to stick with a Premier plan until the exit date are likely to be sicker members who need the plan.”
Premier is no longer offering any coverage in the individual market in Ohio. Premier members who had off-exchange coverage in 2018 are eligible for a special enrollment period through May 30, during which they can pick a new plan from another insurer. Any amount that these members paid towards their deductible and out-of-pocket maximum under the Premier plan in January – March 2018 will not transfer to the new plan, and those members’ will have to start over with their annual cost-sharing under the new plan.
Involuntary loss of coverage is always a qualifying event that triggers a special enrollment period. People who had on-exchange coverage in 2017 in Ohio from one of the three insurers that exited the exchange (Anthem, Humana, and Premier) were mapped to a plan from a different insurer if they didn’t select their own new plan by December 15. But they were still eligible for a special enrollment period, through March 1, 2018, during which they could pick their own plan to cover them for the remainder of 2018.
For people who had off-exchange coverage that ended on December 31, the same special enrollment period applied, but members were not automatically mapped to a new plan if they didn’t pick their own by the end of December.
For Humana, Anthem, and Premier members, the loss of coverage and associated special enrollment period applied to all on-exchange plans, and to most off-exchange plans:
- All ACA-compliant Humana plans terminated, on and off-exchange
- On-exchange Anthem plans terminated. Off-exchange, all Anthem plans terminated except one plan in Pike County.
- All ACA-compliant Premier plans have terminated. On-exchange, this happened on December 31. Off-exchange, all Premier plans terminated on December 31 except one bronze plan, which continued to be available until March 31, 2018 in the full 2017 coverage area. People who had that plan when it terminated have a special enrollment period through May 30, during which they can pick a plan offered by another insurer.
Initially, 20 counties had no plans filed for 2018. But other insurers agreed to cover them.
When Anthem announced that they would exit the exchange at the end of 2017, there were 20 rural counties — which had more than 11,000 exchange enrollees in 2017 — that did not have any insurers slated to offer exchange coverage. But on July 31, 2017, Ohio’s Department of Insurance announced that five existing exchange insurers had agreed to offer coverage in 19 of the 20 bare counties. Buckeye Health Plan, CareSource, Medical Mutual, Molina, and Paramount Health Care agreed to offer coverage in those counties.
Only Paulding County, in northwest Ohio, was still without any insurers slated to offer coverage at that point. State regulators continued to work with insurers to devise a solution for Paulding County, and On August 24, the Ohio Department of Insurance announced that CareSource had agreed to offer coverage in Paulding County. CareSource offered plans in 51 Ohio counties in 2017, and their 2018 rate filing indicated that they would expand to offer coverage in 59 counties in 2017, although the recent additional expansion further increases that number; CareSource agreed in late July to cover eight of the bare counties, and added a ninth with Paulding.
19 of the 20 counties continue to have just a single insurer offering exchange plans, although Hancock County has 2018 plans available from both Medical Mutual and Molina. Each of the five insurers agreed to offer coverage in a handful of the bare counties, and the combined result is that every country in Ohio has at least one insurer offering coverage for 2018.
This has happened in other states too, but insurers have stepped in to fill the bare spots. Previously “bare” counties in Tennessee, Washington, Kansas, Missouri, Indiana, Wisconsin, and Nevada have all been filled, and all areas of the country have plans available in the exchange in 2018.
In their July 2017 statement, the Ohio Department of Insurance noted that they “will continue working with the industry, but those efforts are heavily dependent on market stability and clarity from Washington. We encourage Congress to work on ways to stabilize our health insurance markets.” Insurers repeatedly stated in 2017 that the best way to stabilize the insurance markets would be for Congress to allocate funding for cost-sharing reductions (CSR) and enforce the individual mandate. But instead, the Trump Administration has cut off CSR funding and refused to commit to robust enforcement of the individual mandate — both of which contributed to a substantial portion of the rate increases that insurers implemented for 2018 plans.
But things are different in 2018 in terms of market stabilization efforts. Insurers in most states, including Ohio, added the cost of CSR to silver plan premiums for 2018, which ended up creating larger premium subsidies and making coverage more affordable for many enrollees. With that strategy, known as “silver loading,” people who don’t qualify for premium subsidies can purchase non-silver plans in order to avoid having to pay the extra premiums that were added to cover the cost of CSR, or can shop off-exchange for silver plans if the state allowed insurers to add the cost of CSR only to on-exchange silver plans (Ohio did allow this, so consumers were well protected for 2018). So while federal funding for CSR was at the top of the list in terms of market stabilization proposals in 2017, that is no longer the case. As long as insurers can continue to add the cost of CSR to silver plan premiums, the lack of federal funding for CSR will not destabilize the market or cause insurers to exit the market.
2018 rate changes: revised rates add the cost of CSR to silver premiums
The seven remaining exchange insurers initially filed 2018 rates based on the assumption that CSR funding would continue in 2018, but the Ohio Department of Insurance later directed them to refile new rates based on the assumption that CSR funding would not continue, and with the cost of CSR added to silver plan premiums for 2018. The Ohio Department of Insurance also allowed insurers to create off-exchange-only silver plans with the same benefits as the on-exchange silver plans, but without the cost of CSR added to the premiums (in areas where such plans are available, they present a good option for people who don’t qualify for premium subsidies, but who want to purchase a silver plan; for people who do qualify for premium subsidies, the additional premiums are offset by larger premium subsidies in the exchange).
In the following list, the approved rate increases are listed first, but the previous filing is also listed to provide perspective in terms of how much the lack of CSR funding drove up premiums for 2018.
Note that rate changes are calculated before premium subsidies are applied; for those eligible for premium subsidies — which included 76 percent of Ohio exchange enrollees in 2017 — the subsidies grew to keep pace with the new rates, and enrollees actually have to pay slightly less for the second-lowest-cost silver plan in 2018
The following average rate increases were approved for 2018:
- AultCare: 29.3 percent. Initially, AultCare had proposed a 10.3 percent increase, and revised it to 13.8 percent in June (the initial filings were based on the assumption that CSR funding would continue in 2018). But in August, they revised it again to an average of 29.3 percent. This was based on the assumption that CSR funding would not continue in 2018, and includes an additional 20 percent premium increase added to on-exchange silver plans. AultCare has 5,848 members.
- Ambetter (Buckeye Community Health Plan): 48.9 percent to 49.7 percent, depending on whether the product includes dental and/or vision coverage. Initially, Ambetter proposed a 29.1 percent average increase, which was based on the assumption that CSR funding would continue. They filed the larger average rate increase in August, based on the assumption that CSR funding would not continue. The cost of CSR has been added to on- and off-exchange silver plans. Ambetter/Buckeye has 15,138 members.
- CareSource: 34.15 percent increase for CareSource HMO Basic; 25.06 percent increase for CareSource HMO Enhanced; 43.41 percent increase for Product 3. The initial proposed average rate increase had been 23.9 percent. CareSource has 51,590 enrollees, and plans are available in 59 counties for 2018.
- Medical Health Insuring Corp. of Ohio (Medical Mutual): 24.5 percent. The previous proposed average increase was 19.8 percent. Medical Mutual notes in their revised filing that they have opted to create four new off-exchange-only silver plans with benefits that mirror the on-exchange plans, but without the cost of CSR added to the premiums. For enrollees who don’t qualify for premium subsidies and who want a silver plan, off-exchange-only options are worth considering for 2018. Medical Mutual has 23,120 members.
- Molina: 37.7 percent increase for Molina Marketplace; 40.5 percent increase for Molina Marketplace Options. The initial proposed average increase was 23.9 percent increase, but the revised filings have substantially higher premiums for silver plans, to cover the cost of CSR. Molina has 20,948 members, and is not marketing products outside of the exchange.
- Paramount: 35.92 percent increase. The initial proposed rate increase, based on the assumption that CSR funding would continue, was 20 percent. The cost of CSR has been added to on-exchange silver plans, and Paramount’s revised filing noted that they would offer off-exchange silver plans without the cost of CSR added to the premiums if federal regulators allowed it. Paramount has 3,713 members.
- Summa: 41.1 percent increase. The initial filing had an average proposed increase of 26.6 percent. In the revised filing, the cost of CSR has been added to on-exchange silver plans, and Summa notes that they expect to see an increase in the number of people who purchase silver plans outside the exchange (those plans don’t have the cost of CSR included in the premiums, so they’re a good fit for people who want a silver plan but who don’t qualify for premium subsidies to offset the higher rates). Summa has 4,152 members.
16 counties have no gold plans available for 2018
There are 16 counties in Ohio where gold plans are not available in the exchange for 2018 (Auglaize, Coshocton, Crawford, Erie, Hancock, Hardin, Hocking, Holmes, Knox, Marion, Mercer, Ottawa, Putnam, Richland, Williams, and Wyandot). In all of those counties, a single insurer offers coverage (either Medical Mutual or Paramount).
The lack of gold plans in 16 counties is despite the fact that the 2018 Benefit and Payment Parameters, finalized by HHS in late 2016, calls for all insurers in the federally-facilitated exchange to offer at least one gold plan and one silver plan in all parts of their service areas.
The ACA itself requires exchange insurers to offer at least one silver plan and one gold plan, but it doesn’t specify that they must do so in all parts of their service areas. As a result, there were 209 counties (in Iowa, Missouri, Nebraska, and Tennessee) where there were no gold plans available in the exchange in 2016. The rule change for 2018 was an effort to address this issue and ensure that all enrollees have access to at least silver and gold plans.
However, CMS clarified that Ohio has some flexibility on this issue because they’re a plan-management exchange (ie, the state retains plan management functions and certifies plans as qualified health plans to be sold in the exchange). As such, Ohio regulators allowed Medical Mutual and Paramount to offer gold plans in only part of their service areas. Both insurers do offer at least one gold plan in at least some areas of the state, thus satisfying the underlying statute of the ACA.
238,843 people enrolled in QHPs through the Ohio exchange during the 2017 open enrollment period (November 1, 2016, through January 31, 2017). That’s 2 percent lower than enrollment in 2016, although the drop-off was not as sharp as it was in other HealthCare.gov states, where enrollment declined by an average of almost 5 percent.
The average full-price premium in Ohio’s exchange in 2017 was $413/month. But nearly three-quarters of Ohio exchange enrollees are receiving premium subsidies that bring their average premiums down to $215/month.
Three insurers that offered exchange plans in Ohio in 2016 — InHealth Mutual, Aetna, and All Savers/UnitedHealthcare — did not offer plans in 2017.
And HealthSpan was purchased by Medical Mutual; HealthSpan’s individual market plans ended on December 31, 2016, and were replaced with Medical Mutual coverage — but enrollees had the option to pick a different carrier instead.
The rest of the carriers that offered coverage in the Ohio exchange in 2016 are continuing to offer plans for 2017, with the following average rate changes (all numbers are averages; specific plans can have rate changes that vary considerably from these numbers):
- AultCare: 24.09 percent increase
- Ambetter (Buckeye Community Health Plan): 0.79 percent decrease and 1.14 percent decrease, depending on whether plan includes vision.
- CareSource: 16.91 percent increase (HMO Enhanced) and 17.64 percent increase (HMO Basic). CareSource reported that they enrolled 71,586 people in individual market plans in Ohio during the 2017 open enrollment period; that’s down about 2 percent from their 2016 total.
- Community Insurance Company (Anthem BCBS): 18.2 percent increase (HMO) and 15.5 percent increase (PPO). Anthem will exit the exchange and most of the off-exchange market in Ohio at the end of 2017, retaining just one off-exchange ACA-compliant plan in Pike County.
- Humana: 45.11 percent increase (Humana has left the individual market in several states for 2017, but is continuing to offer coverage in Ohio; they will exit the individual market entirely, however, at the end of 2017)
- Medical Health Insuring Corp. of Ohio (Medical Mutual): 17.13 percent decrease (but they only have 128 members in 2016; this is expected to increase in 2017 with their purchase of HealthSpan’s business)
- Molina: 2.36 percent increase (on the heels of a rate decrease for 2016)
- Paramount: 9.88 percent increase
- Premier Health Plan: 39.82 percent increase
- Summa: 5.33 percent increase
Although Ohio’s exchange is quite robust compared with most states, plan availability varies from one part of the state to another. There are 20 counties (out of 88 counties in the state) where just one carrier is offering plans for 2017 in the exchange. Another 27 counties have only two carriers offering plans. In 2016, every county had plans available in the exchange from at least four carriers.
But there are still a total of ten carriers offering coverage in the exchange in Ohio in 2017. In neighboring West Virginia, there are only two.
Average rates up 17% in 2017, but average benchmark rate up just 2%
At ACA Signups, Charles Gaba calculated a weighted average rate increase of 17.33 percent for the individual market in Ohio. For perspective, the average rate increase approved for 2016 in Ohio was 13 percent, but that was before anyone shopped around for coverage during open enrollment. For 2017, 17.33 percent was still lower than the national average, which was about 25 percent. But it’s important to understand that these percentage rate changes assumed that nobody would shop around and pick a different plan during open enrollment, and they were also calculated before any premium subsidies were taken into consideration.
But that said, the average benchmark premium (second-lowest-cost silver plan) in Ohio only increased in price by 2 percent for 2017. Premium subsidies are tied to the benchmark premium, so there were very modest increases in subsidies in Ohio in 2017. That made it more important than ever for people to actively shop around during open enrollment, as their plan might have been increasing in price significantly more than the second-lowest-cost silver plan in their area. In that case, they could find themselves bearing most of the brunt of the rate hike. On the other hand, if they were willing to switch to a different plan, they could find that their rates are similar to — or even lower than — what they had in 2016.
Small groups: still 1 – 50 employees in Ohio
The ACA originally called for small groups to be defined as up to 100 employees starting in 2016. This would have been for the purpose of grouping plans into a risk pool, and requiring that plans with 51 to 100 employees begin to follow all of the ACA rules related to small groups. Groups of 50 or more employees have to comply with the employer mandate, but groups with 51 or more employees had been purchasing coverage that conformed with large group requirements, which aren’t as stringent as small group requirements. Here’s more about how this works.
The PACE Act, signed into law in October 2015, allowed states the option to keep the definition of small group at up to 50 employees, or make the change (up to 100 employees) called for in the ACA. Ohio opted for the former, and noted that small groups would continue to be defined as 1 – 50 employees, while employers with 51+ employees would be considered large groups.
InHealth Mutual CO-OP liquidated
InHealth Mutual (Coordinated Health Mutual Inc.) was one of the 23 CO-OPs that were created by the ACA. By the end of 2015, 12 of those CO-OPs had closed, but InHealth Mutual was among the 11 that continued to provide coverage in 2016.
But in May 2016, the Ohio Department of Insurance announced that InHealth would be liquidated, and that 21,800 Ohio residents – most of whom had individual plans – would need to select new coverage. The DOI announced that there would be a special enrollment period running from May 26 to July 26, during which InHealth Mutual members would be able to select new plans.
For members who did not select new plans, InHealth Mutual coverage technically remained in place until the end of 2016. But the state guaranty association stepped in to pay claims, which meant that the coverage was no longer considered minimum essential coverage, and had a benefit cap of $500,000. So a member who continued to pay premiums for InHealth Mutual throughout the rest of 2016 was not in compliance with the ACA’s individual mandate, potentially ending up with a penalty as a result. They also lost eligibility for any subsidies through Healthcare.gov.
The Ohio DOI clarified that people who picked new plans would likely have to start over with new deductibles and out-of-pocket exposure on the new plan. In order to continue receiving a premium subsidy, new plans had to be selected through Healthcare.gov. For people who didn’t receive a premium subsidy, new plans could be selected through Healthcare.gov or outside the exchange. The Ohio DOI estimated that there were still about 7,800 people with InHealth Mutual coverage as of early August, 2016.
Ironically, InHealth Mutual may have avoided the first round of CO-OP shut-downs because of the fact that they didn’t get their Ohio license in time to offer subsidized plans in the exchange in 2014. As a result, they had to rely on small group enrollments outside the exchange for 2014, and only ended up with 11 percent of their projected enrollment by the end of the year.
But that first wave of 2014 enrollees turned out to be sicker than expected, and nationwide, carriers lost money. Since InHealth Mutual hadn’t been able to offer plans in the exchange, they were spared the high claims that the other CO-OPs experienced, and ended up with a net income of negative $6 million for 2014 (that’s obviously still not good, but only four other CO-OPs did better that year).
By mid-2015, InHealth’s membership had more than tripled, to 22,000 people. But they still had a loss of $9 million during the first half of 2015, and were placed under enhanced regulatory oversight.
For 2016, InHealth had proposed an average rate increase of 7.7 percent, but later revised their request to 15 percent. The final approved average rate increase for their plans was 14.8 percent. However, regulators noted that in order to stem their losses, InHealth would have needed a rate increase of about 60 percent for 2017 if they had remained operational.
On January 15, InHealth notified the Ohio Department of Insurance that they were planning to drop OhioHealth hospitals and most OhioHealth doctors from their network as of March 1.
But the public outcry over the network restructuring was fierce, and by the end of February, InHealth announced that they would keep OhioHealth in their network until at least the end of 2016. The liquidation order for InHealth Mutual stipulates that in-network providers must continue to honor their network agreements throughout the liquidation process.
243,715 people enrolled in private plans through the Ohio exchange during the 2016 open enrollment period (November 1 to January 31). That was 104 percent of the total number of of people (234,341) who enrolled in plans during the full 2015 open enrollment period, although the 2016 total had already been reduced in real-time to account for uneffected enrollments as of February 1.
According to Kaiser Family Foundation data, there were still 834,000 uninsured residents in Ohio in 2015. 48 percent were eligible for Medicaid, and 20 percent were eligible for premium subsidies in the exchange. In total, more than half a million people in Ohio were uninsured in 2015 and eligible for financial assistance – either Medicaid or premium subsidies.
In March 2017, Ohio regulators opted to go along with the latest extension from the federal government regarding transitional (grandmothered) plans. These are the plans that individuals and small businesses purchased after the ACA was signed into law, but before the exchanges opened for business in October 2013. They’re not compliant with the ACA, but Ohio is one of many states where they will be allowed to continue to remain in force until the end of 2018. But the final decision is up to each carrier.
2016: highest after-subsidy premiums among Healthcare.gov states
80 percent of the enrollees in the Ohio exchange in 2016 were receiving premium subsidies, which averaged $240/month. The average pre-subsidy premium in Ohio was $405/month in 2016, but for people who are receiving subsidies, the average after-subsidy premium is $164. That’s a considerable reduction from the pre-subsidy price, but it’s the highest average after-subsidy premium among the 38 states that are using Healthcare.gov (the average after-subsidy premium across all 38 states is $106/month).
That’s despite the fact that the percentage of Ohio exchange enrollees who picked low-cost bronze plans is higher than the average across Healthcare.gov states, and the percentage who picked silver plans is lower than the average.
2016 carriers and rate changes: Overall rates up about 13%, but benchmark plans slightly less expensive in 2016
In late October 2015, HHS released an overview of benchmark premium changes in the states that use Healthcare.gov. It was admittedly of limited value, since the benchmark plan isn’t necessarily the same plan from one year to the next. But it does give a good idea of how subsidies would change in 2016, and a general feel for the overall rate change trend in many states. Of the 37 states included on the list, only four had an average decrease in their benchmark premiums – and Ohio is among them. The average second-lowest-cost Silver plan in Ohio is 0.7 percent less expensive in 2016 than it was in 2015.
And a Kaiser Family Foundation analysis of second-lowest-cost Silver plan premiums in the Cleveland area found an average decrease of 5.3 percent.
But according to the Dayton Daily News, overall rates in the Ohio exchange have increased by an average of about 13 percent for 2016. However, it’s important to look not just at rate changes, but the rates themselves. According to a Kaiser Family Foundation analysis, a 40-year-old in Cleveland can buy the second-lowest-cost Silver plan for $234/month in 2016, before any subsidies are applied. The analysis examined a major metropolitan area in every state plus DC, and Cleveland, Ohio had the 7th lowest average benchmark price among the 51 exchanges.
Here are the approved average rate changes for the 15 carriers offering plans in Ohio’s exchange for 2016 (some are considerably higher than the carriers proposed):
- Aetna: 13.2 percent increase
- AultCare: 5.47 percent increase
- Buckeye Community Health Plan: 5.31 percent and 7.68 percent increases, depending on whether plan includes vision
- CareSource: 1.2 percent increase
- Community Insurance Company (Anthem BCBS): 4.05 percent increase
- Coordinated Health Mutual (InHealth): 14.8 percent increase (InHealth is being liquidated and is no longer offering plans as of May 2016)
- HealthSpan Integrated Care: 18.22 percent increase
- HealthSpan: 31.96 percent increase
- Humana: 19.25 percent increase
- Medical Health Insuring Corp. of Ohio: 14.47 percent increase
- Molina: 5.78 percent decrease
- Paramount: 9.94 percent increase
- Premier Health Plan: 0.68 percent decrease
- Summa: 0.89 percent and 9.64 percent increase, depending on plan type
- UnitedHealthcare: 1.75 percent increase (United is exiting the individual markets in most states at the end of 2016, including Ohio).
According to a Milliman analysis of the 38 states using Healthcare.gov for 2016, only Wisconsin has more carriers participating in the exchange than Ohio. But an HHS analysis indicated that there are actually 17 carriers in the Ohio exchange – one more than Wisconsin, and trailing only Texas, which has 19 carriers according to HHS (14 according to Milliman). Reports of this nature sometimes conflict simply because a carrier operates under two different names within a state.
234,341 people enrolled in private plans through the Ohio exchange during the 2015 open enrollment period (through February 22, including the week-long extension). 47 percent were new to the exchange for 2015, and 84 percent received premium subsidies. HHS had predicted 200,000 enrollees in the Ohio exchange, so the state ended up well above their target.
But enrollments aren’t the same as effectuated enrollments, since some people never pay their initial premiums and others opt to cancel their coverage for one reason or another. And Healthcare.gov stepped up their enforcement of immigration and/or financial data discrepancies in the first half of 2015, which means that there was more real-time adjustment of enrollment totals based on missing enrollment data. By the end of March 2015, effectuated enrollment in private plans through the Ohio exchange stood at 188,867 people. That number dropped slightly during the second quarter, with effectuated enrollments totaling 188,223 by June 30. Outside of open enrollment, attrition can generally be expected to outpace new enrollments, which require a qualifying event. But the drop in effectuated enrollments in Ohio was only about six hundred people during the second quarter of the year – about 0.3 percent of the total.
Ohio expanded Medicaid under the ACA. Medicaid/CHIP enrollment continues year-round, and total Medicaid/CHIP enrollment in Ohio grew by 623,626 people from late 2013 to October 2015. This includes people who were newly-eligible under the expanded guidelines, as well as people who were previously eligible but didn’t enroll prior to 2014. It also includes people who enrolled through Healthcare.gov as well as those who enrolled directly through Ohio Medicaid.
Uninsured rate plummets
The uninsured rate in Ohio was cut in half between 2013 and early 2015, largely as a result of Medicaid expansion (Ohio’s program was expanded as of January 1, 2014) and the subsidies that have made individual insurance affordable for low and middle-income households.
By mid-2015, the drop in uninsured rate was even more pronounced: According to Gallup data, 13.9 percent of Ohio’s population was uninsured in 2013, and that had fallen to 6.1 percent during the first half of 2015 – a 56 percent drop.
2015 rates and carriers
Sixteen carriers sold 2015 individual plans in the Ohio exchange, up from twelve in 2014. All except Time/Assurant returned to the exchange for 2016.
Ohio was tied with Michigan for having the most carriers of any exchange in the country for 2015. After reviewing plans and rates, the Ohio Department of Insurance announced in the fall that the average rate increase for 2015 would be 12 percent in the individual market – a double-digit hike that was immediately held up by ACA opponents as evidence of the law’s failure to rein in premiums.
But the Department of Insurance used very basic math in their calculation, and the result was not particularly informative. A weighted average would have been much more helpful, and appears that it would also have indicated a lower overall average rate increase.
If we consider only plans sold within the exchange, a Commonwealth Fund analysis found an average price increase in 2015 of just 4 percent across all plans and all metal levels, for a 40-year-old non-smoker. For the least expensive silver plans, in 42 of Ohio’s 88 counties, prices were either flat or decreasing for 2015.
People who were enrolled in the second-lowest-cost silver plan (the benchmark plan) in 2014 were able to obtain lower premiums in 2015 if they were willing to shop around and make sure that they enrolled in the benchmark plan for 2015. In many cases, this meant switching to a new plan, but in most areas of the state, it resulted in a premium decrease or just a small increase. For benchmark plan enrollees who qualified for premium subsidies, the changes were mostly offset by adjustments to the premium subsidies for 2015.
In the Cleveland area, the lowest and second-lowest cost silver plans and the lowest cost bronze plan were all offered by new carriers in 2015. All three switched from the carriers that were offering them in 2014, highlighting the importance of shopping around during open enrollment.
Also in the Cleveland area, the benchmark plan for a 40-year-old non-smoker averaged $247 per month in 2015, down two dollars from $249 in 2014.
Medicaid expansion in the Buckeye state
Ohio Governor John Kasich is not an ACA proponent, but he’s long been a supporter of expanding Medicaid in Ohio, which was approved in late October 2013. Eligible residents were able to begin enrolling in expanded Medicaid on December 9, 2013 and the state received 1,165 applications on the first day of enrollment. By October 2015, net enrollment in Ohio’s Medicaid program had grown by 27 percent since the fall of 2013.
However, opponents of Medicaid expansion brought a lawsuit against the Ohio Department of Medicaid and the state’s Controlling Board because the General Assembly was bypassed in the decision to expand Medicaid. The plaintiffs hoped to block the state from expanding Medicaid, but on December 20th, 2013 the Ohio Supreme Court sided with Governor Kasich and kept Ohio Medicaid expansion on track. The Court’s ruling came less than two weeks before expanded Medicaid took effect.
Although Medicaid expansion is going well in Ohio, Governor Kasich has continued to reiterate his support for repealing Obamacare. In October 2014, he said that he’d like to see a full repeal, but with an accommodation for Medicaid expansion. ACAsignups’ Charles Gaba crunched the numbers and points out that if Ohio were to pay for its own expanded Medicaid (which would have to be the case if they wanted to keep it even in the face of a full repeal of the ACA), it would amount to an $840 million annual tax increase shouldered by the people of Ohio (reminiscent of Mitch McConnell pushing for repeal of the ACA while allowing Kentucky to keep Kynect?).
Kasich campaigned — but lost — in the 2016 GOP presidential race, and he’s worked to distance himself from Obamacare — officially calling for repeal — while supporting many pivotal aspects of the law. But his support for Medicaid expansion remains steadfast, with Kasich noting — correctly — that if the state had not expanded Medicaid, Ohio residents would have been footing the tax bill to provide coverage for residents of other states, while realizing none of their benefits in their own state.
2014 enrollment and prices
By mid-April, 154,668 Ohio residents had completed their Obamacare enrollment, selecting private plans in the exchange.
And by the end of August, 367,395 people in Ohio had enrolled in the newly-expanded Medicaid program in Ohio – surpassing the state’s estimate for this year and next year combined. In addition, by mid-April another 124,195 people had enrolled in Medicaid who qualified based on the old guidelines but had not been previously enrolled. Their enrollment is due in large part to the attention that ACA implementation has brought to the Medicaid program, called the “woodwork” effect.
All told, that’s over 646,000 people in Ohio who obtained new health insurance by the fall of 2014, thanks to Obamacare.
A report released by HHS in June 2014 compared after-subsidy premiums paid by exchange enrollees in the 36 states where HHS was running the exchange that year. In Ohio, the average after-subsidy premium was $121 per month – significantly higher than the $82 per month average across all 36 states.
Ohio’s after-subsidy premiums in 2014 were the fourth highest among the 36 states (only New Jersey, North Dakota and Delaware are higher), but the discrepancy is a factor of the enrollees’ incomes and the plans they selected: The ACA completely levels the field for people with the same incomes who select the second-lowest-cost silver plan in their exchanges. But among enrollees who qualify for subsidy, there are significant differences in income, and enrollees are free to apply their subsidies to any “metal” plan in the exchange.
Although the average after-subsidy premiums are higher in Ohio than in most other states, base rates in the Ohio exchange are just slightly lower than the average of the 36 states where HHS is running the exchange. Averaged across all age groups, the lowest cost 2014 bronze plan in the Ohio exchange was $263/month, and the lowest cost silver plan was $304/month.
Exchange history in Ohio
In November 2012, Governor Kasich formally announced that Ohio would not implement a state-run health insurance exchange. In the same letter, Kasich indicated that Ohio would retain control of plan management activities and determining eligibility for the state’s Medicaid and Children’s Health Insurance Plan (CHIP). Ohio is one of seven states that use the marketplace plan management model.
CMS announced on November 22 that the technology necessary for applicants to enroll in exchange plans directly through insurers was working and being piloted in three states, including Ohio. The program was summarized in a presentation by Families USA in early March.
Ohio residents can compare plans, determine subsidy eligibility and enroll in coverage at Healthcare.gov.
Leadership’s opposition to the ACA
In June 2013, the Ohio Department of Insurance issued a press release announcing that 14 insurers filed plans to offer more than 200 options for individual insurance, and seven insurers would offer 84 options for small businesses (ultimately, two carriers backed out, leaving 12 in the exchange in 2014). Lt. Gov. Mary Taylor, who also directs the state’s insurance department, stated in the press release that “consumers will have fewer choices and pay much higher premiums for their health insurance starting in 2014.”
Both opponents and supporters of the Affordable Care Act jumped on the press release. Opponents claimed Ohio was the latest example of “rate shock.” Supporters dismissed the announcement for making “apples-to-oranges” comparisons and pointed out that both Kasich and Taylor have been outspoken about their opposition to the ACA.
Taylor is still no fan of the ACA, and was the Director of the Ohio Department of Insurance until 2017, when Jillian Froment was appointed by Kasich to lead the agency (Taylor is still the Lieutenant Governor, and is a candidate for governor in the 2018 race). In a May 2014 press release, Taylor said that “Obamacare is hitting us harder and driving our costs up significantly.”
Laws were enacted in Ohio to make it more difficult for navigators to be certified, which means that the state has fewer people available to assist applicants, and there was a delay in getting them started as navigators after the exchange opened in October 2013.
Ohio health insurance exchange links
State Exchange Profile: Ohio The Henry J. Kaiser Family Foundation overview of Ohio’s progress toward creating a state health insurance exchange.