In a change from 2015, only two carriers will offer plans in South Dakota’s exchange in 2016, as DAKOTACARE opted to switch to only offering plans outside the exchange in 2016 (they offered both on and off-exchange plans in 2014 and 2015). Of the two remaining exchange carriers, both have requested double digit rate increases, in the range of 13 to 14 percent:
- Avera: proposed 13.69 percent rate increase (13 percent when weighted based on 2015 enrollment, but the 13.69 percent increase is based on projected 2016 enrollment)
- Sanford: proposed 13.2 percent rate increase (3,181 members – all on-exchange – according to Sanford).
Celtic also offers off-exchange plans in South Dakota, but their market share is very small in 2015.
Rates have not been finalized yet, and regulators are reviewing each carrier’s proposed rates to determine whether they need to be adjusted. In general, carriers have cited higher-than-expected claims costs for 2014 enrollees as a reason for the proposed premium increases, but some experts believe that the “pent-up” demand for healthcare in that group of enrollees will not continue to be seen in future years, since 2014 enrollees were more likely to have been previously uninsured.
Also, it’s important to remember that the average premium in South Dakota decreased in 2015, and the possibility of higher rate hikes for 2016 have to be viewed with that in mind.
Subsidies will absorb much of the rate increase for most enrollees in the South Dakota exchange, but it will be important for consumers to shop around during open enrollment (November 1 to January 31), as subsidies are tied to the second-lowest-cost silver plan in each area, and that “benchmark” plan can change from one year to the next.
In addition to Sanford and Avera, two other carriers requested double digit rate increases, but they’re both only offering plans outside the exchange for 2016:
- DAKOTACARE (SD State Medical Holding Co. Inc.) initially proposed an average rate increase of 18 percent, but later refiled new, higher rates with an average rate increase of 63.2 percent.
- Wellmark: average proposed rate increase of 43 percent.
Unlike the past two years, DAKOTACARE has opted to only offer plans outside the exchange in 2016. Current on-exchange DAKOTACARE enrollees will need to switch to Sanford or Avera if they wish to continue to have coverage through the exchange (this is essential for any enrollees who are receiving subsidies, as those are only available through the exchange).
Wellmark has never participated in the South Dakota exchange. But given the magnitude of their requested rate increase for 2016, their current enrollees should consider options on the exchange during open enrollment and compare them with what Wellmark is offering for 2016; they may find that a switch to an on-exchange carrier could result in lower premiums, even if they don’t qualify for subsidies.
21,393 people had enrolled in private plans through the exchange in South Dakota as of the end of open enrollment on February 22. This was a 63 percent increase from the total enrollment at the end of the 2014 open enrollment period last April. Of the 21,393 people who enrolled for 2015, 53 percent of the 2015 enrollees were renewing coverage from 2014, while the other 47 percent were new to the exchange this year.
Enrollment in South Dakota for 2015 was the fourth lowest among states with HHS-run exchanges – North Dakota, Alaska, and Wyoming all had lower total enrollment.
Attrition is a normal part of the individual health insurance market; some people never pay their initial premiums, some cancel their coverage, and others have their coverage cancelled because they failed to provide proof of immigration status. By June 2015, in-force enrollment in private plans through the South Dakota exchange stood at 18,983 people. 87.5 percent of them are receiving premium subsidies that average $224 per month.
For the first half of 2015, there was great concern that those subsidies would have evaporated if the King plaintiffs had prevailed in King v. Burwell. If the Court had ruled that subsidies could only be provided by state-run exchanges, coverage for many of those 16,610 South Dakota residents would have become unaffordable; the Kaiser Family Foundation estimates that their premiums would have increased an average of 178 percent if their subsidies had been eliminated. Fortunately for those enrollees and the entire individual health insurance market, that did not come to pass.
In addition to private plan enrollments, 2,861 South Dakota residents enrolled in Medicaid or CHIP through the exchange between November 15 and February 22. Medicaid enrollment continues year-round, but tends to peak during the general open enrollment due to the additional outreach and exchange marketing.
Open enrollment has ended for 2015, but it will begin again for 2016 on November 1, 2015. Residents who have a qualifying event can still purchase coverage for 2015. Enrollment is also year-round for Native Americans and anyone who qualifies for Medicaid or CHIP.
Lower rates for 2015
In 2015, three insurers offered policies through the marketplace in South Dakota: Avera Health Plans, Sanford Health Plan, and DAKOTACARE. The three companies offered a total of 38 options for individuals and families.
Although there were no new carriers in the South Dakota exchange in 2015, the three existing carriers are offering a variety of plans, including some new HSA-qualified options from Avera and an Avera plan that gives insureds lower out-of-pocket costs if they use an Avera provider.
The South Dakota Division of Insurance announced in their fall 2014 newsletter that 2015 rates were available on their website. The page includes links to all of the participating medical and dental carriers, as well as a searchable rates page and summaries that show minimum, maximum, and average rates based on age and location within the state.
According to a report released by the U.S. Department of Health and Human Services (HHS), the average cost for a bronze plan —the lowest-cost option — in South Dakota was $298 a month in 2014. The national average for a bronze policy was $249 a month in 2014. The lack of competition is one of the main reasons South Dakota’s premiums are higher than the nation average.
But the news was much better for 2015. A Commonwealth Fund analysis of average premiums across all metal levels for a 40 year-old non-smoker found an average premium decrease of 21 percent in South Dakota from 2014 to 2015. And an interactive map from the NY Times Upshot shows that in most areas of the state, people who switched from the 2014 benchmark (second lowest-cost silver) plan to the new benchmark plan for 2015 were able to obtain premium decreases.
When we include both on and off-exchange plans and look at the entire individual market in South Dakota, the average premium increase for 2015 was 2 percent, as calculated by PricewaterhouseCooper LLC. This was still dramatically lower than the nationwide historical trend for the individual market.
Insurance ballot initiative making headlines
South Dakota was in the national news in the fall of 2014 because of a ballot initiative pertaining to health insurance networks that voters overwhelmingly approved in November. Amendment 17 was billed by supporters as “freedom to choose your doctor” but critics pointed out that it’s not as simple as proponents made it seem. Doctors and small or specialty hospitals were generally in favor of Amendment 17, while large insurers (including Sanford and Avera) and hospital networks were opposed. Ultimately, the measure passed 62 percent to 28 percent.
This does not mean that patients can choose any doctor they want though. Rather, it means that any doctor who is willing and able to comply with the terms and conditions of the health insurance carrier could enter the carrier’s network.
Because narrower networks have become commonplace over the last year, policy experts in other states were closely watching the outcome of the SD ballot initiative. A total of 27 states have “any willing provider” laws on their books, although only about half of them are as broad as South Dakota’s.
Three nonprofits providing enrollment help
Two nonprofit agencies in South Dakota received navigator grants from HHS in September 2015, and will have navigators available to help people enroll in person and over the phone. Great Plains Tribal Chairmen’s Health Board, and South Dakota Community Action Partnership received a total of $600,000 in navigator grants for funding through September 2018.
Wellmark avoids SD exchange, still #1 in sales
Wellmark Blue Cross Blue Shield had 73 percent of the market share in South Dakota prior to the 2014 open enrollment period, but the insurance giant opted to stay out of the exchange in 2014, in 2015, and again in 2016. People who wish to purchase coverage from the state’s largest insurer must do so off-exchange, without the ACA’s subsidies.
Despite that caveat, Wellmark said it sold more policies outside the exchange in South Dakota in 2014 than the two on-exchange carriers combined (new policies sold outside the exchange are still fully compliant with the ACA).
So exchange enrollment low in 2014
13,104 people had enrolled in private plans in the South Dakota exchange by April 19, 2014, at the end of the first open enrollment period. Of those enrollees, 11,000 selected plans from Avera. Sanford enrolled 2,262 people and had another 500 applicants whose enrollment was pending because of unpaid premiums.
During the first half of the 2014 open enrollment period (October 1 – December 24), the large majority of the enrollments in South Dakota were with Avera (1,889). Sanford reported 629 enrollees by December 24, while DAKOTACARE – which is focusing more on the small group market – had fewer than 50 enrollees. The carriers have not yet released total enrollment numbers for the second half of open enrollment.
89 percent of South Dakota residents who enrolled in the exchange during the 2014 open enrollment period received a premium tax credit, and the average after-subsidy premium was $101 per month – a 73 percent reduction from the $372 per month average pre-subsidy premium.
But during the 2014 open enrollment period, only 11.1 percent of South Dakota’s subsidy-eligible residents enrolled in coverage through the exchange – tying Iowa for the lowest percentage in the nation.
The fact that Wellmark did not participate in the exchange is cited as one of the reasons for the low enrollment in the state. The carrier’s huge market share and name recognition coupled with the fact that existing Wellmark members had no means of keeping their carrier and also obtaining subsidies, meant that enrollment lagged behind the rest of the country in South Dakota.
No Medicaid expansion
3,850 exchange applicants enrolled in the state’s Medicaid program by mid-April 2014, qualifying under the state’s existing eligibility guidelines. South Dakota has not expanded Medicaid under the ACA, although Governor Dennis Daugaard has twice submitted a proposal to HHS for a waiver that would allow the state to expand Medicaid to people with incomes up to 100% of poverty level, instead of 138% of poverty level. As of mid-January 2015, Daugaard is still holding firm with his position, pushing for Medicaid expansion just for people with incomes below 100 percent of the poverty level.
HHS has rejected Daugaard’s proposals though, saying that expansion must extend to people with incomes between 100% and 138% of poverty level in order to be approved. Because the state has not accepted federal funds to expand Medicaid, 26,000 South Dakota residents fall into the coverage gap – they earn too much money to qualify for Medicaid, but too little to qualify for subsidies in the exchange.
As of late October 2014, 45 percent of surveyed South Dakota residents said they favored Medicaid expansion, while just 37 percent opposed it.
The decision to not expand Medicaid disproportionately affects the Native American population in South Dakota. Officials estimate that there are 14,000 Native Americans who would gain access to Medicaid if the state were to expand the program. This includes people who earn between 100 percent and 138 percent of poverty and are currently eligible for subsidies in the exchange. Many of them have not opted for private exchange plans though, for a variety of economic and cultural reasons.
But uninsured rate lower than average
Despite the lackluster exchange enrollment and the state’s refusal to expand Medicaid, the uninsured rate in South Dakota is lower than the national average. In South Dakota, 14 percent of the population was uninsured in 2013, and that number had dropped to 11.3 percent by mid-2014 and 7.2 percent during the first half of 2015 (the average for states that did not expand Medicaid and also opted to have HHS run their exchanges was 13.4 percent by mid-2015).
Grandmothered plans can renew
On November 26, 2013 the state announced that it would allow carriers to extend existing policies per President Obama’s suggestion that non-compliant plans be allowed to remain in effect for one more year. Sanford, Wellmark and DAKOTACARE all opted to allow existing policies to be renewed into 2014, giving insureds another option to compare with the new ACA-compliant plans.
The state also accepted the HHS proposal to allow those plans to renew again in late 2014 and continue in force until as late as September 2017.
Exchange history and outreach
Gov. Daugaard announced in late September 2012 that HHS would be running the state’s exchange, citing the high cost — estimated at $6.3 to $7.7 million — for ongoing operation of the exchange.
The state is not playing any role in promoting the new health insurance options or educating consumers about the marketplace. That decision leaves outreach efforts to the insurers and federally funded “navigators.” Navigators are affiliated with established community outreach and advocacy groups, and they are trained to help consumers understand and use the new online marketplace.
South Dakota health insurance exchange links
State Exchange Profile: South Dakota
The Henry J. Kaiser Family Foundation overview of South Dakota’s progress toward creating a state health insurance exchange.