Community Health Alliance ceasing operations
On October 14, the Tennessee Department of Commerce and Insurance announced that Community Health Alliance, the state’s ACA-created CO-OP, would wind down its operations by the end of the year. Regulators noted that the shut-down at the end of 2015 was based on the fact that “the risk of CHA’s potential failure in 2016 was too great and would have caused substantial detrimental effects on the market as a whole if it were to collapse.”
Community Health Alliance is the sixth CO-OP to shut down thus far, and the fifth since July. As was the case with Kentucky‘s CO-OP earlier in October, Community Health Alliance’s demise was at least partially triggered by the fact that HHS announced on October 1 that risk corridor payments to insurers in December (based on 2014 losses) would end up being only 12.6 percent of what was owed.
Community Health Alliance had the lowest prices in the exchange for 2015, but proposed an average rate increase of 32.6 percent for 2016 (and regulators increased the rate hike to 44.7 percent in an effort to keep the carrier sustainable). The CO-OP stopped selling 2015 plans as of January 15, 2015, noting that they had already met their enrollment goal for the year. No new enrollees joined the CO-OP since January, but there are still 27,000 current enrollees who will need to select new coverage for 2016 from a different carrier. Community Health Alliance had planned to begin selling plans again during the 2016 open enrollment, but instead they’ll be ceasing operations altogether by the end of 2015.
Community Health Alliance members can keep their current coverage through the end of the year, and can continue to incur claims. Provider networks will remain intact throughout the rest of the year.
Tennessee mayors urge residents to get covered
The ACA’s third open enrollment period is underway, and the mayors of Tennessee’s four largest cities are reaching out to their constituents to urge them to visit Healthcare.gov or GetCoveredTenn.org to seek assistance with the enrollment process.
Chattanooga Mayor Andy Berke, Knoxville Mayor Madeline Rogero, Memphis Mayor AC Wharton, and Nashville/Davidson County Mayor Megan Barry have joined together with Get Covered Tennessee and Enroll America “to make it as easy as possible for every resident of our great cities to get access to the information they need to get covered.”
2016 rates and carriers
Tennessee had among the highest rate average rate increases in the country for 2015, yet still ended up with among the lowest overall rates (see below). And Tennessee once again made headlines with rate filings for 2016.
Of the five carriers in the Tennessee exchange, four filed proposed rates for 2016. The fifth carrier, Assurant, announced they are exiting the individual market nationwide, and will not participate in open enrollment this fall.
Then, just two weeks before the start of open enrollment, regulators in Tennessee announced that Community Health Alliance would cease operations by the end of 2015, and their plans would not be for sale during open enrollment.
But UnitedHealthcare is joining the Tennessee exchange for 2016, so there will be four carriers from which to choose. Rates were finalized by the Tennessee Department of Commerce and Insurance in late August:
- Blue Cross Blue Shield of Tennessee: 36.3 percent average rate increase. BCBS is the dominant carrier in the state, with 70 percent of the market share. Their proposed 36.3 percent average rate increase was approved as requested.
- Humana: 5.8 percent average rate increase. Initially, Humana requested a 15.8 percent rate increase, and state regulators approved it. But Humana subsequently decided to stop offering their platinum plans, resulting in an average rate increase of just 5.8 percent for their remaining plans.
- Cigna: 0.4 percent average rate increase. State regulators approved Cigna’s proposed 0.4 percent average rate hike.
- UnitedHealthcare: Monthly premiums range from about $94 to $1,123; 2016 will be UHC’s first year offering plans in the exchange, so there’s no rate increase.
In terms of market share in the exchange, BCBS of Tennessee has 164,896 enrollees in 2015, while Community Health Alliance had 35,761 members in May, but that had dropped to around 27,000 by October. The other 30,783 exchange enrollees are spread among the three remaining carriers.
The exit of Community Health Alliance from the marketplace actually serves to reduce the weighted average rate increase, since CHA had the highest rate increases of any of the carriers (44.7 percent). But all of CHA’s enrollees will need to switch to a plan offered by one of the other carriers in order to continue to have coverage in 2016.
The rate changes described above are for pre-subsidy premiums; subsidies will cushion the impact of rate increases for the majority of the exchange enrollees in Tennessee (84.5 percent of private plan enrollees in the Tennessee exchange are receiving premium subsidies). Subsidies will limit benchmark plan premiums to a set percentage of an enrollee’s income, as long as the enrollee doesn’t earn more than 400 percent of the federal poverty level.
Carriers note that the proposed rate changes for 2016 are much more fact-based than the rates we saw in 2014 and 2015. For 2014, carriers could do little more than make educated guesses. Even for 2015, the rates were filed in the spring of 2014, within weeks of the end of the first open enrollment period. That meant there was very little in the way of actual claims data for actuaries to use when creating rates for the coming year. But the rates that carriers proposed for 2016 were based on more than a year of claims data (all of 2014 plus the early part of 2015). And industry experts point out that there shouldn’t be as much price variation from one carrier to another as we go forward, since they’re all able to base premiums on actual claims experience now.
Although Tennessee’s rate hikes will be considerable in 2016, these changes have to be viewed against the backdrop of Tennessee having lower-than-average rates in 2014 and 2015. And as always, it is vitally important that enrollees shop around during open enrollment to make sure they end up with the plan that represents the best value for their needs in 2016.
The five exchange carriers are also selling plans outside the exchange in Tennessee. In addition, four other carriers sell plans only outside the exchange: Tennessee Rural Health, UnitedHealthcare Life Insurance Company, Aetna, and Freedom Life Insurance Company of America.
King v. Burwell – subsidies are safe
On June 25, the Supreme Court ruled that subsidies are legal in every state, regardless of whether the exchange is run by the state or federal government.
The Tennessee Department of Insurance confirmed that if the Supreme Court had eliminated subsidies in Tennessee (and other states that use Healthcare.gov), carriers in Tennessee would have been required to submit revised rates for 2016. There is no doubt those rates would have been considerably higher than the initially-proposed rates, so everyone who purchases individual insurance in Tennessee is certainly better off with the Court’s ruling against the King plaintiffs.
In addition to sharply higher rates market-wide, an estimated 164,000 people in Tennessee would have lost their subsidies – and in most cases, their health insurance – if the subsidies had been struck down.
But some lawmakers in Tennessee supported the King plaintiffs, and tried to eliminate subsidies in states like Tennessee that use the federally facilitated marketplace. In December 2014, 19 Tennessee lawmakers (some current, some former) signed an amicus brief that was delivered to the Supreme Court, asking the Court to rule that subsidies are not legal in states with HHS-run exchanges.
2015 enrollment data
231,440 people enrolled in private plans through the exchange during the 2015 open enrollment (November 15 to February 22, including the week-long extension). 53 percent of Tennessee’s enrollees were new to the exchange for 2015, and 83 percent were eligible for premium subsidies.
HHS had projected that Tennessee’s exchange would enroll 195,000 people during the 2015 open enrollment period (up from the 151 thousand who enrolled during the 2014 open enrollment period). Ultimately, the exchange far surpassed that target – unsurprisingly, given that it was already at 99 percent of the projected enrollment in January.
But by the end of June, attrition had resulted in the effectuated (paid-up) enrollment falling to 177,453 people. Nearly 85 percent of them are receiving premium subsidies, and 63 percent are receiving cost-sharing subsidies.
In addition to the private plan enrollees, 40,373 Tennessee exchange enrollees were eligible for Medicaid or CHIP between November 15 and February 22, despite the fact that the state has not yet expanded Medicaid and is continuing to use the old eligibility guidelines.
According to Gallup data, the uninsured rate in Tennessee in 2013 was 16.8 percent, and fell to 12.9 percent by the first half of 2015. It would be considerably lower if Tennessee had expanded Medicaid, but even still, the state is making progress.
In mid-2014, Blue Cross Blue Shield of Tennessee filed rate proposals with an average increase of 19 percent for 2015. Cigna was proposing a rate increase of 7.5 percent, while Humana’s came in at 14.4 percent. Once rates were approved, the average rate increase in Tennessee across all eight carriers in the individual market (including on and off-exchange plans) came in at 12.5 percent, making it one of eight states in the PricewaterhouseCooper analysis with double digit average rate increases.
But that’s only part of the story. Because Tennessee had rates so much lower than the national average in 2014, their rates are still much lower than most states in 2015, even after the rate hikes. A Kaiser Family Foundation analysis of benchmark plan (second lowest-cost silver plan) premium changes in major metropolitan areas in all 50 states found that the Nashville area still has the fifth lowest average benchmark premium in the country in 2015, even after an increase of nearly 8 percent.
Tennessee’s rate changes are a perfect example of why it’s so important for enrollees to go back to the marketplace and double check their options for the coming year, rather than simply letting their plan auto-renew. In virtually every area of Tennessee, people who enrolled in the benchmark plan in 2014 and opted to renew that plan for 2015 were subject to rate increases that averaged at least 15 percent. But people who shopped around and switched to the new benchmark saw much more modest rate changes in most areas – even a decrease in the western part of the state.
Across all metal levels and plans sold in the exchange, a Commonwealth Fund analysis found an average 2015 rate increase of 9 percent in the Tennessee exchange, for a 40 year-old non-smoker.
Outreach and education
Blue Cross Blue Shield of Tennessee – by far the dominant carrier in the exchange in 2014, began conducting outreach to target Latino and Millennial populations during the second open enrollment period, as both demographics were under-represented during the first round of enrollments.
Blue Cross Blue Shield of Tennessee is also focusing on general education and enrollment assistance state-wide, after a survey found that 80 percent of the 2014 enrollees signed up without any help, just using HealthCare.gov on their own. Many of them didn’t understand all of the details of their coverage as a result, and BCBSTN has been working for the last year to make sure that people receive help with the renewal and enrollment process.
The Tennessee Health Care Campaign is also working to provide education and enrollment outreach in Tennessee.
Get Covered America-Tennessee announced in June 2014 that Jacob Flowers would be their new director. Flowers’ job initially was to educate and enroll as many people as possible during the 2015 Obamacare open enrollment period, utilizing resources that have already been allocated to Tennessee. In September 2015, Flowers announced that Get Covered Tennessee had been awarded $1.65 million to fund outreach activities for 2015. In announcing the award, CMS noted that Get Covered Tennessee “is a statewide network of agencies that will provide a physical ACA presence in all 95 TN counties—a first for TN.”
2014 enrollment stats
151,352 Tennessee residents had completed their Obamacare enrollment in private plans through the exchange by April 19, 2014. The final total was 23% more than the original projected target for Tennessee.
Although Tennessee had a strong 2014 open enrollment period, there is still a long way to go. Prior to the first open enrollment period, the Kaiser Family Foundation estimated that 645,000 Tennessee residents would be eligible to purchase policies in the exchange, and 387,000 of them would qualify for subsidies to do so.
But as in all states, the realities of getting people enrolled – especially people who have never had insurance before and are entirely unfamiliar with the system – have proved challenging in Tennessee.
Governor pursued Medicaid expansion
Although the state’s Medicaid enrollment system has been plagued with difficulties, an additional 83,591 exchange enrollees were eligible for Medicaid under the state’s existing rules, despite the fact that Tennessee has not expanded Medicaid. In November 2013, TennCare requested an additional $180 million for its budget as a result of the influx of new applications.
In late March, Tennessee Democrats called on their state and their governor to move forward with Medicaid expansion, or at the very least, Governor Bill Haslam’s “Tennessee Plan,” noting that anything is better than nothing for the 161,000 residents who are currently in the “coverage gap” – not eligible for Medicaid, and not eligible for exchange subsidies.
Haslam spent much of 2014 discussing options with the federal government and TennCare. Although public approval for the ACA overall is relatively low in Tennessee, the majority of the state’s voters – 56 percent according to a November Vanderbilt poll – support Medicaid expansion.
Then in mid-December, Haslam unveiled his Insure Tennessee plan that would include two options: one would involve privatized TennCare participation, and the other would involve vouchers that would allow workers access to previously-unaffordable employer-sponsored coverage. Enrollees with incomes between 100 percent and 138 percent of poverty level would be required to pay modest premiums for their coverage.
A study conducted by the University of Tennessee’s Center for Business and Economic Research determined that Haslam’s Insure Tennessee plan would bring about 50,000 jobs to the state, along with $1.14 billion in new spending to drive the economy. But the legislature still had to agree to Haslam’s plan…
but Senate committee rejected expansion
A special legislative session to address Governor Haslam’s Insure Tennessee plan convened on February 2. But ultimately, just two days later, the Senate Committee for Health and Welfare rejected the proposal by a 7 to 4 vote. That means it will not proceed to the Senate floor for debate, and Medicaid expansion is likely off the table in Tennessee for this year.
But there is certainly some support within the legislative body for Medicaid expansion. In fact, US Rep. Steve Cohen has called out Gov. Haslam on his opposition to straight Medicaid expansion (Haslam’s plan involves private insurance for the Medicaid-eligible population), and wants Tennessee to move forward with Medicaid expansion – including accepting $1 billion in federal funds – as outlined under Obamacare.
And after the Supreme Court’s King v. Burwell ruling kept subsidies available in the Tennessee exchange, supporters of Medicaid expansion renewed their push for expanded access to healthcare, rallying in Nashville on June 29 for a news conference to call attention to the fact that millions of Americans – including 161,000 in Tennessee – are essentially locked out of health coverage altogether, since they have incomes below the poverty level and they’re in states that haven’t expanded Medicaid.
Supporters of Insure Tennessee continue to advocate for the expansion of Medicaid, and are touring the state raising awareness of the need to accept federal funds to expand the state’s Medicaid program.
Tennessee ACA legislation and regulations
Although the ACA is obviously popular with the hundreds of thousands of Tennessee residents who have new coverage in place, GOP lawmakers in the state moved forward in mid-January 2014 with a bill that would prevent state and local government entities – and state contractors – from participating in the HHS-run exchange.
By late March 2014, the bill was still in committee in the senate, and no further action was taken during the 2014 legislative session.
The Tennessee Department of Commerce and Insurance drew attention for emergency rules issued shortly before the Oct. 2013 launch of the new marketplace. The emergency rules require individuals who will help others use the new health insurance marketplace be fingerprinted and undergo background checks, and would have forbidden lay people from assisting their friends and neighbors with health insurance applications.
Religious and community groups questioned the motivation behind the rules and sued to block the rules. A judge didn’t block the emergency rules, but did agree they were too broad and could be interpreted to apply to those giving informal advice, and a temporary restraining order against the rules was issued. Two lawsuits were brought against the emergency rules, and by mid-October the state government had backed off of the rules, making it easier for people to assist others in Tennessee, both formally and informally.
History of the Tennessee exchange
In December 2012, Gov. Haslam announced Tennessee would not develop its own health insurance exchange, citing a lack of information from the federal government.
Prior to his 2012 announcement, Haslam had leaned toward a state-run exchange. He believed local state control was preferable and that the state could run the exchange more cost-effectively that the federal government.
However, Republican legislators opposed the exchange, Tea Party supporters staged repeated protests, and Tennessee eventually ended up with an exchange run by HHS.
Tennessee health insurance exchange links
Health Assist Tennessee
Helps connect Tennesseans with public and private programs to meet health care needs and assists TennCare members with access to medical care.
State Exchange Profile: Tennessee
The Henry J. Kaiser Family Foundation overview of Tennessee’s progress toward creating a state health insurance exchange.