2017 rates and carriers
14 carriers are planning to sell plans in the Texas exchange in 2017, although Cigna is considering withdrawing from the exchange, which would reduce the total to 13.
Scott & White, Aetna, and All Savers/UnitedHealthcare are exiting the state’s individual market at the end of 2016—details below.
Humana is also exiting exchanges in several states, but they filed rate and plan information for their HumanaOne HMO product to be sold on the Texas exchange in 2017—albeit with a proposed rate increase of more than 45 percent. As of August 2016, Humana had indicated that they would be exiting the exchange in some counties, including Harris County.
At ACA Signups, Charles Gaba has calculated a weighted average proposed rate increase of about 35 percent across the full individual market in Texas (including carriers that only sell off-exchange plans). Texas does not have an effective rate review program, so CMS (specifically, CCIIO) conducts the rate review for plans that are sold in the Texas exchange.
The following average rate increases have been proposed by the carriers that plan to offer coverage in the Texas exchange in 2017:
- Allegian: 27.48 percent
- AmBetter (Celtic): 15.51 percent
- Blue Cross Blue Shield of Texas: 58.4 percent
- CHRISTUS Health: 17 percent to 30 percent
- Cigna: 23.5 percent (but possibly exiting the exchange)
- Community First: 7.5 percent to 8.7 percent
- Community Health Choice: 6.91 percent
- FirstCare (SHA): 29.13 percent
- Humana: 45.35 percent
- IdealCare (Sendero): 19.68 percent
- Insurance Company of Scott & White: 19.62 percent
- Molina: 9.6 percent
- Oscar: 11.7 percent to 22.3 percent (coverage area is being reduced; plans will not be available in the Dallas area in 2017)
- Prominence Health First: 31.85 percent
Although rate hikes in the Texas exchange are likely to be substantial in 2017, premium subsidies will offset some or all of the rate increase for eligible enrollees. Particularly in a market like Texas, where there are numerous plans available and a strong possibility that the benchmark plan will be offered by a different carrier from one year to the next, it’s essential for enrollees to compare all of their options during open enrollment. As of March 2016, nearly 84 percent of Texas exchange enrollees were receiving premium subsidies.
UnitedHealthcare exiting at year end
UnitedHealthcare is exiting the exchange in Texas at the end of 2016, as is the case in most of the states where United currently offers exchange plans. The carrier will continue to offer group plans in Texas, but not through the exchange, and will not offer any individual market plans in the state, on or off-exchange. United’s decision follows mounting losses in the ACA-compliant market, which the carrier deemed unsustainable.
According to a Kaiser Family Foundation analysis, United only offers plans in 30 of the 254 counties in Texas. But they are the counties with the most enrollees: 80 percent of Texas exchange enrollees have UnitedHealthcare as an option in 2016. If no other carriers join or expand coverage areas, United’s departure will result in seven Texas counties having only one exchange insurer in 2017, while another three counties will have only two carriers offering plans.
The vast majority of the counties in Texas will continue to have three or more carrier options, which is not surprising given that Texas is among the states with the highest number of participating exchange carriers. All UnitedHealthcare enrollees will need to select plans from other carriers during the upcoming open enrollment period that begins on November 1.
Although United sells exchange plans in 30 Texas counties, there are only eight counties where United offers one of the two lowest-cost Silver plans. The lowest-priced silver plans tend to be the most popular with enrollees.
According to the Texas Department of Insurance, three carrier entities are impacted by United’s exit. No plans will be available in 2017 from these three entities in Texas, and their current policy-holders will need to secure new coverage during open enrollment, which begins November 1:
- All Savers Insurance Company – currently 128,055 members
- UnitedHealthcare Life Insurance Company – currently 28,611 members
- UnitedHealthcare Insurance Company (SHOP exchange for small businesses) – current member count not available, and small group products from UnitedHealthcare Insurance Company will still be available off-exchange in 2017.
The member counts include both on and off-exchange enrollments, and are a relatively small portion of the Texas individual market (just on-exchange, there were 1.09 million enrollees in Texas as of March 31).
Aetna, Scott & White also exiting
In August, Aetna announced that they would exit the exchanges in 11 of the 15 states where they currently offer exchange plans. Texas is one of the states where Aetna’s exchange enrollees will have to secure new coverage. Off-exchange plans will still be available from Aetna in Texas in 2017.
Scott & White Health Plan also announced in August that they would exit the exchange in Texas at the end of 2016. They will continue to offer coverage outside the exchange, but only bronze plans — they’re discontinuing all of their silver and gold plans. Scott & White currently has plans in the Texas exchange in 58 counties.
Oscar reducing coverage area
Oscar will remain in the Texas exchange, but not in the Dallas area. They will continue to offer plans in San Antonio in 2017.
Uninsured rate down to 16.8%
Prior to the ACA’s implementation, the uninsured rate in Texas was about 25 percent. By 2015, it had fallen to 16.8 percent, according to the Centers for Disease Control and Prevention. Texas still has the highest uninsured rate in the country, and the national average in 2015 was down to 9.1 percent. But Texas has made considerable progress in the last few years, despite the fact that the state still has not accepted federal funding to expand Medicaid under the ACA.
1.3 million enrolled for 2016, effectuated enrollment still over 1 million
1,306,208 people enrolled in private plans for 2016 through the Texas exchange during open enrollment. The total includes new enrollees as well as renewals. For perspective, total enrollment at the end of the 2015 open enrollment period was 1,205,174.
Overall, Texas had the second-highest 2016 enrollment in the country, but is trailing Florida by a significant margin – some of the reasons why are addressed in this Dallas Morning News article.
By March 31, effectuated enrollment stood at 1,092,650. That’s an attrition rate of about 16 percent, which is higher than the national average. But the effectuated enrollment total at the end of the first quarter of 2016 is still 13 percent higher than the effectuated enrollment total (966,412) at the end of the first quarter of 2015.
The Texas Hospital Association mounted a significant marketing campaign to get people enrolled in health insurance through the exchange, and their efforts seem to have paid off, particularly during the final enrollment push in late January. Across all 38 states that use Healthcare.gov, in the final week the 2016 open enrollment period, eight of the ten local areas with the fastest-growing enrollment numbers were in Texas: Corpus Christi, Harlingen, Laredo, El Paso, Odessa-Midland, San Antonio, Abilene-Sweetwater, and Lubbock.
Open enrollment ended January 31. Coverage for 2016 (including off-exchange coverage) is now only available for people who experience a qualifying event that triggers a special enrollment period. Although Native Americans can enroll year-round (through the exchange), as can anyone eligible for Medicaid or CHIP.
Few remaining PPO options
In some parts of Texas – including Houston – there are no PPO plans available on the exchange for 2016.
Following a similar trend that’s happening in many other states, Blue Cross Blue Shield of Texas decided to stop offering their individual PPO plans in 2016, and instead move to an HMO-only model. They retained their Blue Advantage HMO network, but the Blue Choice PPO network is no longer available to individuals who purchase their own coverage.
BCBS of Texas has 5 million members across the state, but most of them are enrolled in employer group plans. The PPO plans is still available in the employer group market, and grandfathered PPO plans in the individual market (those that were already in force in 2010 when the ACA was signed into law) are not impacted by the decision. But 300,000 people (possibly as many as 367,000) were transitioned to one of the HMO options offered by Blue Cross Blue Shield of Texas – and they also had the option to shop around and select a plan from another carrier, as long as they did so by January 31 (incidentally, Ted Cruz was in this group, and there was quite a media circus regarding his plan).
BCBS of Texas said that the decision to end their PPO plans was not reached lightly, but in 2014, their individual market claims exceeded premiums by $400 million. Switching to an HMO model is expected to help the carrier keep their individual products sustainable under the new rules that prohibit medical underwriting.
Cigna and Human also opted to stop offering PPO plans, citing sustainability as their reason for switching to more cost-efficient HMO models. Scott & White Health Plan and Allegian are both still offering PPO plans in the exchange in 2016, but their plans are not available in all areas of the state (Scott & White is exiting the exchange altogether at the end of 2016). In Harris County, Houston – the fourth-largest city in the US – has no PPO plans available at all for 2016 in the exchange, despite having plans available from seven different carriers.
Roughly two thirds of the carriers that offered plans in the Texas exchange in 2015 were losing money, paying out more in claims than they’re collecting in premiums. Switching to and HMO model is one way that carriers can better predict their costs and keep claims expenses down.
2016 rates and carriers
According to a Milliman report, there are 14 carriers offering individual plans in the Texas exchange for 2016, up from 13 in 2015. But Milliman’s analysis eliminates multiple carriers that have one parent company. If we look at the rate changes on Healthcare.gov’s rate review tool and also check available plans around the state on Healthcare.gov, there are options available from at least 18 separate legal entities.
Texas is one of five states that does not conduct its own review of proposed premiums for exchange plans. Instead, HHS reviewed the submitted rates, approving some as-proposed, while making adjustments to others. Most of the carriers participating in the Texas exchange also offered plans in 2015, so their average rate changes are available on Healthcare.gov’s rate review tool. Rates decreased for five carriers, and increased by between 5 percent and 34 percent for the remaining carriers:
- All Savers: 16.1 percent rate increase (a subsidiary of UnitedHealthcare; exiting at the end of 2016)
- Allegian: 12.4 percent rate increase for PPO plans; 0.06 percent rate decrease for HMO plans
- Blue Cross Blue Shield of Texas: rate changes vary from a 3.7 percent decrease, to an 18.8 percent increase for HMO plans.
- CHRISTUS Health
- Cigna: 14 percent rate increase for EPO plans; 17.3 percent rate increase for their Local Plus plans (off-exchange)
- Community First: rate decreases that range from 2.1 percent to 9.2 percent.
- Community Health Choice: 5 percent average rate increase
- FirstCare (SHA): 12.6 percent increase
- Humana: 23 percent increase for HMO; 21 percent increase for PPO (off exchange); 30 percent increase for EPO
- IdealCare (Sendero): 5.1 percent decrease
- Insurance Company of Scott & White: 34 percent average rate increase (only 1,807 insureds in 2015)
- Molina: 6.7 percent rate decrease
- Prominence Health First
- Scott & White Health Plan: 32.4 percent increase (24,294 insureds in 2015)
- UnitedHealthcare (exiting at the end of 2016)
The average rate increases are before the application of any subsidy, and the vast majority of Texas exchange enrollees are receiving subsidies. It was vitally important to shop around during open enrollment, as subsidy amounts are tied to the price of the benchmark plan (second-lowest-cost silver plan).
Statewide, the average benchmark plan is 5.1 percent more expensive in 2016, which means subsidies are higher, but only modestly. If you’re on a plan that experienced a sharp price increase for 2016, it’s likely that your subsidy didn’t increase by enough to make up the difference in premium. But the good news in Texas is that in most areas of the state, there are exchange plans available from several carriers and consumers were able to shop around during open enrollment to find the best option.
Once all of the plan selections for 2016 were finalized, 84 percent of Texas exchange enrollees qualified for premium subsidies. Their average pre-subsidy premium was $344/month, but after subsidies, they are paying an average of just $87/month.
In 2015, 85 percent of Texas exchange enrollees qualified for subsidies. Their average pre-subsidy premiums were $328/month, and their average after-subsidy premiums were $89/month. Despite sharp variations in rate increases, the average amount that people with premium subsidies are paying for their coverage is virtually unchanged from 2015.
Texas targeted for increased enrollment
Dallas and Houston are among five metropolitan areas nationwide that were targeted by HHS for enrollment growth (the others are Chicago, Miami, and Northern New Jersey) in 2016. These are areas with particularly high numbers of uninsured residents, and HHS has designated them as places where enhanced outreach and education could result in significant new enrollments – and a corresponding decline in the uninsured rate. Texas still has the highest uninsured rate in the country: 20.1 percent according to Gallup.
A study published in late January 2016 found that more than 69 percent of uninsured Texans don’t have insurance because they can’t afford it. The study involved 1,500 uninsured adults, including people who are eligible for premium subsidies as well as those who are in the coverage gap because Texas has refused federal funding to expand Medicaid. For everyone in the coverage gap – not just in Texas, but also in the 17 other states where there’s a coverage gap, as well as Louisiana until Medicaid expansion takes effect – health coverage is not realistically available. People in the coverage gap aren’t eligible for premium subsidies in the exchange, and they aren’t eligible for Medicaid because their states have refused to expand coverage. As a result, they can only get health insurance if they can pay the full premium themselves, which is unlikely to be possible when people have incomes below the poverty level.
Exchange enrollees identified on ID cards
At the end of May 2015, the Texas state senate passed House Bill 1514, and Governor Abbott signed it into law the following month. The law became effective in September 2015, and requires insurance carriers to label policy ID cards with “QHP” (qualified health plan) if the plan was purchased through the exchange.
The initial version of the House bill called for two different designations for exchange-purchased policy ID cards: “QHP” for plans purchased without a subsidy, and “QHP-S” for plans purchased with a subsidy (86 percent of the exchange enrollees in Texas are receiving subsidies). But the version that was ultimately signed into law dropped the “S” and simply calls for identifying all exchange enrollees with the “QHP” designation.
Many provider organizations were in support of HB 1514, because there’s a 90 day grace period for subsidized exchange enrollees who fall behind on their premiums, as opposed to the 30 day grace period for plans purchased outside the exchange and for non-subsidized exchange plans. During that time, carriers have to pay claims from the first 30 days, but can retroactively deny claims from the following 60 days (assuming the patient doesn’t pay the past due premiums) and can require the provider to refund payments made during that time.
Supporters of the bill claim that the QHP designation simply serves to keep providers aware of the need to remind their patients to remain current with their premiums. But the QHP label lets providers know that chances are, the patient is receiving a subsidy and thus has a 90 day grace period to remain current on premiums. It’s not unreasonable to assume that some providers would then choose to not work with those patients. The bill has generated considerably controversy between provider organizations and consumer advocates.
Texas sues feds over Obamacare. Again.
In October 2015, Texas Attorney General Ken Paxton joined AGs from Louisiana and Kansas in filing a lawsuit against HHS Secretary Sylvia Burwell and IRS commissioner John Koskinen. The suit contends that the ACA’s Health Insurance Provider Fee amounts to an illegal tax on states, since most states utilize private health insurance carriers to operate Medicaid managed care programs. The ACA fee is levied on private health insurance carriers, but the money that states pay to the carries to manage their Medicaid programs is utilized to pay the provider fee as well.
In Texas, 87 percent of Medicaid enrollees are covered under private plans in the managed care system, so the state is effectively paying the provider fee for those enrollees. But ACA supporters note that the state has always paid carriers enough to cover whatever fees they’re required to pay – the reason this particular fee has resulted in a lawsuit is because it’s part of the ACA, which is much-hated by Texas leadership.
In January 2016, the federal government said that Texas, Louisiana, and Kansas have no standing in this case because the Health Insurance Provider Fee doesn’t mention states, and states aren’t required to contract with Medicaid Managed Care Organizations that are subject to the fee. The case was ongoing as of spring 2016.
Lawmaker tried to establish state-run exchange
Although Texas has generally resisted the ACA over the last five years, two bills were introduced in the 2015 legislative session that would create a state-run exchange in Texas. Texas State Representative Chris Turner, a Democrat from Arlington/Grand Prairie, filed HB817 and HB818 in January.
HB817 would have required the state to create an exchange if the Supreme Court had ruled that subsidies are not permitted in the federally-run exchange (King v. Burwell). HB818 would create a state-run exchange regardless of the Court’s position in King v. Burwell. Neither bill made it out of committee, but now that we know subsidies will continue to be available through Healthcare.gov, the need for a state-run exchange is no longer as pressing.
1,205,174 people enrolled in private plans through the Texas exchange during the 2015 open enrollment period – the third highest in the country, trailing only Florida and California. But not everyone paid their initial premiums, and for a variety of reasons, some people cancelled their coverage early in 2015. By the end of March, 966,412 people in Texas had effectuated coverage through the exchange; by the end of June, effectuated enrollments had dropped to 943,218. 84.5 percent are receiving premium subsidies, and 63 percent are receiving cost-sharing subsidies (only available on silver plans for people with incomes up to 250 percent of the poverty level).
Of the people who selected a plan during the 2015 open enrollment period, 57 percent are new to the exchange for 2015. The Texas exchange exceeded the HHS target of 940,000 enrollees by more than a quarter of a million people during open enrollment, and ever after the initial attrition in the early part of the year, enrollment remains above the target level.
An additional 146,548 people enrolleed in Medicaid or CHIP through the exchange between November 15 and February 22, qualifying under the state’s unchanged guidelines, as Texas has not expanded Medicaid. Open enrollment continues year-round, but during the period from November 15 to February 22, the Texas exchange had the highest number of Medicaid enrollments of the states that have not yet expanded Medicaid (and only eight of the states that have expanded Medicaid had higher total Medicaid enrollment during that time).
Open enrollment for 2015 has ended, but 2015 coverage can still be purchased if you have a qualifying event, or if you’re Native American. In addition, Medicaid/CHIP enrollment is year-round for people who are eligible under the state Medicaid/CHIP guidelines.
2015 Texas exchange rates
A Commonwealth Fund analysis found an average rate increase of 5 percent in the Texas exchange for 2015. For silver plans, it was just 2 percent. Rate increases tended to be lower in urban areas of Texas.
In Houston, the 2015 benchmark plan (second lowest-cost silver plan) is still from the same carrier that offered it in 2014, but the lowest cost silver and bronze plans are both from different carriers in 2015. All in all, it pays to shop around during open enrollment in Texas, as there are significant differences in rate changes from one carrier to another.
For a 40 year old non-smoker, the average bronze plan in the Texas exchange in 2015 is $269 per month (pre-subsidy). This is slightly higher than the national average of $256.
New carriers and more plans for 2015
The exchange in Texas had 15 carriers offering plans in Texas for 2015, up from 12 in 2014. Only Michigan and Ohio have more carriers in their exchanges, with 16 each. There are an average of 31 plans available in each county in Texas for 2015, up from 25 in 2014. In Dallas county, there are 64 plans available, a huge increase over the 36 that were available in 2014.
Grandmothered plans may renew
In November 2013, the federal government announced that states could allow non-grandfathered, pre-2014 health plans (dubbed “grandmothered” plans) to renew again and remain in force in 2014. In March 2014, they issued another extension for these transitional policies, allowing states to let them continue to renew as late as September 2016. The majority of the states have accepted that proposition, but in 2014, Texas regulators simply didn’t issue any guidance whatsoever on the matter (in interviews with insurance officials in each state, Texas was alone in this regard – every other state took a position either for or against renewal of grandmothered plans).
Because Texas didn’t issue any guidelines for renewal of grandmothered plans, regulators initially said that grandmothered plans would not be allowed to renew in Texas in 2014. But eventually they reversed course on this, with the Department of Insurance simply noting that they do not object to carriers renewing grandmothered plans up until October 2016. HHS has since issued another extension (at states’ discretion) for transitional plans, allowing them to renew as late as October 2017, and remain in force until the end of December 2017. Texas has not yet issued guidance on whether they’ll go along with the latest extension, but most states with remaining grandmothered plans have accepted the additional extension.
HHS has since issued another extension (at states’ discretion) for transitional plans, allowing them to renew as late as October 2017, and remain in force until the end of December 2017. Texas has not yet issued guidance on whether they’ll go along with the latest extension, but most states with remaining grandmothered plans have accepted the additional extension.
ACA making coverage affordable
There is no doubt that Obamacare has expanded access to affordable health insurance for most people in Texas. A study released by HHS on June 18, 2014 found that the average net premium for people receiving tax credits in the Texas exchange was just $72/month (a 76 percent reduction from the $305/month “retail” price).
And 84 percent of Texas residents who enrolled through the exchange in 2014 qualified for tax credits. The $72/month after-subsidy premium in Texas is the seventh lowest out of the 36 states where HHS is running the exchange – the average across all 36 states is $82/month.
2014 enrollment exceeded 7o0,000
Enrollment in the Texas exchange skyrocketed to 733,757 by April 19, 2014 As of March 1, private plan enrollment in the Texas exchange had been at 295,000. The increase during March and the extension period in the first half of April was the largest of any state in the country. That followed January and February enrollment of more than 90,000 new enrollees per month in Texas.
Total enrollment in Texas was the second highest of the states where HHS is running the exchange, trailing only Florida.
An additional 141,494 exchange applicants had enrolled in Medicaid, despite the fact that Texas is not expanding Medicaid under the ACA (those applicants were already eligible under existing rules). Total enrollment – including private plans and Medicaid – was just over 875,000 people as of April 19.
No Medicaid expansion in the near future
There is no regularly scheduled legislative session in Texas in 2016. So although legislation has been introduced again in many of the other states that haven’t yet expanded Medicaid, there’s no legislative progress on the issue in Texas this year.
According to a Gallup poll, 27 percent of Texas residents were uninsured in 2013 — the highest rate in the nation. That rate fell slightly during the first half of 2014, but remained at an alarmingly high 24 percent by mid-2014, and was still over 20 percent in the first half of 2015 – the only state where more than one in five people were still uninsured in 2015.
A report prepared by the Hobby Center for the Study of Texas at Rice University estimated that 3 million people could gain coverage in 2014 if the state implemented the provisions of the Affordable Care Act. But with the state’s current refusal to expand Medicaid, approximately one million of those people will fall into a “coverage gap” (and likely remain uninsured) because they earn too much to qualify for Medicaid but too little to qualify for subsidies in the exchange.
But Texas has a new Governor – Greg Abbott – who took office in January 2015, and he’s expressed interest in Utah’s Medicaid expansion waiver. Governor Abbott has also said that although he’s opposed to expanding the current Medicaid system, “like anyone with an inquiring mind, we’ll look at any idea anyone has” on improving access to healthcare.
Although Abbott’s comments in December 2014 and early January 2015 triggered hopes among Texas Democrats that Medicaid expansion could be in the cards, Abbott clarified in mid-January 2015 that he believes the current Medicaid system is too broken to be expanded, and noted that the optimism about Medicaid expansion in Texas was simply based on his question about how Utah’s expansion waiver works – he reiterated that he has not changed his position on Medicaid expansion, and that he’s still opposed to it. This has continued to be his position throughout 2015 and 2016.
Abbott would like to see Texas use federal Medicaid funds in the form of block grants, but HHS has opposed that possibility with other governors, and it’s unlikely they’ll relent with Texas.
Rates and carriers in 2014
Twelve carriers offered a total of 95 different health plans in the Texas exchange in 2014 (this increased to 15 in 2015), so residents have many options from which to choose and competition among carriers is helping to keep the rates below the national average. Not only are there a wide range of plans available in Texas, but there are also several big-name health insurance carriers participating in the Texas exchange, including Aetna, Cigna, Blue Cross Blue Shield of Texas and Humana.
There has been some concern that not enough doctors are accepting health plans purchased through the exchange, but in many cases it’s impossible for medical offices to know whether a plan was obtained in the exchange. But a USA Today article published in late October notes that doctors in Texas are pushing for a requirement that insurance id cards indicate whether a plan was purchased through the exchange, and what metal level coverage it is.
Exchange history and legislation
Texas Gov. Rick Perry formally notified the Department of Health & Human Services (HHS) in July 2012 that Texas would not implement a state-run health insurance exchange. In his notification letter, Perry —a long-standing opponent of the Affordable Care Act — called the ACA provisions “brazen intrusions into the sovereignty of our state.”
Texas State Representative Eric Johnson, a Democrat from Dallas, did introduce bills in early 2013 that would have created a state-run exchange and expanded Medicaid, but neither was successful. HHS is running the exchange in Texas, and the state is not expanding Medicaid.
The significant enrollment numbers in Texas are testament to a law that is working well, and its success is being praised by Texas Democrats. But Republicans in the state legislature have vowed to continue their fight against the ACA in the 2015 legislative session.
CMS announced on November 22, 2013 that Texas applicants can enroll in QHPs directly through insurers – bypassing the exchange website entirely – with premium and cost-sharing subsidies available for eligible enrollees (the federal data hub is used to verify identity and determine subsidy eligibility for enrollments that go directly through insurance carriers).
The Texas High Risk Pool (a health plan for people with pre-existing conditions that pre-dates the ACA) remained open for the first three months of 2014, after originally being scheduled to cease operations at the end of 2013.
In early January, the Perry Administration’s efforts to make it more difficult to be a navigator in Texas drew criticism from ACA supporters and Democratic lawmakers, who claim that Perry is simply trying to impede enrollment in the Texas exchange.
According to a Kaiser Health News article, Blue Cross Blue Shield of Texas is playing a major role in educating state consumers about the federal health insurance marketplace. The Blues plan is using many strategies to reach consumers: creating a website, launching a texting campaign, and engaging churches, community clinics, nonprofits, and other community organizations.
Texas health insurance exchange links
Federal Health Care Reform Resource Page
From the Texas Department of Insurance
State Exchange Profile: Texas
The Henry J. Kaiser Family Foundation overview of Texas’ progress toward creating a state health insurance exchange.