Washington marketplace highlights and updates
- 13 insurers plan to offer 2021 coverage in the exchange, including four newcomers (UnitedHealthcare of Oregon, Community Health Network of Washington, Regence BlueCross BlueShield of Oregon, and Regence BlueShield). And all counties will have at least two participating insurers.
- Across the entire individual market in Washington, insurers have proposed an average rate decrease of 1.8 percent for 2021.
- Washington will have standardized plans and public option plans available for 2021, although the public option plans will only be available in 20 of the state’s 39 counties in the first year.
- Washington is also studying the possibility of state-based premium subsidies, but 2020 legislation to directly create the subsidies did not advance.
- Legislation was enacted in 2019 to protect consumers from surprise balance billing.
- Average rates decreased slightly for 2020, plus a look at rate changes in prior years.
- Short-term health plans can be sold with terms of up to three months in Washington, but not during ACA open enrollment for a January effective date.
- More than 212,000 people enrolled for 2020, down from the exchange’s record high enrollment in 2018.
Washington exchange overview
Washington runs its own exchange, Washington Healthplanfinder. Carrier participation in the exchange is robust, with nine insurers offering plans for 2020 (up from seven in 2019), including newcomers Providence Health Plan and PacificSource Health Plans. And for 2021, there are 13 insurers that plan to offer coverage in the exchange, including UnitedHealthcare of Oregon, Community Health Network of Washington, Regence BlueShield, and Regence BlueCross BlueShield of Oregon, none of which offer exchange plans in 2020.
The state also has a strong off-exchange market, but subsidies are only available through Washington Healthplanfinder. Washington expanded Medicaid (Apple Health) under the ACA, and residents can enroll via Washington Healthplanfinder.
Washington Healthplanfinder charges a per member per month fee to fund the exchange. For 2016 through 2018, the fee was $7.46 per member per month. So a family of four was paying almost $30/month in fees to fund the exchange, as part of their health insurance premiums. But because enrollment grew so much in 2018, and because the exchange has been working to improve its financial efficiency, the fee has been reduced by 55 percent for 2019, to just $3.36 per member per month. Although enrollment declined in 2019, the exchange kept the $3.36 per member per month fee in effect for 2020 as well (and reduced the fee on dental plans from $1.54 to $0.81 per member per month).
For the first two years it was in operation, Washington Healthplanfinder collected premiums from enrollees and sent them to insurers (enrollees had the option to send payments directly to the insurers, but about 80 percent opted to pay premiums to the exchange). But the exchange struggled with billing problems and ultimately decided to switch to the approach used in other states, in which enrollees pay their premiums directly to insurers, rather than the exchange. This change took effect in September 2015.
In 2019, Washingon implemented fairly strict rules for short-term health plans. As a result, there were no short-term plans available in the state in late 2018 and early 2019. LifeMap revised their plans to be compliant with the state’s new rules, and began selling the new plans in April 2019. But under Washington’s new rules, short-term plans with January effective dates cannot be sold between November 1 and December 15, which is the open enrollment period that applies to ACA-compliant plans. This is an effort on the state’s part to make sure that consumers aren’t confused during open enrollment and inadvertently purchasing short-term plans.
Washington also enacted legislation in 2019 to codify various ACA consumer protections into state law. As long as the ACA remains in effect, the legislation is essentially redundant. But if the ACA were to be repealed by Congress or overturned by the Supreme Court, Washington’s new law would continue to provide extensive consumer protections in the state. Washington’s law requires insurers to cover pre-existing conditions and essential health benefits without any annual or lifetime benefit caps, and places limits on annual out-of-pocket costs.
COVID-19 Special Enrollment Period ended May 8
The first reported cases of COVID-19 in the US were diagnosed in Washington state, so it was not surprising that Washington Healthplanfinder was the first state-run exchange to issue a special enrollment period related to the pandemic. The special enrollment period was initially scheduled to end on April 8, but was extended until May 8. The special enrollment period was specifically for people who were uninsured; it was not an opportunity for insured residents to change their coverage.
The exchange reported that roughly 19,500 people enrolled during the COVID-19 special enrollment period. Now that the window has ended, Washington residents need a qualifying event in order to enroll in a health plan, on-exchange or off-exchange. The next open enrollment period, for coverage effective in 2021, will begin November 1, 2020.
Thirteen insurers plan to offer coverage in Washington’s exchange in 2021, up from 9 in 2020 and 7 in 2019; Average premiums decreasing for 2021
Washington’s Insurance Commissioner, Mike Kreidler, announced in May 2020 that 15 insurers had filed individual market health plans for 2021, with 13 of them planning to offer coverage in the exchange. As described below, the state’s new standardized plans and public option will be available for 2021. All insurers will offer standardized plans (although they’ll be able to continue to offer additional, non-standardized plans), although only five of them will offer public option plans.
The participating exchange insurers for 2021 include two that are new to the state’s individual market (UnitedHealthcare of Oregon and Community Health Network of Washington, both of which will only offer public option plans), as well as two that already offer coverage outside the exchange, but plan to join the exchange for 2021 (Regence BlueShield and Regence BlueCross BlueShield of Washington). So Washington’s exchange is expected to go from nine insurers in 2020 to 13 insurers in 2021. And three other exchange insurers (BridgeSpan, Coordinated Care, and PacificSource) all plan to expand their coverage area in 2021.
Regence had previously participated in the Washington exchange, but had exited at the end of 2017. UnitedHealthcare of Oregon is new to the state’s individual market, but UnitedHealthcare of Washington had participated in the exchange in previous years, leaving at the end of 2016. Community Health Network of Washington is new to the state’s individual market, but Community Health Plan of Washington — an affiliated entity — exited the market at the end of 2017.
The 15 insurers that will offer individual market plans in Washington in 2021 (including Asuris Northwest Health and Health Alliance Northwest Health Plan, both of which will only offer plans outside the exchange) have proposed an overall average rate decrease of 1.8 percent. The insurers that will offer plans through Washington Healthplanfinder have proposed the following average rate changes for 2021:
- BridgeSpan Health Company: 0.03 percent increase (will offer public option plans)
- Community Health Network of Washington: New for 2021 (will only offer public option plans)
- Coordinated Care Corporation: 2.1 percent increase (will offer public option plans)
- Kaiser Foundation Health Plan of the Northwest: 1.93 percent decrease
- Kaiser Foundation Health Plan of Washington: 4.87 percent decrease (second year in a row with nearly a 5 percent decrease)
- LifeWise Health Plan of Washington: 3.44 percent increase (will offer public option plans)
- Molina Healthcare of Washington: 0.27 percent increase
- PacificSource Health Plans: 3.54 percent increase
- Premera Blue Cross: 8.99 percent decrease (following a 6 percent decrease in 2020)
- Providence Health Plan: 2.99 percent increase
- Regence BlueCross BlueShield of Oregon: 4.71 percent decrease (new to the exchange for 2021, but already in the individual market in 2020)
- Regence BlueShield: 2.71 percent decrease (new to the exchange for 2021, but already in the individual market in 2020)
- UnitedHealthcare of Oregon: New for 2021 (will only offer public option plans)
The coronavirus pandemic did not appear to be a factor in the proposed rates for most of those insurers. Molina accounted for an expected 3 percent increase in claims in 2021 due to COVID-19, while UnitedHealthcare added 2.5 percent. The rest of the insurers did not adjust their 2021 projections based on COVID-19.
All counties in Washington will have at least two participating exchange insurers by 2021. This is a significant reversal from just a few years earlier, when insurers were exiting the market and reducing their coverage areas, leaving Kreidler scrambling to ensure that the state wouldn’t be left with areas that didn’t have any participating insurers at all.
There had been seven participating exchange insurers in 2019, but Providence and PacificSource joined the exchange for 2020. There are still six counties that have just one participating insurer in 2020; although that’s down from 14 in 2019, it will drop to zero in 2021. There are also bronze plans available statewide as of 2020; whereas some counties had no available bronze options over the last couple of years, making their lowest-cost options more expensive than the lowest-cost options for people in most of the state.
More details about the specifics of insurer participation each year are detailed at the bottom of this page.
Standardized plans and a public option available starting in 2021, but public option will only be available in 20 of the state’s 39 counties
In May 2019, Washington enacted legislation (S.B.5526; the House version was H.B.1523) calling for the creation of standardized health plans and a “public option” health plan that will be available as of 2021 (with enrollment beginning in November 2020), plus additional premium subsidies that are expected to be available by 2022. The legislation is known as “Cascade Care” and implementation work has been ongoing ever since the bill was enacted.
HealthCare.gov briefly offered standardized plans in many areas of the country, and several states currently have standardized plans; Washington will join them in 2021, with standardized plans — and a public option in about half of the state’s counties — available through Washington Healthplanfinder.
Washington’s insurance commissioner announced in May 2020 that the proposed rate filings for the Cascade Care plans had been submitted by insurers. In early July, the state confirmed that five insurers will offer Cascade Care public option plans in 2021. But the public option plans will only be available in 20 of the state’s 39 counties.
Under the terms of the Cascade Care legislation, Washington officials were tasked with designing up to three standardized plan designs at the bronze, silver, and gold metal levels. In October 2019, the exchange published a draft proposal with four standardized plan designs: One gold, one silver (plus CSR variations), and two bronze, one of which is an HDHP and would allow an enrollee to contribute to an HSA. A detailed report of the standardized plan designs and their expected impact on the market is available here.
The standardized plan designs include a wide variety of services, all of which would be covered with the same cost-sharing regardless of which insurer offers the plan (ie, the deductible, out-of-pocket maximum, coinsurance, and various copays would be the same from one plan to the next). The idea is to make it easier for a consumer to compare plans based on things like provider networks and customer service, since the dollar-level benefits wouldn’t vary. The exchange is sought public comments on the proposed plan designs, and announced in early December that the plan designs had been approved.
Insurers that offer plans in the exchange will have to offer at least one standardized plan at the silver and gold level starting in 2021. If an insurer offers plans at the bronze level, they will have to offer at least one standardized bronze plan, but some Washington insurers choose to not offer bronze plans (for the public option, discussed below, insurers would have to offer plans at each metal level, including bronze).
For the time being, insurers will be able to continue to also offer non-standardized plans, but the state will have to analyze what the expected impact would be if all plans were required to be standardized starting in 2025, with a report that has to be delivered to the legislature by 2023. California requires all plans to be standardized, but all of the other states with standardized plan designs also allow insurers to offer non-standardized plans.
Washington’s public option plan, which will be available by the fall of 2020, for coverage effective in 2021, will be the first of its kind in the nation (Colorado’s was expected to debut in 2022, but has been postponed amid the COVID-19 crisis). But some have argued that its design will be different from what people tend to think of as a “public option,” as that term is often used to describe Medicaid buy-in programs and new coverage options that would be administered by the government. But Washington is taking an approach that involves private insurers (so is Colorado, if and when the program gets revived; Nevada lawmakers passed a Medicaid buy-in public option in 2019, but the governor vetoed it).
Starting in 2021, Washington’s Cascade Care “public option” will involve the state contracting with five private health insurance companies to offer standardized qualified health plans at the bronze, silver, and gold levels in the Washington exchange. The standardized plan design will be the same as the regular standardized plans detailed above, but the public option versions are expected to have lower premiums due in large part to lower reimbursements for medical care.
The idea behind S.B.5526 is to provide additional plan options to individual market enrollees. But the legislation does not require the Cascade Care plans to be available statewide. An insurer’s contract with the state would be to offer the plans “in a single county or in multiple counties,” and it was not clear until mid-2020 how widespread the public option plans would be in 2021. They will be available in 20 of the state’s 39 counties for 2021 (with plans available for purchase as of November 1, 2020). In six of those 20 counties, public option plans will be offered by two or three different insurers. The other 14, including King County (Seattle), will have public option plans offered by a single insurer. The remaining 19 counties in Washington will not have public option plans available in 2021, although the state is hoping that the plans will be more widely available in future years.
For most services, the plans will cap provider reimbursements at 160 percent of the Medicare reimbursement amounts, at least initially (there are exceptions for rural hospitals and primary care, and also for situations in which the plan can’t maintain an adequate network under the prescribed reimbursement constraints).
The legislation went through several iterations, and the cap on provider reimbursements changed each time, but lawmakers ultimately settled on 160 percent of Medicare rates — a middle-of-the-road approach designed to keep pricing at least a little lower than other comparable plans (the state is aiming for 5-10 percent lower), while still ensuring adequate provider participation (Colorado’s proposal calls for private insurers to offer a “state option” with reimbursements capped at 175 to 225 percent of Medicare rates).
State-based premium subsidies
S.B.5526 also called for the state to “develop a plan to implement and fund” premium subsidies for people with modified adjusted gross income up to 500 percent of the poverty level. The federal government provides ACA premium subsidies to people with MAGI up to 400 percent of the poverty level, but people with income between 400 and 500 percent of the poverty level are not eligible for federal subsidies, and are thus often impacted by the subsidy cliff.
S.B.5526 is an effort to help make coverage more affordable for people in this income range, and calls for net premiums to be capped at 10 percent of MAGI. Washington Healthplanfinder is working with stakeholders to develop a state-based premium proposal, and will submit a report to the legislature by November 15, 2020. The idea is that lawmakers will then be able to act on the report during the 2021 legislative session, to create state-based premium assistance.
In addition to the report that the exchange is drafting for lawmakers, legislation (H.B.2901) was introduced in 2020 that would have created state-based premium subsidies that would be available by 2022. It did not advance in the 2020 session, but it does provide some insight into how lawmakers might address the issue in the 2021 session. H.B.2901 called for a tax on health insurers equal to 1 percent of all claims paid in the prior year (assessed starting in 2021, based on claims paid in 2020). The money would have been used to fund a new “premium assistance account,” run by the state treasury to provide sliding scale premiums to exchange enrollees with income up to 500 percent over the poverty level.
People who are currently eligible for the ACA’s premium subsidies (ie, with income above 138 percent of the poverty level, but not in excess of 400 percent) would have been eligible for the state’s subsidies under H.B.2901, making coverage more affordable than it currently is for that population. But importantly, the state subsidies under H.B.2901 would have also extended to those earning up to 500 percent of the federal poverty level (FPL), helping to make coverage more affordable for people who are currently impacted by the ACA’s subsidy cliff (ACA subsidies stop at 400 percent of the poverty level). For perspective, a family of four earning up to $103,000 can qualify for the ACA’s subsidies in 2020; if subsidy eligibility extended to 500 percent of the poverty level, it would be $128,750 for a family of four.
Massachusetts and Vermont both have state-based premium subsidies (which pre-date the ACA) for lower-income enrollees. And California implemented a new state-based premium subsidy program as of 2020, offering subsidies to households with income up to 600 percent of the poverty level.
Legislation to protect consumers from surprise balance billing
Governor Jay Inslee signed H.B.1065 into law in 2019, after similar bills failed in the two previous legislative sessions. The new law, summarized here by Insurance Commissioner Mike Kreidler’s office, took effect in January 2020 and provides strong consumer protections against surprise balance billing when a patient receives emergency treatment at an out-of-network facility, or visits an in-network facility but is treated by an out-of-network provider.
- The law requires insurers to maintain adequate networks.
- Out-of-network providers will not be allowed to balance bill patients in emergency situations or in situations in which the out-of-network services were received at a facility that was in-network with the patient’s insurance.
- In these situations, insurers must pay out-of-network providers “a commercially reasonable amount, based on payments for the same or similar services provided in a similar geographic area.”
- If the provider and insurer disagree on what the payment amount should be, it is sent to binding arbitration. But the provider cannot bill the patient.
- H.B.1065 applies to plans that are regulated by the Washington Insurance Commissioner. This does not include self-insured group plans — which account for the majority of very large group plans — as those are regulated by the federal government instead, under ERISA. Self-insured group plans can choose to opt into the state’s balance billing protection rules.
2020 enrollment, plus a look back at enrollment since 2014
Open enrollment for 2020 coverage began on November 1, 2019, and the exchange extended the enrollment deadline to December 30, 2019. By the time the enrollment window ended, more than 212,000 people had purchased coverage. That was a drop from the 220,765 people who had enrolled the year before, for 2019 coverage, and was the second year in a row with a year-over-year drop in enrollment.
For perspective, here’s a look back at enrollment in Washington Healthplanfinder since the exchange opened for business in 2014:
- 2014: As of April 2019, 163,207 people had enrolled in private health plans through Washington Healthplanfinder and paid their premiums to effectuate their coverage. In addition to the private plan enrollments, 909,752 people had enrolled in Medicaid through the Washington exchange by mid-April (nearly half of those people were already enrolled previously, but renewed their Medicaid coverage through the exchange).
- 2015: Total enrollment in qualified health plans through Washington Healthplanfinder amounted to 160,732 people by the end of open enrollment. On April 22, Washington Healthplanfinder announced that total private plan enrollment for 2015 had reached 170,101 people. This was the third-highest total (behind California and New York) of any of the state-run exchanges. All of these enrollees had paid for their coverage; Washington only reported enrollments in 2014 and 2015 if they were paid-up.
- 2016: HHS announced that Washington Healthplanfinder’s total enrollment for 2016 was 200,691 as of February 1 (this was the first year that Washington switched to reporting all enrollments — instead of only effectuated enrollments — bringing them into line with how most other states’ enrollments are reported). In June 2016, Washington Healthplanfinder reported that 169,182 people had effectuated their coverage for 2016.
- 2017: By the time 2017 open enrollment ended on January 31, more than 225,000 people had enrolled in private plans (QHPs) through the exchange. This was a 13 percent increase, which was notable given that total enrollment among states using HealthCare.gov was slightly lower in 2017 than it was in 2016 (the Trump Administration reduced advertising for HealthCare.gov in the final week of enrollment, while state-run exchanges like Washington Healthplanfinder were able to continue their advertising efforts as planned).
- 2018: Enrollment in Washington’s exchange reached a record high in 2018, with 242,850 people enrolled in private plans (CMS reported a slightly higher official enrollment total of 243,227). Although HealthCare.gov switched to a much shorter enrollment window (just over six weeks long) for 2018 coverage, Washington Healthplanfinder was one of ten state-run exchanges that opted for a longer enrollment window that year, allowing people to enroll until January 15, 2018.
- 2019: Enrollment dropped in 2019, with 220,765 people purchasing plans during open enrollment. Nationwide, there was an average decline in enrollment, although it was only about 2.4 percent. And among state-run exchanges, average enrollment increased slightly in 2019. Washington Healthplanfinder was one of just four state-run exchanges (out of 12 total) where enrollment declined in 2019.
Rate changes in Washington’s exchange in previous years
When the exchange began offering health plans for 2014, premiums were essentially an educated guess, as there was no ACA-compliant individual market claims experience on which to base rates. Here’s a summary of how full-price (ie, pre-subsidy) premiums have changed over the years in Washington’s exchange:
- 2015: Washington Healthplanfinder’s rates increase by an average of just 1.9 percent for 2015.
- 2016: The average rate increase for 2016 was 3.84 percent. A Kaiser Family Foundation analysis determined that the benchmark plan for a 40-year-old in Seattle was $254 in 2015, and dropped to just $227 in 2016 (the benchmark plan isn’t necessarily from the same carrier that offered it the year before — it’s just the second-lowest-cost silver plan in a given year). That’s more than a 10 percent decrease, which means that premium subsidies (which are based on the cost of the benchmark plan) were smaller in 2016.
- 2017: The average premium increase in the individual market in Washington was 13.6 percent for 2017 (nationwide, the average premium increase, before any subsidies were taken into consideration, was about 25 percent). Premera had the largest segment of Washington Healthplanfinder market share in 2016, at 22 percent. And their approved rate increase for 2017 was the highest of any of the state’s plans, at 18.9 percent.
- 2018: In September 2017, Washington Healthplanfinder announced that the exchange had finished certifying plans for 2018, with an average rate increase of 24 percent for plans sold in the exchange (final rate changes available here). At that point, the approved rates were still based on the assumption that CSR funding would continue, but the exchange noted that the premium increases were due to “cost trend and federal uncertainty, particularly enforcement of individual mandate” (the individual mandate penalty was eventually eliminated altogether, at the end of 2018).
The exchange also explained that the state was taking a unique approach to the CSR funding issue: Regulators approved rates that assumed CSR funding would continue, and those were the rates they intended to implement when open enrollment began on November 1. But they also approved a backup set of rates for silver plans sold in the exchange (including the off-exchange versions of those plans), which were high enough to make up for the loss of federal CSR funding. They noted that if CSR funding were to be cut off at some point during 2018, Washington regulators would use their authority to implement the higher on-exchange silver plan rates at that point.
Ultimately, the Trump Administration announced just two weeks later, on October 12, that CSR funding would end immediately. At that point, Washington regulators had to switch to the backup rates, and they announced on October 26 that the higher rates for on-exchange silver plans had been finalized, driving the overall average rate increase up to 36.4 percent.
- 2019: The average approved rate increase was 13.8 percent for 2019, which was a little lower than the insurers had proposed.
- 2020: Overall average premiums in Washington’s exchange decreased by 3.27 percent for 2020. And two new insurers — Providence Health Plan and PacificSource Health Plans — began offering plans in the exchange for 2020.
How rates changed for an average enrollee in 2019
As of 2018, 63 percent of Washington’s exchange enrollees were receiving premium subsidies, while the other 37 percent were paying full price. Nationwide, 87 percent of enrollees were receiving subsidies, so while subsidies are less common in Washington, they still apply to the majority of the enrollees there. Let’s take a look at how an enrollee’s after-subsidy premiums changed for 2019 in a couple of different areas of the state.
First, in Wenatchee, where Coordinated Care is the only insurer offering plans: A 40-year-old earning $30,000 could get a premium subsidy of about $195/month. After the subsidy is applied, the available plans (eight different options offered by Coordinated Care) range from $191/month to $262/month. There are no bronze plans available, so the lowest-priced plan is silver.
In 2018, a 40-year-old in Wenatchee earning $30,000 was eligible for a premium subsidy of about $122/month, but the after-subsidy premiums were fairly similar to 2019’s prices, ranging from $194/month to $274/month. There were 10 Ambetter plans available in that area for 2018, but again, all silver and gold, with no bronze options. (Washington was one of a handful of states where some counties had no bronze plans available starting in 2018, and that situation was the impetus for new HHS and IRS rules allowing people to qualify for an affordability exemption based on the lowest-cost plan, rather than the lowest-cost bronze plan in a given area.)
Now let’s consider the same 40-year-old earning $30,000 but living in Seattle. For 2018, this applicant was eligible for a premium subsidy of about $134/month. There were 21 plan options available from Kaiser, Premera, Molina, and Coordinated Care, with after-subsidy premiums ranging from about $130/month to $472/month (including mostly silver plans, as well as four gold plans and four bronze plans).
For 2019, a 40-year-old applicant earning $30,000 in Seattle can choose from among 19 plans, and qualifies for a premium subsidy of about $177/month. After the subsidy is applied, the premiums range from about $142/month to $435/month.
As described above, the exchange fee (which is built into the premiums) is 55 percent lower for 2019 than it was for 2018. That helps to keep premiums a little lower than they would otherwise have been, but adjustments in the cost of the benchmark plan (and the resulting adjustments in premium subsidies) tend to have more of an impact.
Small business coverage no longer available through the exchange
Washington Healthplanfinder Business, the state-run SHOP exchange, reported in June 2015 that more than 100 small businesses had enrolled in small group plans for 2015. They also announced that they would make coverage available for businesses with up to 100 employees starting in November 2015. But that changed in October 2015 when President Obama signed HR1624 (the PACE Act) into law. The law repealed the ACA provision that would have expanded the definition of “small group” to include businesses with up to 100 employees. States are free to independently define small groups as businesses with up to 100 employees, but in Washington, Insurance Commissioner Mike Kreidler announced that the state would go along with the PACE Act and continue to define small group plans as those with up to 50 employees.
By March 2016, a total of 174 employers had enrolled in coverage through Washington Healthplanfinder. The plans were covering 606 employees, and 164 dependents. UnitedHealthcare offered small group plans statewide through Washington Healthplanfinder Business in 2016, and Kaiser offered plans in Clark and Cowlitz counties (Moda had planned to offer small business plans state-wide as well, but their last-minute exit from the Washington market at the end of 2015 meant that there was just one state-wide SHOP option in 2016).
And for 2017, United’s exchange exit left Washington Healthplanfinder’s SHOP exchange limited to only Kaiser, and only in Clark and Cowlitz counties. The state noted however, that there continued to be a robust off-exchange market for small businesses, with 11 insurers offering plans in 2017 — although the small business health insurance tax credit is only available through the exchange.
By 2018, even Kaiser had stopped offering SHOP plans in Washington, so there are no longer SHOP plans for sale in the state. Small businesses can select from a wide range of off-exchange small group plans, however, all of which are compliant with the ACA.
Washington Healthplanfinder history
Washington was one of the first states to move ahead with a state-run health insurance marketplace as envisioned by the Affordable Care Act. Former Gov. Chris Gregoire signed legislation creating the state exchange in May 2011. In March 2012 Gregoire signed additional legislation, which further defined how the exchange would be governed and operated.
The Washington Health Care Authority (HCA) helped establish the Washington marketplace. HCA transitioned governing authority to an 11-member board of directors in March 2012. The governor appointed eight voting members and a board chairperson who votes only if needed to break a tie. In addition, the insurance commissioner and the administrator of the Health Care Authority are non-voting members.
In March, 2014, Washington legislators tried to pass a bill that would have created much more transparency in the state’s health insurance industry, providing consumers with data on how much insurers are paying for services in each region of the state. It had widespread support, but opposition from Premera Blue Cross — the state’s largest insurer — sank the bill and Washington did not join the 11 other states that had all-payer claims databases by 2014. But lawmakers persisted, and in 2015, SB5084 was signed into law, advancing the process of creating an all-payer claims database in Washington state (S.B.5741 was enacted in 2019, and will improve the state’s all-payer claims database).
The federal government funded the Washington Healthplanfinder in 2014. In 2015, marketplace operations were funded by the state with $21 million that was previously earmarked for the state’s high-risk insurance pool, and with an additional tax on premiums on plans sold through the exchange.
No grandmothered plans
Washington Insurance Commissioner Mike Kreidler and Governor Jay Inslee took a strong progressive stance with regards to consumer protections: existing plans that did not meet ACA standards were canceled at the end of 2013 and needed to be replaced in January 2014 with new, ACA-compliant policies. Following President Obama’s announcement that carriers could extend existing plans into 2014 if states allowed it, Kreidler and Inslee were quick to declare that Washington would not allow non-compliant plans to continue into 2014. Thus, the only non-ACA-compliant individual and small group plans in Washington are grandfathered plans; there are no grandmothered plans.
Insurer participation by year
Insurer participation in Washington’s exchange has changed significantly over time (a detailed list of the counties where each carrier offered plans is available here). The Office of the Insurance Commissioner has clarified over the last few years that federal actions had been creating instability and uncertainty in the individual market, and insurers tend to want to avoid that sort of uncertainty (this is a big reason insurers exited the market in 2017 and 2018). The federal actions include the elimination of the individual mandate penalty in 2019 (under the terms of the GOP tax bill that was enacted in late 2017), the elimination in late 2017 of federal funding for cost-sharing reductions, and the regulations that expanded access to short-term health plans and association health plans (although Washington stepped in with new regulations for short-term plans).
In 2019, there were 14 counties in Washington with only one insurer offering plans in the exchange, up from nine in 2018. And when rates were initially filed for 2018, there were two counties where no insurers had proposed plans. That was eventually remedied before the start of open enrollment, but lawmakers also wanted to address the issue in the 2018 legislative session.
H.B. 2408 (signed into law in March 2018) mandates that as of 2020, any insurer that offers coverage to school employees must also offer at least one silver and one gold plan in the individual market via Washington Healthplanfinder in any areas where the insurer offers coverage for school employees. In the meantime, if necessary, the legislation would have made coverage in the Washington state health insurance pool more affordable for people who live in counties where no insurers offer exchange plans. But all areas of the state have continued to have plans available in the exchange from at least one insurer, and there will be at least two insurers in each county as of 2021.
Here’s a summary of insurer participation in Washington’s exchange has changed over time:
- 2014: Plans were available from eight insurers in 2014: BridgeSpan, Community Health Plan of Washington, Coordinated Care (Ambetter/Centene), Group Health Cooperative, Kaiser Foundation Health Plan of the Northwest, LifeWise, Molina, and Premera.
- 2015: Plans were available from 10 insurers in 2015, with Moda and Columbia United Providers joining the exchange, along with the eight insurers that had offered plans in 2014. But both insurers’ forays into the exchange were short-lived.
- 2016: On October 28, 2015, Moda Health announced they were exiting the Washington market in order to focus on Alaska and Oregon (Moda subsequently left Alaska’s market as well, but remains in Oregon). Effective immediately, they ceased sales and renewal of health plans in Washington, and 47,000 existing policy-holders had to select coverage from a different carrier for 2016.
In November 2015, Columbia United Providers also announced that they would exit the individual market in Washington. Their plans were only available in Clark County, and they only had about 100 enrollees. But Regence BlueCross BlueShield, United Healthcare of Washington, and Health Alliance Northwest all joined the exchange for 2016, resulting in 11 insurers offering plans.
- 2017: For 2017, United Healthcare exited the exchanges in nearly every state where they participated in 2016, including Washington (United had 2,978 enrollees in the Washington exchange in 2016, or about two percent of the total exchange enrollments). And Health Alliance Northwest also exited the exchange, although the impact of that was minimal, as they only had nine on-exchange enrollees in 2016. There were no new entrants in 2017, so nine insurers offered plans in the exchange that year.
- 2018: For 2018, BridgeSpan and Regence BlueShield had both initially said they would discontinue their exchange participation and would only offer off-exchange plans after 2017. And Community Health Plan of Washington planned to exit the individual market altogether at the end of 2017. At that point, no individual market insurers had filed plans for 2018 in Klickitat County or Grays Harbor County.
So Washington Insurance Commissioner Mike Kreidler began working with insurers to fill in the bare counties. Kreidler’s first success was in Grays Harbor County; he announced on June 19 that Premera had stepped up and agreed to offer coverage there. And on June 26, Kreidler announced that two insurance companies had agreed to offer exchange plans in Klickitat County, including BridgeSpan. This was particularly notable given that BridgeSpan had initially intended to exit the Washington exchange altogether at the end of 2017. But thanks to Kreidler’s negotiations, BridgeSpan and Molina both agreed to offer plans in the exchange in Klickitat County in 2018.
Every area of the state had on-exchange options available in 2018, although nine counties (out of 39 in the state) had just one insurer offering plans: Chelan, Douglas, Ferry, Grays Harbor, Island, Pend Oreille, San Juan, Skagit, and Skamania. And there were seven counties in Washington where there were no bronze plans available in the exchange for 2018: Chelan, Douglas, Ferry, Lincoln, Pend Oreille, Skamania, and Stevens.
- 2019: Seven insurers offered plans in the Washington exchange; 14 counties had just one participating insurer.
- 2020: Providence and PacificSource joined the exchange for 2020, bringing the total number of participating insurers to nine. There are six counties with just one participating insurer.
- 2021: Proposed plans for 2021 include 13 insurers offering coverage in the exchange. Four insurers plan to join the exchange: UnitedHealthcare of Oregon, Community Health Network of Washington, Regence BlueShield, and Regence BlueCross BlueShield of Washington (the latter two are already part of Washington’s individual market, but only offer plans outside the exchange in 2020, after exiting a few years ago).
Contact the Washington exchange
More Washington State health insurance exchange links
Washington Health Benefit Exchange
Information about marketplace planning and development
State Exchange Profile: Washington
The Henry J. Kaiser Family Foundation overview of Washington’s progress toward creating a state health insurance exchange.
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.