West Virginia has a partnership exchange, which means residents enroll in exchange plans through Healthcare.gov, but the state oversees the plans that are sold through the exchange.
West Virginia’s exchange had just one carrier in 2014 and 2015, but two carriers participated in 2016, and are continuing to do so in 2017.
Benchmark premiums (second-lowest-cost silver plan) increased by an average of 32 percent in West Virginia for 2017 (the national average was 22 percent). But subsidies offset all or most of that increase for the majority of West Virginia exchange enrollees. Subsidies are based on the cost of the benchmark plan relative to enrollees’ income, so although rates have increased, subsidies are also significantly larger in West Virginia in 2017.
HHS estimated in 2016 that there were 15,000 people enrolled in off-exchange plans in West Virginia who would be eligible for subsidies if they switched to the exchange.
West Virginia accepted federal funding to expand Medicaid under the ACA, so HealthCare.gov enrollees with household income under 138 percent of the poverty level are enrolled in Medicaid rather than private plan.
34,035 people enrolled in private plans through the West Virginia exchange during the 2017 open enrollment period, from November 1, 2016, to January 31, 2017. For perspective, 37,284 people enrolled during the 2016 open enrollment period, so the 2017 total represented a year-over-year decrease of nearly 9 percent.
Enrollments on the HealthCare.gov platform were lower nationwide than they were in 2016. There are a variety of reasons for that, including higher premiums for people who don’t get premium subsidies, the uncertainty surrounding the future of the ACA, and the Trump Administration’s move to cut back on advertising and outreach in the final week of open enrollment (state-based exchanges averaged slightly higher enrollment for 2017, and their advertising/outreach wasn’t impacted by the HealthCare.gov advertising situation).
Open enrollment for 2017 coverage has ended, but you can still enroll (on or off-exchange) if you experience a qualifying event. Native Americans can enroll year-round (without a qualifying event), as can anyone eligible for Medicaid or CHIP.
West Virginia exchange and the Trump Administration
When President Trump won the 2016 election, Republican lawmakers indicated that their first priority would be to repeal the ACA. They kicked off the 2017 legislative session by passing a non-binding budget resolution that directed four legislative committees to make recommendations to the Senate Budget Committee, so that reconciliation legislation could be introduced to repeal spending-related parts of the ACA.
The soft deadline was January 27, but as of mid-February, no recommendations had been made. And the chances that repeal/replace might not happen at all were starting to resonate by that point; the House Freedom Caucus voted on February 13 to only support ACA repeal legislation that’s at least as strong as 2015’s H.R.3762, which would have completely eliminated premium subsidies, cost-sharing subsidies, Medicaid expansion, and the various taxes and penalties in the ACA (including the individual and employer mandate).
But there are Republican lawmakers from red states that have expanded Medicaid (like West Virginia) who will hesitate to fully repeal Medicaid expansion, and there are Republican lawmakers who are unwilling to proceed with reconciliation repeal bill without concurrent replacement legislation. All in all, repeal/replace is looking much less certain than it was in mid-November.
But what would happen in West Virginia if the ACA were to be repealed? HHS announced in late 2016 that 156,000 people had gained coverage in West Virginia from 2010 to 2015, as a result of the ACA. But that number has continued to grow, and ACA Signups estimates that up to 194,000 people would lose coverage in West Virginia if the ACA is repealed and either not replaced (replacement would require 60 votes in the Senate) or replaced with something less-robust.
174,026 people had enrolled in expanded Medicaid in West Virginia as of January 2017. They make up the bulk of the population that would lose coverage without the ACA. Their incomes are lower than average and their health status is also poorer than average, making them particularly susceptible to being stuck without any realistic coverage options.
West Virginia has the highest rate of drug overdose deaths in the country. But Medicaid expansion has made it possible for tens of thousands of people in West Virginia to get treatment: 22,000 people who are covered under expanded Medicaid were being treated for mental health or substance abuse disorders as of February 2017.
As of 2016, nearly 88 percent of private plan enrollees in West Virginia’s exchange were receiving premium subsidies (premium tax credits). ACA repeal would eliminate those as well, making coverage unaffordable for many residents. Most of the Republican replacement proposals have called for at least some form of tax credit or other government funding to help cover the cost of health insurance, but most of them aren’t as targeted at lower-income people as the ACA’s tax credits, and might not make coverage affordable enough for some people who currently receive exchange subsidies.
West Virginia also disproportionately benefits from the ACA’s black lung benefits for disabled miners and their surviving spouses, which is just one of many protections that would disappear without the ACA.
For 2017, the two exchange carriers are offering plans, and implemented the following average rate increases:
- Highmark Blue Cross Blue Shield:
31.82 percent35.81 percent (refiled in September 2016 with the higher average rate increase, which was deemed justified).
- CareSource: 49.8 percent (deemed justified)
These are undoubtedly steep rate increases, but for the nearly 88 percent of West Virginia exchange enrollees who are receiving premium subsidies, the increases are mostly offset by higher subsidies. But for people with income too high to qualify for subsidies, and for everyone who purchases coverage outside the exchange, the rates are considerably higher in 2017 than they were in 2016.
West Virginia’s average rates were already among the highest in the country, and although average rate increases for 2017 were substantial all across the country, West Virginia’s average rate increases were higher than the national average.
37,284 people enrolled in private plans through West Virginia’s exchange during the 2016 open enrollment period. More than 12,600 were new enrollees, while the rest already had coverage through the West Virginia exchange and either renewed it for 2016 or switched to a different exchange plan. 86 percent of the 2016 enrollees are receiving premium subsidies to offset the cost of their coverage.
For comparison, 33,421 people enrolled in private plans through the West Virginia exchange during the 2015 open enrollment period. So the exchange ended up with almost 112 percent of last year’s total, despite the fact that HHS began accounting for attrition in real-time this year, and the February 1 total already reflects policy cancellations (including unpaid enrollments) through that date.
By March 31, 2016, effectuated enrollment stood at 33,235, and 87.7 percent of those enrollees were receiving premium subsidies that average $388 per month.
Open enrollment for 2016 coverage ended January 31. The next open enrollment period – for coverage effective in 2017 – will begin November 1. Between now and then, enrollment will only be available to people who have a qualifying event (Native Americans can enroll year-round however, as can anyone eligible for Medicaid or CHIP).
Medicaid enrollment continues year-round. West Virginia expanded Medicaid under the ACA, and has been extremely successful at enrolling eligible residents. As of early May 2016, total enrollment in expanded Medicaid had reached 173,582. Originally, West Virginia officials had projected that Medicaid expansion would cover about 150,000 people, but they surpassed that number in 2014. As of March 2016, there were 556,843 West Virginia residents enrolled in Medicaid/CHIP (including traditional and expansion populations), or about 30 percent of the state’s population.
CareSource expanded coverage area in 2017
In 2014 and 2015, West Virginia’s exchange had just one carrier – Highmark Blue Cross Blue Shield. West Virginia was the only state in the country that had just one participating exchange carrier in 2015, although Wyoming has just one in 2016, and several states are expected to have just one carrier in their exchanges in 2017.
Starting in 2016, CareSource — a nonprofit insurer — began offering plans with competitive rates in 10 of West Virginia’s 55 counties (Brooke, Cabell, Hancock, Kanawha, Lincoln, Marshall, Mason, Ohio, Putnam, and Wayne). In February, CareSource announced that they had enrolled 1,800 people through the West Virginia exchange for 2016. According to MetroNews, that was about 20 percent higher than they had projected. But in November 2015, CareSource had stated in a press release that their projected enrollment target in West Virginia for 2016 was “up to 3,000 consumers.”
CareSource had planned to “significantly” increase the areas of West Virginia where they would offer plans in 2017, and began the process of opening an office in Charleston. For 2016, the vast majority of the state’s exchange enrollees signed up with Highmark, which still has the lion’s share of the market in West Virginia – so there was still plenty of room for competition state-wide. For 2017, CareSource had planned to double their membership in West Virginia.
CareSource’s rate filing noted that they offered coverage in the exchange in 10 counties in 2016, but were planning to “expand to additional counties” in 2017. In September 2016, Metro News reported that CareSource would offer coverage in the exchange in 32 counties in West Virginia in 2017. In addition to the ten counties where they offer coverage in 2016, they’re now also offering exchange plans in Barbour, Boone, Calhoun, Clay, Doddridge, Fayette, Gilmer, Harrison, Jackson, Logan, Marion, Monongalia, Pleasants, Preston, Raleigh, Ritchie, Roane, Taylor, Tyler, Wetzel, Wirt, and Wood counties.
Highmark prepared for increased competition
Highmark’s total in-force enrollment in the ACA-compliant individual market in West Virginia was 42,000 as of late February 2016. Most of those enrollees had coverage through the exchange, but the total also included off-exchange enrollments.
And in Highmark’s redacted rate filing memo for 2017, they noted that “These projections reflect expected changes in market share due to an expected increase in market competition” — presumably referring to CareSource’s planned expansion.
Kentucky Health Cooperative (a CO-OP created under the ACA) had planned to expand into the West Virginia exchange in 2015, but in early November 2014, the CO-OP announced that they were postponing their expansion into West Virginia by a year. Then in September 2015, The West Virginia Office of the Insurance Commissioner confirmed that the Kentucky CO-OP would not be offering plans in the West Virginia exchange for 2016.
Ultimately, it was a moot point, as Kentucky Health CO-OP announced in October 2015 that they would cease operations at the end of 2015. The CO-OP is no longer operational.
Although Highmark and CareSource are the only carriers offering plan in the exchange, several carriers offer plans outside the exchange in West Virginia, including Aetna, Celtic, Freedom Life, and Health Plan of the Upper Ohio Valley.
Premiums higher than national average
For West Virginia exchange enrollees who selected plans during the 2016 open enrollment period and qualified for subsidies (85 percent of the state’s enrollees are receiving subsidies), the average pre-subsidy premium was $542 per month—significantly higher than the $396 average across all states using Healthcare.gov.
But West Virginia’s enrolles are older than average, and more likely to select gold plans (older enrollees pay higher premiums, and gold plans are more expensive—than thus generally less popular—than bronze and silver plans). 38 percent of West Virginia’s exchange enrollees are between the ages of 55 and 64, while the average across all Healthcare.gov states is 25 percent. And 11 percent of West Virginia’s exchange enrollees picked gold plans, as opposed to just six percent of enrollees across all of the states that use Healthcare.gov.
The average after-subsidy premium in West Virginia is just $155 per month, a 71 percent reduction from the pre-subsidy price. The average after-subsidy premium across all Healthcare.gov states is considerably lower, at $106 per month. But the higher percentage of enrollees selecting gold plans in West Virginia results in a higher average after-subsidy premium.
Highmark initially requested an average rate increase of 19.7 percent for individual plans in the West Virginia exchange, but the requested average rate increase was subsequently changed to 24 percent, and was approved by regulators at that level. Because West Virginia had just one carrier in 2015, it ended up among the three states where one hundred percent of the exchange plans requested double digit rate increases for 2016.
Highmark noted that they considered pulling out of the exchange at the end of 2015. But the carrier ultimately felt they have a “social mission” to provide coverage to residents in West Virginia (since there are no other options in most counties in the state). And the 24 percent rate increase that was approved by regulators made it possible for Highmark to continue to offer plans for 2016.
According to HHS data, the average benchmark (second lowest-cost Silver) plan premium in West Virginia is 18.5 percent more expensive in 2016 than it was in 2015. Subsidy amounts are tied to the cost of the benchmark plan in each area, so subsidies are higher in West Virginia in 2016, and offset a significant portion of the premium hikes for subsidy-eligible enrollees.
For residents of the counties where CareSource is offering plans in 2016, there is some competition and choice. But in the other 45 counties, Highmark remains the only option. The good news for the vast majority of exchange enrollees is that subsidies increased for 2016, just as they did for 2015.
Additional enrollment assistance
When CMS announced navigator grant recipients in September 2015, they noted that West Virginia would have an additional 42 counties covered by local navigators during the 2016 open enrollment period (November 1 to January 31), dramatically improving access to in-person enrollment help.
In 2015, CMS awarded nearly $607,000 in navigator grants to three West Virginia agencies: the Appalachian Area Agency on Aging, First Choice Services, Inc., and West Virginia University Research Corp.
In 2016, only two agencies received navigator funding (First Choice Services, Inc. and WVU Research Corp.). Their combined total grant was $242,319.
State-run exchange costly and unlikely
West Virginia is one of 23 states where leadership’s opposition to the ACA is strong enough that there was little chance of an agreement to create a state-run exchange, even when subsidies were in danger pending the outcome of King v. Burwell (a lawsuit to determine whether subsidies were legal in states that use the federally-run exchange; if the plaintiffs had prevailed, subsidies would have disappeared in West Virginia).
Prior to announcing in 2013 that West Virginia would be expanding Medicaid, Governor Earl Ray Tomblin’s administration had hired out cost analyses for both Medicaid expansion as well as setting up a state-run exchange, and ultimately decided that Medicaid expansion would provide more bang for their buck.
Now that subsidies are no longer in jeopardy in the federally-run exchange (the Supreme Court ruled in King v. Burwell that subsidies are legal in every state), there is little incentive for states to spend the money and resources necessary to create their own exchanges; West Virginia will likely continue to use the federally-run exchange going forward.
AG supported elimination of subsidies
Incidentally, West Virginia’s Attorney General Patrick Morrisey joined AGs from five other states in December 2014 in an amicus brief submitted to the Supreme Court in support of the plaintiffs in King v. Burwell. Despite the fact that about 25,000 West Virginia residents would have lost subsidies if the plaintiffs had prevailed in the case, West Virginia’s Attorney General supported that outcome.
Governor Tomblin made it clear however that he did not support Morrisey’s amicus brief position, and has argued that when the state opted to use the federally-run exchange, they were under the impression that subsidies would be available either way.
2015 enrollment numbers
33,421 people enrolled in private plans through the West Virginia exchange during the 2015 open enrollment period (through February 22). 49 percent were new to the exchange for 2015. The other 51 percent were people who had plans in 2014 and either renewed them or selected a different exchange plan for 2015.
HHS had projected 25,000 private plan enrollees in the West Virginia exchange by the end of open enrollment, and at ACAsignups, Charles Gaba set a higher projection: 31,000 enrollees by February 15. Enrollment reached nearly 134 percent of the HHS projection, and even exceeded Gaba’s prediction (although the final count reflected a week-long extension that HHS added to allow people additional time to finish their enrollments).
But some enrollees didn’t pay their initial premiums, and others cancelled their coverage mid-way through the year. In addition, Healthcare.gov stepped up enforcement of immigration/financial documentation requirements in 2015, resulting in more real-time disenrollments and subsidy adjustments. By the end of June, effectuated enrollment in private plans through the West Virginia exchange stood at 31,106 people. Nearly 86 percent received premium subsidies that average $310 per month.
An additional 5,063 people enrolleed in Medicaid or CHIP through the exchange between November 15, 2014 and February 22, 2015. From the end of 2013 to December 2015, total enrollment in Medicaid/CHIP grew by 193,836 people in West Virginia – a 55 percent increase.
2015 rates and plans
West Virginia had just one carrier in its exchange in 2015 – Highmark Blue Cross Blue Shield – although the carrier only offered 12 plans in 2014, and bumped that up to 14 in 2015.
In 2014, the lowest cost bronze plan in the WV exchange was an average of $280/month, higher than the national average of $249. For 2015, the average rate increase in the individual market in West Virginia was 6.7 percent, although there was variation from one plan and region to another, and the average included off-exchange plans as well as plans in the exchange. Because the Kentucky CO-OP filed rates alongside Highmark for 2015, experts believed (and Highmark has confirmed) that Highmark was forced to be more competitive with their rates for 2015. Highmark’s rates were not able to be adjusted heading into the 2015 open enrollment, even after the CO-OP pulled out of the WV market. So despite the fact that Highmark remained the only carrier in the state’s exchange in 2015, rates were as competitive as they would have been with a second participating carrier.
Because the exchange only had one participating carrier, there wasn’t as much to be gained as there was in other states by shopping around again during the 2015 open enrollment. The NY Times Upshot showed that people who had the benchmark plan (second lowest cost silver plan) in 2014 saw an average rate increase of 9 percent in most of West Virginia for 2015. Since the benchmark plan didn’t change to a new carrier, there was no option to switch to a cheaper plan, unless enrollees wanted to go with the lowest-cost silver plan or a bronze plan.
Across all metal levels in the exchange, a Commonwealth Fund analysis found an average rate increase of 10 percent in 2015 for a 40 year-old non-smoker in West Virginia. Of course, most enrollees qualify for subsidies, and the subsidies rose to keep pace with the increase in price for the benchmark plan.
The ACA’s impact in West Virginia
Although West Virginia opted to let HHS run the exchange, the state chose to expand Medicaid under the ACA, and has been working diligently to enroll as many people as possible in expanded Medicaid. Their efforts have paid off: From 2013 to December 2015, West Virginia’s Medicaid/CHIP enrollment grew by 55 percent – the seventh-highest increase in the country (only Oregon, Kentucky, Colorado, Nevada, New Mexico, and Washington had higher percentage increases).
By December 2015, West Virginia had 548,380 residents (almost 30% of the state’s population) enrolled in Medicaid or Children’s Health Insurance Program. And as of September 2014, reports indicated that the state had already enrolled virtually all of the people who were eligible for expanded Medicaid. Medicaid enrollment continues year-round, so any remaining eligible residents can enroll at any time.
According to US census data, about 14 percent of the West Virginia population was uninsured in 2013. By 2014, that number had fallen to 8.6 percent. A Wallet Hub survey pegged the state’s uninsured rate at just 6.6 percent in July 2014, and Gallup data put the uninsured rate at 8.3 percent during the first half of 2015, starting from a high of 17.6 percent in 2013. Another study in 2015 confirmed similar data, pegging West Virginia’s uninsured rate at 6.59 percent.
Regardless of what study we consider, the reduction in the state’s uninsured rate is due almost entirely to the ACA.
In a 2014 study conducted by Wallet Hub, West Virginia was ranked second in the nation in terms of how much the states and their residents benefit from Obamacare. If all provisions of the law were fully implemented in every state (including Medicaid expansion, which West Virginia has already implemented), West Virginia would rise to the top of the list as the state the benefits the most from the ACA.
Anti-ACA legislation didn’t advance
Despite how much the ACA has helped West Virginia, lawmakers introduced a pair of anti-ACA bills shortly after the 2015 legislative session convened. HB 2216 would have given only the legislature the authority to create a state-based health insurance exchange – the Governor would not be able to create an exchange without legislative approval if HB 2216 had passed. The bill was approved by the House Health and Human Resources Committee in a 14 – 9 vote in January 2015, but it didn’t advance after that.
And HB 2509 went a step further – it would have invalidated the ACA in West Virginia. This bill was also reviewed by the House Health and Human Resources Committee, but did not advance to the House floor.
In the 2016 legislative session, HB2660 was introduced in an effort to tighten up qualifications and state requirements for people wishing to serve as navigators and nonnavigator assisters. HB2660 did not advance out of committee.
How many people enrolled in 2014?
In addition to Medicaid and CHIP enrollments, 25,856 people had completed their private plan Obamacare enrollments through the West Virginia exchange by early July 2014, which represented an increase of about 6,000 people since the end of the 2014 open enrollment period (qualifying events trigger special enrollment periods for private plans.)
Another 6,171 people had enrolled directly (outside the exchange) through Highmark Blue Cross Blue Shield – the only carrier offering 2014 plans in the WV exchange – between October 1, 2013 and April 15, 2014. Off-exchange plans are ACA-compliant.
Prior to open enrollment, there were an estimated 99,000 West Virginians eligible for private Obamacare plans, so the combined total of on and off-exchange enrollments in the first year represented nearly a third of those individuals. Perry Bryant, Executive Director of West Virginians for Affordable Health Care, called the first year’s enrollment numbers “not as robust as we would have liked” but noted that HealthCare.gov was much more functional by its second year.
Why has West Virginia been so successful?
West Virginia expanded Medicaid, and is using auto-enrollment directly through the state’s Medicaid program, in addition to Medicaid enrollment through the exchange. The state has been working to contact residents who receive SNAP and WIC benefits, as well as households where some members were already receiving Medicaid benefits. By letting these individuals know about the expanded Medicaid program, the outreach program has been wildly successful.
Actuaries had predicted that 63,000 people would enroll in WV’s expanded Medicaid program in 2014, but by September 2014, the number of new Medicaid enrollments in WV had grown to between 132,00 and 145,000 people, out of an estimated total of between 143,000 and 150,000 eligible people.
West Virginians for Affordable Health Care is a group that has been instrumental in pressing for healthcare reform in West Virginia for nearly a decade. They have been involved in education and outreach about the ACA, and are pushing for better management of chronic illnesses, which account for three-quarters of the state’s health care spending. Their efforts have helped to bolster WV’s exchange enrollment numbers, for both Medicaid and private plans.
In December 2014, West Virginia University’s School of Public Health received a $2 million grant that will be used to pilot innovative approaches to improving public health and controlling healthcare costs. The initiative was sponsored by CMS, and initially focused on people using Medicare, Medicaid, and Children’s Health Insurance Program (CHIP). But WVU and its public health partners envision that eventually “… all West Virginians will benefit from these initiatives…”
West Virginia exchange history
After first developing plans to operate a state-run health insurance exchange, West Virginia submitted a blueprint for a partnership exchange to the U.S. Department of Health and Human Services (HHS). The blueprint for the West Virginia Health Insurance Marketplace was approved in March 2013.
Gov. Earl Ray Tomblin’s administration cited cost, particularly the expense associated with information technology systems, as a key factor in ultimately deciding against a fully-state-run exchange. Administration officials also said the partnership gives the state some control over the exchange.
Under the partnership, West Virginia is responsible for regulating companies that sell health insurance policies on the exchange.
The state also oversees the In-Person Assister (IPA) program. Assisters are under contract with the state and provide individuals impartial help with the enrollment process. In November 2014, the state announced that it would be hiring an additional 100 people to help residents enroll in the exchange and the state’s expanded Medicaid program.
West Virginia initially did not allow non-grandfathered pre-2014 policies in the individual market to renew again in 2014; they had to be replaced with ACA-compliant coverage as of their renewal date in 2014.
But in April 2014, the state reversed course, agreeing to allow grandmothered (transitional) plans to be renewed as late as 2016.
In February 2016, HHS agreed to give states additional flexibility on grandmothered plans, allowing the plans to renew as late as October 1, 2017, and remain in force until as late as December 31, 2017. States have freedom to accept that proposal as-is, reject it, or implement it with additional restrictions—which is what West Virginia has done
In May 2016, the WV Office of the Insurance Commissioner confirmed by phone that West Virginia is allowing small group transitional plans to remain in force until the end of 2017, at the carriers’ discretion, as long as the plans are renewed by January 2017. The state is not allowing small group transitional plans to renew after January 2017.
The OIC noted that there are no longer any grandmothered individual plans in West Virginia, as the state’s carriers have already terminated those plans and replaced them with ACA-compliant coverage.
The state also filed a lawsuit in 2014 against the Obama Administration because the federal government deferred to the states on the decision about whether or not to renew grandmothered plans. A district court found that West Virginia lacked standing in the case, because they did not suffer an injury-in-fact as a result of HHS letting states decide whether or not to allow grandmothered plans to continue to exist. The state appealed that decision.
Then in July 2016, the US Court of Appeals concurred with the district court, ruling that the state lacks standing. The ruling states that West Virginia’s “injury is nothing more than the political discomfort in having the responsibility to determine whether to enforce or not – and thereby annoying some West Virginia citizens whatever way it decides. And no court has ever recognized political discomfort as an injury-in-fact”
Contact the exchange
West Virginia residents enroll through the federally facilitated exchange; 2017 enrollment runs November 1, 2016 through January 31, 2017.
West Virginia health insurance exchange links
State Exchange Profile: West Virginia
The Henry J. Kaiser Family Foundation overview of West Virginia’s progress toward creating a state health insurance exchange.