Wyoming uses the federally-run exchange, so residents enroll through Healthcare.gov. There is only one insurer in the Wyoming exchange in 2017, as was the case in 2016. But enrollment in the Wyoming exchange grew for 2017, despite lower average enrollment across all the states that use HealthCare.gov.
Wyoming premiums are higher than most of the rest of the country, but the ACA’s income-based premium subsidies keep coverage affordable for most enrollees.
According to an HHS report released in December 2016, there are roughly 20,000 more people with health insurance in Wyoming than there would be without the ACA.
The average pre-subsidy premium in Wyoming’s exchange for 2017 is $614/month, considerably higher than the $476/month average across all the states that use the federally-run exchange. But the ACA’s premium subsidies are larger in states with higher premiums, so Wyoming’s average after-subsidy premium is just $164/month — very similar to the $153/month average across all states using the federally-run exchange.
Still just one exchange carrier in 2017
Wyoming was the only state in the US that had just one exchange carrier in 2016, although West Virginia was in that situation in 2014 and 2015, and Alaska nearly ended up with just a single carrier in 2016.
For 2017, Alaska and Wyoming both have just one exchange carrier, as is the case in Oklahoma, Alabama, and South Carolina. Numerous states across the country have partial areas of the state with just a single carrier offering plans in the exchange in 2017.
In the spring of 2016, Melody Health Insurance (which later became Canopy Health Insurance) had announced their plan to offer health insurance in the Wyoming and Nevada exchanges—limited to the Cheyenne and Las Vegas metro areas—for 2017. But the Wyoming Insurance Department confirmed in August that Canopy had been unable to get licensed in Nevada, which was the first step towards getting their Wyoming license.
As a result, they were not able to get licensed in Wyoming, and are not offering coverage in the Wyoming exchange in 2017. Blue Cross Blue Shield of Wyoming continues to be the only carrier participating in the exchange in Wyoming in 2017.
Blue Cross Blue Shield of Wyoming had a 102.1 percent medical loss ratio in 2017, which is not sustainable long-term. Medical loss ratio refers to the percentage of premiums that are spent on medical costs (as opposed to administration and profit), and a number above 100 means that the insurer is spending more on claims than it’s collecting in premiums.
Average rate hike much smaller than national average
Wyoming has among the highest premiums in the nation; in 2017, only Alaska, North Carolina, Oklahoma, and West Virginia have higher average pre-subsidy premiums than Wyoming.
But despite the lack of competition, the average rate increase for Blue Cross Blue Shield of Woming’s individual market plans was very modest for 2017, especially compared with the national average for 2017 (about 25 percent). BCBSWY’s average rate increase for exchange plans was 8.18 percent for BlueSelect plans without pediatric dental and 7.85 percent for BlueSelect plans with pediatric dental. All of the plans are PPOs, which is unusual in 2017 — many states have very limited selection in terms of PPO options, and some states have no PPOs available at all in the exchange.
Although a lack of competition in the exchanges obviously means that consumers have few total options from which to choose, the ACA’s medical loss ratio applies regardless of how many carriers participate: In the individual market, a health plan must spend at least 80 cents of every premium dollar on medical claims; there’s no mechanism for increasing rates just because there’s no competition (as noted above, BCBSWY had an unsustainably high medical loss ratio in 2016 — well above the minimum requirements of the ACA).
Wyoming does not have an effective rate review process, which means the federal government (CCIIO) is in charge of reviewing rates in Wyoming. That system does not give federal regulators the ability to deny rate requests; rather, they’re only able to say whether or not the rate request is actuarially justified.
Because most Wyoming exchange enrollees (89 percent at the end of the 2017 open enrollment period) are receiving subsidies, the subsidies offset the bulk of the rate increases for most enrollees. Because of the way the subsidies interact with the federal poverty level, they keep premium increases in check from one year to the next for eligible enrollees. It’s important to shop around during open enrollment, as the benchmark plan can change from one year to the next. However, in a state with just one participating exchange carrier, the benefit of shopping around is obviously much less significant than it is in states with multiple carriers.
2016 effectuated enrollment > 22k
During the 2016 open enrollment period, 23,770 people enrolled in private plans through the Wyoming exchange, including new enrollees and renewals. For perspective, 18,065 people had in-force coverage through the Wyoming exchange as of June 2015, and total enrollment at the end of the 2015 open enrollment period stood at 21,092 people.
Enrollment grew from 2015 to 2016 in all but one county in Wyoming. Only Fremont county (Lander is the county seat) experienced an enrollment decline, with a 267-person drop in enrollment. Wyoming consumer advocates believe that is likely due to the federal government ruling that the Northern Arapahoe Tribe is a large employer and is thus required to offer health insurance to its full-time employees. As a result, some of the tribe’s employees may have switched from exchange plans to group coverage offered by the tribe.
By March 31, 2016, effectuated enrollment through the Wyoming exchange stood at 22,076 people. 92 percent were receiving subsidies that averaged $459 per month.
All of the enrollments in the Wyoming exchange for 2016 are through Blue Cross Blue Shield of Wyoming, since WINhealth stopped offering coverage as of December 31, 2015 (details below), leaving BCBS of WY as the lone carrier. All former WINhealth members had to pick a new plan by the end of December; otherwise they were uninsured as of January 1. But they also qualified for a special enrollment period (through February 29, 2016) because loss of coverage is a qualifying event.
Increased penalty for being uninsured in 2016 and beyond
For people who don’t have insurance in 2016 and aren’t exempt from the ACA’s penalty, the penalty is significantly higher than it was in 2014 and 2015. The penalty for 2016 is the greater of $695 per uninsured adult (half that amount for a child) up to $2,085 per household, OR 2.5 percent of household income above the tax filing threshold. For tax filers who owe a penalty, the average penalty is expected to be almost $1,000 for 2016. That’s about five times what it was for 2014. Any applicable penalty for 2016 will be collected when tax returns are filed in early 2017.
The flat rate penalty is indexed for inflation in years after 2016, but the IRS confirmed in late 2016 that there would be no adjustment for 2017. The flat-rate penalty will remain $695 per uninsured adult in 2017.
No DOI oversight for Direct Primary Care Practices
In early 2016, Governor Mead signed SF49 into law, exempting direct primary care programs from state Department of Insurance regulations and oversight. That makes it easier for doctors to establish direct primary care practices, charging members a set monthly fee in return for whatever primary care the patient might need.
Particularly in states like Wyoming, where unsubsidized health insurance is much more expensive than average, and where the “subsidy cliff” is much more of an issue than it would be in places with lower premiums, direct primary care models can be an attractive alternative to higher-priced major medical health insurance. And like healthcare sharing ministries, direct primary care practices pose a potential threat to the stability and health of the regular insurance risk pool, since sicker applicants are more likely to gravitate to higher-priced – but much more comprehensive – ACA-compliant health insurance.
With that said, it’s important to note that membership in a direct primary care practice does not constitute minimum essential coverage under the ACA. So if an individual is not exempt from the ACA’s individual mandate and relies solely on a direct primary care membership, the ACA’s penalty for being uninsured will be assessed when that person files a tax return. A direct primary care membership can be used in conjunction with a health insurance plan in order to fulfill the ACA’s individual mandate, but it cannot replace major medical health insurance.
It’s also important to note that direct primary care memberships only cover primary care. If a members needs care that involves hospitalization or treatment that cannot be provided in a primary care setting, the primary care membership will not provide any value.
On October 8, 2015, WINhealth – one of the two carriers that offered plans in Wyoming’s exchange in 2015 – announced that they would exit the individual market at the end of 2015. At that point, they were still planning to offer offer group plans, but 8,234 people with individual WINhealth plans were informed that they would need to find new coverage for 2016.
The decision to exit the individual market was triggered by the shortfall in risk corridors payments. WINhealth found out on October 1, 2015 that they would not receive $4.4 million they were due under the risk corridors program (nationwide, insurers were shorted about $2.5 billion in risk corridors payments).
But Wyoming Insurance Commissioner Tom Glause noted that WINhealth’s decision “did not come as a surprise to the Department [of Insurance],” as they were already aware of the financial challenges WINhealth had been facing prior to the risk corridors shortfall.
And on October 21, the other shoe dropped when WINhealth was placed in receivership by the Wyoming Department of Insurance. They ceased sales of new plans at that point, and in January 2016, a Laramie County District judge signed an order to liquidate the company. The company’s assets will be used to pay claims that were incurred through December 31, 2015, and the Wyoming Life and Health Guaranty Association will serve as a back-up if there aren’t enough assets to cover claims.
The Wyoming Department of Insurance has been in discussions with several out-of-state carriers about the possibility of them entering the Wyoming market in 2017 or beyond. But for now, WINhealth’s exit leaves Blue Cross Blue Shield of Wyoming as the sole carrier offering individual and small group plans in the Wyoming exchange for 2016 (Altius(Aetna/Coventry) and UnitedHealthcare also offer small group plans outside the exchange; Celtic and Altius also offers individual plans outside the exchange in some areas).
2016 rates: BCBS of WY up about 6%
Wyoming’s pre-subsidy health insurance rates are much higher than the national average. Only Alaska and Vermont have higher pre-subsidy average benchmark rates in the exchange for 2016.
90 percent of the people who selected a plan through the Wyoming exchange for 2016 were eligible for premium subsidies to offset the cost of their coverage. For those enrollees, the average pre-subsidy premium is $571/month, which is far higher than the $396/month average across all 38 states that use Healthcare.gov. But after subsidies, the average premium in Wyoming is just $117/month – only slightly higher than the $106/month average for Healthcare.gov states.
Premium subsidies cover an average of 80 percent of the cost of coverage for eligible enrollees, and are an excellent example of how the ACA’s subsidies even out discrepancies in pricing from one state to another, for enrollees with income under 400 percent of the poverty level.
2016 rates were already set for BCBS of WY prior to WINhealth’s departure, and despite the lack of competition, the carrier is still bound by the ACA’s medical loss ratio rules requiring at least 80 percent of premiums to be spent on medical claims.
Prior to the release of BCBS of WY’s rate changes for 2016, CEO Rick Schum offered some reassurance to Wyoming exchange enrollees, saying “I would highly doubt any of our customers – or future customers – are in for any sticker shock.”
Wyoming is one of five states that leaves the rate review process entirely up to HHS for ACA-compliant products. It was already known that BCBS of WY had proposed rate hikes of less than 10 percent, as any proposed rate increases of 10 percent or more were made public on Healthcare.gov’s rate review tool in June. Ultimately, BCBS of WY ended up with average rate increases of about 6 percent. The average benchmark premium is 5.6 percent higher in 2016 than it was in 2015. Benchmark (second-lowest-cost Silver) plan premiums are used to determine subsidy amounts, so the average subsidy is higher in Wyoming in 2016 assuming average incomes remained the same.
WINhealth had proposed a rate increase of 13.37 percent, but their enrollees ended up having to switch to a different plan for 2016. In most cases, that was a plan from BCBS of WY (the carrier offers 28 different plan options in the exchange), although Celtic and Altius offer plans in limited areas outside the exchange in Wyoming (total enrollment in those plans was negligible as of 2015; the Department of Insurance said in September 2015 that BCBS and WINHealth accounted for virtually all of the individual market in Wyoming). Plans purchased outside the exchange are not eligible for subsidies though.
Time insurance also offered plans outside the exchange in Wyoming in 2015, but they announced in June 2015 that they would exit the individual market nationwide, and would not participate in the 2016 open enrollment period.
ACA makes coverage affordable in Wyoming
Among people who enrolled in coverage through the Wyoming exchange during the 2016 open enrollment period, 90 percent are receiving premium tax credits (subsidies). Across all states that use Healthcare.gov, only Florida has a higher subsidy-eligibility rate, at 91 percent, and Mississippi is tied with Wyoming at 90 percent (both of those states have considerably lower pre-subsidy premium averages and average subsidy amounts than Wyoming. Across all Healthcare.gov states, an average of 85 percent of exchange enrollees are receiving subsidies.
Health insurance in Wyoming is much more expensive than the national average, which explains the high percentage of people who qualify for subsidies. In addition, because coverage is so expensive in Wyoming, the average subsidies is considerably higher there than it is in other states: Among all Healthcare.gov states, the average subsidy is $290 per month; in Wyoming, it’s $454 per month (only Alaska has higher average subsidies in 2016).
Because of the way the ACA’s premium subsidies are structured, they are particularly helpful in regions where the “retail” cost of health insurance is higher than average. Wyoming is a great example. Although Wyoming has among the most expensive pre-subsidy health insurance premiums in the US, the after-subsidy premiums are just a few dollars per month higher than average. Subsidies make up most of the difference, for people whose income doesn’t exceed 400 percent of the poverty level.
Cadillac tax particularly concerning in Wyoming
Because health insurance is so much more expensive in Wyoming, the state was concerned about the impact of the ACA’s “Cadillac tax” that was set to go into effect in 2018. The idea behind the tax was to generate revenue by placing an excise tax on employer-sponsored health insurance with premiums that exceed a pre-determined annual cap (the tax is only assessed on the portion of the premium that exceeds the cap).
In 2018, that cap was to be $10,200 for a single individual, and $27,500 for a family plan. Nationally, it’s estimated that just ten percent of employer-sponsored plans would be subject to the tax in 2018, but there was concern that it will impact a far higher percentage of employer-sponsored plan in Wyoming, simply because it’s more costly to provide health insurance in the state.
But on December 18, 2015, federal lawmakers passed H.R.2029, a $1.8 trillion federal spending bill that includes a provision to delay the Cadillac tax for two years, pushing its implementation out to 2020.
And the Trump Administration, together with a Republican-led Congress, has been pushing to repeal numerous parts of the ACA. The AHCA, which has not yet advanced to a vote on the House floor, would delay the Cadillac tax until 2026.
Only a slight change in uninsured rate
Wyoming’s uninsured rate decreased slightly from 2013 to 2014, but the decrease from 2014 to 2015 was not statistically significant (only two other states — North Dakota and South Dakota) had similarly insignificant decreases).
According to U.S. Census data, the uninsured rate in Wyoming in 2013 was 13.4 percent. By 2015, it had dropped to 11.5 percent. The overall decrease was much less significant than the U.S. average.
Wyoming’s lack of progress on this front is largely blamed on the fact that Wyoming lawmakers have refused to accept federal funding to expand Medicaid under the ACA (that is still the case, although Governor Mead has been pushing for expansion). Wyoming also didn’t establish their own state-run exchange, but even among other states that followed the same path (no state-run exchange, and no Medicaid expansion), the average uninsured rate dropped more sharply from 2013 to mid-2015.
But nine states still had higher uninsured rates than Wyoming in 2015.
2015 enrollment data
The Wyoming exchange enrolled 21,092 people in private plans during the 2015 open enrollment period (through February 22, including the week-long extension). This is about a third of the exchange’s total target population.
As of January 9, Wyoming had the highest percentage increase in the country when comparing 2015 enrollment numbers with enrollment totals as of April 2014. On January 9, the 2015 enrollment count was 42 percent higher than the prior year’s total. By January 30, the growth over last year had increased to 54 percent – with two more weeks remaining in open enrollment. HHS had set an enrollment projection of just 15,000 people for Wyoming’s exchange by February 15, and the exchange easily surpassed that goal. Total enrollment at the end of open enrollment was 176% of what they had at the end of the first open enrollment last year.
But some enrollees didn’t pay their initial premiums and their coverage was never effectuated, while others opted to cancel their plan early in the year. And some plans and/or subsidies were terminated because the enrollees didn’t provide adequate verification of immigration or financial data. By the end of June, 18,065 people had in-force private plan coverage through the Wyoming exchange.
Of the people who selected a plan during the 2015 open enrollment period, 48 percent were new to the exchange for 2015. Among those who still had coverage in force at the end of June, 92.2 percent received premium subsidies that averaged $424 per month. That’s much higher than the national average, but Wyoming’s unsubsidized health insurance rates are also much higher than the national average, necessitating larger subsidies to keep premiums at the percentage of income determined to be affordable under the ACA.
An additional 847 people enrolleed in Medicaid or CHIP through the exchange during the second open enrollment period, qualifying under the state’s unchanged guidelines, as Wyoming has not expanded Medicaid under the ACA. Medicaid and CHIP enrollment continue year-round.
Wyoming carriers and rates – 2015
Rates decreased in many areas of the country for people willing to switch plans for 2015, but that was not the case in Wyoming. The NY Times Upshot pegs the increase in benchmark plan premiums in Wyoming at 7 percent or more, although the Kaiser Family Foundation shows the average benchmark plan in Wyoming increasing by just 1.6 percent for 2015.
Across all plans and metal levels in the exchange, a Commonwealth Fund analysis found that rates in Wyoming’s exchange were an average of 5 percent higher in 2015 for a 40 year-old non-smoker.
For people who qualified for subsidies however (roughly 93 percent of enrollees) the state’s high health insurance premiums were dramatically offset by the premium tax credits in 2014, and that continued to be the case in 2015. The average after-subsidy premium for the benchmark plans in Wyoming for a 40-year-old earning $30,000/year was $208 in 2015, a dollar less than it was in 2014.
The federally-run Wyoming health insurance exchange had 40 plans available (up from 18 in 2014) from two health insurance carriers: Blue Cross Blue Shield of Wyoming and WINHealth Partners, both of which participated in the exchange in 2014.
No Medicaid expansion yet
Unfortunately for Wyoming residents living below the poverty line, the high cost of unsubsidized coverage means that the coverage gap is particularly harsh in Wyoming. Since the state has not expanded Medicaid under Obamacare, residents with incomes below 100% of poverty are not eligible for subsidies, and Medicaid is not available for most of them either.
Their only alternative is to pay full price for private insurance, which is particularly unrealistic in a state where the average premium is more than five hundred dollars a month.
Medicaid expansion could still come with time. Governor Matt Mead has been discussing the issue with the federal government, and he noted in early November 2014 that HHS is “more open” to modified Medicaid expansion than they were in the past. Shortly after that, the Governor released the details of his Medicaid expansion proposal, which would include modest premiums for enrollees with incomes between 100 percent and 138 percent of poverty, and along with small copays for many newly-eligible enrollees.
But lawmakers proposed a different plan (not vetted for budget neutrality or by HHS) and a Wyoming Senate committee approved a proposal that was essentially a combination of the two. The full Senate ultimately rejected the bill however, and Medicaid expansion was off the table for the 2015 legislative session.
But in the fall of 2015, Mead renewed his push for Medicaid expansion, and presented the legislature with two different budgets – one with Medicaid expansion and one without – so they can see the financial impact of expanding Medicaid. Mead has noted that declining revenue from gas and oil has resulted in the need for a tighter budget in the state, and the federal funding from Medicaid expansion would benefit the state financially – as well as the 17,000 people who are currently in the coverage gap and unable to obtain health insurance.
While 70 percent of Wyoming residents disapprove of the ACA in general, 55 percent support Medicaid expansion according to a recent poll conducted by the University of Wyoming.
2014 enrollment numbers
The total private plan enrollment was the fourth lowest in the country, but Wyoming has the smallest population in the US.
An additional 2,216 exchange applicants had been found to be eligible for the state’s existing (not expanded) Medicaid or CHIP.
Originally, the federal projection was that Wyoming would have 13,000 private plan enrollees by March 31, 2014. That was revised to around 10,000, and officials were optimistic that a March surge in application volume would put total enrollment into the five figure range. That projection proved to be correct, and the exchange far surpassed the 10,000 mark by the end of the 2014 open enrollment window.
Wyoming exchange history
Gov. Matt Mead announced in late 2012 that Wyoming would default to the federal health insurance exchange for 2014, with the possibility of moving to a state-run exchange at some unspecified future date.
In 2012, the Wyoming legislature passed a bill requiring a small committee to study the federal government’s implementation and operation of the exchange. The committee will monitor how many state residents use the federal exchange, what problems they encounter, operating costs, and other factors in deciding whether to recommend the state eventually take over operations of the exchange.
The committee held its first meeting in April 2013, and the study may take more than two years according to the committee co-chair. This round of study continues the evaluation process started by the Wyoming Health Insurance Exchange Steering Committee, which Mead appointed in 2011.
Gov. Mead initially refused to expand Medicaid, but began supporting expansion as the year went on. Two bills that would expand Medicaid passed out of committee in January by a small margin. Both failed introduction during the budget session in mid-February, and the 2014 legislative session did not result in any further legislation on the issue.
In November 2014, Gov. Mead and the Health Department presented lawmakers with a modified Medicaid expansion proposal, and the governor asked them to approve it. Although a Senate committee approved a modified version of Mead’s proposal, the full senate rejected it in early February. Medicaid still has not been expanded in Wyoming as of the end of 2015.
Wyoming health insurance exchange links
Wyoming Insurance Department
Provides consumer protection and support to Wyoming residents by investigating consumer complaints and resolving issues on insurance matters.
(307) 777-7401 / Toll Free: 1-800-438-5768 / firstname.lastname@example.org
State Exchange Profile: Wyoming
The Henry J. Kaiser Family Foundation overview of Wyoming’s progress toward creating a state health insurance exchange.