2019 OPEN ENROLLMENT ENDS (most states)

Time: D H M S

As I noted last month when I first analyzed the requested 2019 rates for North Dakota insurers, ND was somewhat unique last year in that it was one of only two states (the other was Vermont) which didn't tack on any extra premium increases for 2018 to account for the lost Cost Sharing Reduction reimbursement revenue after Donald Trump cut off those payments last October.

This led to one of North Dakota's three carriers, Medica, dropping off the ACA exchange altogether, though they still ended up enrolling a few hundred people directly via the off-exchange market.

A few years back I posted an entry which breaks out the income eligibility thresholds for Medicaid and CHIP in every state. I've reposted an updated version below, which also takes into account Basic Health Plan (BHP) eligibility in Minnesota and New York. This comes directly from the Centers for Medicare & Medicaid. Note the footnotes at the bottom. The pink cells on the right indicate that the state has not yet expanded Medicaid under the ACA (Maine and Virginia have passed but note implemented doing so, while Medicaid expansion is on the ballot in Idaho, Nebraska and Utah this November).

As a reminder, here's the 2018 Federal Poverty Level income chart for every state except Alaska and Hawaii (Alaska is 25% higher, Hawaii is 15% higher):

via Montana Standard:

The state is exploring whether a Montana-run reinsurance program would help lower the premiums people pay when buying their health insurance on the federal marketplace, in some cases by 10-20 percent.

Yes. Yes, it would.

...Montana Gov. Steve Bullock and Department of Administration Director John Lewis are creating a 13-person working group to explore how a state-run reinsurance program might work in Montana. The group will use information from a recent study commissioned by the Montana Healthcare Foundation looking at what reinsurance could mean for the state.

The study shows reinsurance could lower premiums that have risen by double digits in recent years. Those rates could drop anywhere from 9.6 percent to nearly 30 percent on extreme ends of the spectrum, according to the study.

As I noted back in July, in addition to the Trump Administration's Centers for Medicare & Medicaid (CMS) chopping down the marketing budget for HealthCare.Gov by 90% last year, they also slashed the navigator/personal outreach budget by over 40% as well, from $63 million down to $36 million...and this year have cut it by another $26 million, to just $10 million across all 34 states which rely on HealthCare.Gov to host their ACA exchange open enrollment functionality (there are 5 more states which are hosted by HC.gov, but which I believe operate their own exchange and navigator budget: Oregon, New Mexico, Nevada, Kentucky and Arkansas). Combined, that makes an 84% reduction in navigator funding over a 2 year period.

BREAKING: Governor @JerryBrownGov today signed several #Care4AllCA bills that protects patients and places greater accountability on health insurers now on Gov's desk:#SB910 & #SB1375 to ban/limit "junk" insurance;#AB2499 on MLR; and#AB2472 on a public option study.

— Health Access CA (@healthaccess) September 22, 2018

With the 2019 Open Enrollment Period rapidly approaching, I figured this might be a good time to remind everyone that while it starts on November 1st for most of the country, the largest state, California, is kicking things off 2 weeks early (17 days early, actually). Covered California is launching their 2019 ACA Open Enrollment Period on Monday, October 15th, 2018:

Open enrollment for 2019 coverage will begin October 15, 2018 in California, and continue until January 15, 2019

Nationwide, open enrollment for 2019 coverage is scheduled to run from November 1, 2018 to December 15, 2018 — the same schedule that was followed in late 2017 for 2018 coverage. But Covered California was one of only three state-run exchanges that opted in 2017 to keep open enrollment at three months in duration for 2018 coverage (the others were New York and DC).

And the state enacted legislation (A.B.156) in late 2017 that codifies a three-month open enrollment period going forward — California will not be switching to the November 1 – December 15 open enrollment window that other states will be using.

This is a pretty minor update, but I'm trying to lock in all of the approved 2019 rate changes as they come in. Last month, South Dakota's two carriers, Avera and Sanford, posted requested rate increases which I thought were 2.6% and 10.0% at the time. I also estimated their relative enrollment at around 27,000 and 4,000 enrollees apiece for market share calculations, which gave a statewide average increase of around 3.5%.

I checked the South Dakota Insurance Division website again today, and it certainly looks like the filings have been approved by the state insurance regulators...however, when I double-checked the filings themselves, it looks like they were actually slightly lower than I thought: 2.5% and 9.7% respectively.

In addition, I was able to find the hard enrollment numbers for each...the total is pretty close to what I had it at (29,180 vs. 31,000), but the splut is quite different. Insetad of Avera still having an 87% market share, it looks ike the split is more like 63/37 this year. Since Sanford is requesting a significantly higher increase than Avera, that means the weighted statewide average is higher as well...around 5.2% instead of 3.5%.

I posted Montana's preliminary/requested 2019 ACA indiividual market rate change requests back in late June. At the time, they were seeking average rate increases of 6.0% statewide, and I estimated that the GOP's repeal of the ACA's individual mandate penalty, combined with the Trump Administration's expansion of #ShortAssPlans, accounted for about 9.9 percentage points of that.

More recently, the state insurance commissioner's website published approved 2019 rate changes. The average increases have been sliced down slightly (from 6.0% to 5.7% on average), and I've lowered my estimate of #ACASabotage impact from 9.9% to 6% based on the lack of either factor being prominently mentioned in the actual carrier rate filings. If accurate that means rates would have been flat year over year on average in 2019 if not for those factors.

Unsubsidized Montana enrollees are paying an average of $637/month this year, so that's roughly a $38/month difference, or around $460 for the full year.

When Maryland insurance carriers originally submitted their proposed 2019 premium changes back in May, it looked pretty grim...they were expected to average around 29.5% statewide for the ACA-compliant individual market., increasing from around $631/month on average to roughly $817/month for unsubsidized enrollees.

Thanks to swift, bipartisan action on the part of the Democratically-controlled Maryland state legislature and the Republican Governor, Maryland was able to pass several bills which partially negated or cancelled out Trump/Congressional Republican sabotage of the Affordable Care Act. In particular, they passed laws which locked in current restrictions on both short-term plans and association health plans (the types of "junk policies" which Trump is pushing hard to expand upon)...along with an extremely robust reinsurance program.

 

Just in case anyone thinks state insurance regulatory boards can't be hard-core badasses, consider the Optima Health situation in Virginia which I wrote about a couple of weeks ago:

By early September, it was clear that Trump would indeed be cutting off CSR funding. With just a few weeks left before the final deadline to sign 2018 ACA exchange contracts, Optima suddenly announced that they were not only jacking up rates a whopping 81%, they were also pulling out of a large chunk of the state, leaving large areas at risk of "going bare" without any ACA carriers whatsoever.

...Then, on September 14, with just days to spare and thanks to what I assume were some pretty intense backroom deals being made, Anthem suddenly announced that they were back in the game after all!

Back in July, I wrote about a lawsuit filed by twelve state Attorneys General against the Trump Administration over their attempt to vastly expand "Association Health Plans" as an alternative to ACA-compliant healthcare policies:

A group of 11 states and Washington, D.C., are suing the Trump administration in an attempt to roll back a regulation that allowed for the expansion of certain health plans that skirt ObamaCare regulations.

The lawsuit, led by New York Attorney General Barbara Underwood (D) and Massachusetts Attorney General Maura Healey (D), alleges that the Department of Labor violated the Administrative Procedures Act when it wrote a rule expanding access to association health plans.

Association health plans allow small businesses and other groups to band together to buy health insurance. The rule allows more groups to join together to form associations.

The move is part of a broader Trump administration effort to open up skimpier, cheaper plans as an alternative to ObamaCare plans.

 

via Nicholas Bagley of The Incidental Economist:

Maryland files suit to protect health reform from Texas.

... the Maryland attorney general today filed a separate lawsuit in a Maryland district court. Among other things, he’s seeking an injunction requiring the continued enforcement of the law. Depending on how quickly the Maryland case moves, it’s possible we could see dueling injunctions—one ordering the Trump administration to stop enforcing the law, the other ordering it to keep enforcing.

That’s an unholy mess just waiting to happen. Now, it may not come to that. My best guess is that the Texas lawsuit will fizzle: any injunction will likely be stayed pending appeal, either by the Fifth Circuit or the Supreme Court, and the case is going nowhere on the merits. The Maryland lawsuit will likely prove unnecessary.

I don't have much to add to this other than to note how much this case underscores just how much power and importance state attorneys general have.

As I just noted earlier this afternoon, Massachusetts is NOT expecting the repeal of the ACA's individual mandate to impact their 2019 individual market enrollment or premiums for a simple reason: The Bay State never formally repealed their own, pre-ACA mandate penalty. They basically mothballed it once the ACA's version went into effect, and are simply dusting it off for 2019 and beyond now that the federal mandate has been formally repealed.

However, the two mandate penalties don't work quite the same way. For the federal mandate, unless you qualify for an exemption (and there's a whole bunch of those), the penalty for not having ACA-compliant healthcare coverage is (or has been up until now) as follows:

This Just In...

Ready for Open Enrollment, Health Connector sets 2019 plans with lower premium increases, selects community organizations to provide in-person support to residents

Boston – September 13, 2018 – The Massachusetts Health Connector Board of Directors today approved 57 Qualified Health Plans from nine carriers for individuals and families, with new plan designs that create better value for members and premium increases that average under 5 percent from 2018.

Unfortunately, the press release doesn't specify what "under 5%" means, nor does it break that out by carrier/market share. I've put in a request for those details and will update this as soon as I hear back from them. They sent me the following chart, but this only includes enrollees earning between 300-400% of the Federal Poverty Level, which means the marketshare across the entire individual market is likely somewhat different. I'm assuming the 4.4% overall average applies to the entire market but could be wrong about that as well:

For months now, I've been trying to get people to understand that when it comes to sabotage of the Affordable Care Act, especially in terms of individual market premium increases, you have to include the impact of actions taken by Donald Trump and Congressional Republicans in BOTH 2017 and 2018, not just 2018 alone.

In 2017, the single largest factor in the ~28% average national unsubsidized premium increase for ACA plans was Donald Trump's cutting off of Cost Sharing Reduction (CSR) reimbursement payments to carriers. This alone accounted for fully half of the 2018 increase. However, there were other, smaller actions taken which added up to another 3% or so: Slashing the Open Enrollment Period in half, CMS slashing the marketing budget for the federal exchange down 90%, slashing the outreach/navigator budget down 40% and so on.

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