What Consumers in Kentucky, Tennessee, and Virginia Need to Know

What Consumers in Kentucky, Tennessee, and Virginia Need to Know about Open Enrollment October 31, 2017 Jennifer Tolbert, Kaiser Family Foundation Karen Pollitz, Kaiser Family Foundation Kelli Cauley, Assister Program Supervisor, Kentuckiana Regional Planning & Development Agency (KIPDA) Emilie Fauchet, Lead Navigator for the Hispanic Community (Middle TN), Family and Children's Service Jill Hanken, Director, ENROLL! Virginia

Karen Pollitz Senior Fellow

Jennifer Tolbert Director of State Health Reform

Kelli Cauley Assister Program Supervisor Kentuckiana Regional Planning and Development Agency

Emilie Fauchet Lead Navigator for the Hispanic Community (Middle TN) Family and Children’s Service, Nashville

Jill Hanken Director ENROLL! Virginia

Figure 7 Events leading up to open enrollment added to uncertainty for insurers and confusion for consumers. Debate over Affordable Care Act repeal ended with no legislation enacted 2018 Open Enrollment shortened to 6 weeks Resources for outreach and consumer assistance have been reduced – 90% reduction in federal funding for advertising – 41% reduction in federal navigator grants; varying effects by states and programs Cost-sharing reduction (CSR) payments to insurers have been terminated – Bipartisan effort underway in Senate to restore CSR payments to insurers and federal funding for marketing and in-person assistance, though prospects are uncertain

Figure 8 Most are aware the individual mandate is still in effect, but four in ten uninsured are unaware or unsure. As you may know, the health care law passed in 2010—known as the Affordable Care Act or Obamacare— required nearly all Americans to have health insurance, or else pay a fine. As far as you know, is this requirement still in effect, or not? Still in effect (correct) Don't know 71% Total public Uninsured ages 18-64 Not in effect 59% 14% 18% 15% 23% All non-group enrollees ages 18-64 79% 12% 9% Marketplace enrollees ages 18-64 79% 13% 8% NOTE: Refused responses not shown. SOURCE: Kaiser Family Foundation Health Tracking Polls (pooled interviews from September and October 2017)

Figure 9 The Affordable Care Act is still the law. The law has not been repealed or replaced Individuals must have health insurance in 2018 or risk paying a tax penalty – Penalty in 2018 is greater of: 695/adult ( 347.50/child), up to 2,085/family; or 2.5% of household income above the tax filing threshold, capped at the cost of national average bronze plan premium – Exemptions for affordability (if lowest cost marketplace premium is more than 8.05% of income in 2018), poor adults in states not expanding Medicaid, hardship, others To satisfy the individual mandate: – Sign up for health coverage offered at work – Apply for Medicaid/CHIP Over 300,000 in KY, TN, and VA are eligible for Medicaid/CHIP but not enrolled – Apply for private, non-group health insurance on or off Marketplace Premium subsidies available in Marketplace for people with income 100%-400% FPL Private non-group health insurance can only be purchased during open enrollment or special enrollment periods (SEP) following life change events

Figure 10 Most uninsured and large shares of non-group enrollees are unaware of the timing of open enrollment. As you may know, under the health care law there are specific open enrollment periods each year when individuals can sign up for new insurance or change their current health insurance plans. Do you happen to know when the next open enrollment period begins? November 1st (correct) Don't know Uninsured ages 18-64 All non-group enrollees ages 18-64 Marketplace enrollees ages 18-64 15% 17% 33% 40% Incorrect 5% 14% 68% 23% 23% Do you happen to know when the next open enrollment period ends? Dec. or January, depending on state (correct) Incorrect Don't know 43% 36% 20% 25% 81% 27% 28% NOTE: Refused responses not shown. SOURCE: Kaiser Family Foundation Health Tracking Polls (pooled interviews from September and October 2017) 53% 47%

Figure 11 Open enrollment for 2018 will be shorter in most states. November 1 – December 15, 2017 in Healthcare.gov states – Open enrollment period will be 6 weeks, compared to 12 weeks in prior years State run marketplaces have option to extend dates, and many have VT WA MT ND MN OR ID NV WY CO CA AZ NM PA IL KS OK MO OH IN KY AK WV VA NH MA RI CT NJ DE MD DC NC TN SC AR MS AL TX NY MI IA NE UT WI SD ME GA LA FL HI Healthcare.gov State (39 States) State-Based Marketplace (12 States including DC)

Figure 12 Nearly one-quarter of Marketplace enrollees auto-renewed in 2017. 2017 Marketplace Plan Selections by Enrollment Type New Enrollees 32% Auto Renewals 24% Active Renewals 44% Auto-renewal will still be an option in 2018, but active shopping is strongly recommended Issuer exits means auto-renewal could assign consumers to new insurer with new provider network Unlike prior years, consumers will not have the opportunity to change plans in January if they do not like the autorenewal results With 2018 premium changes, subsidy amounts could change substantially Renewal notices with 2018 premium amounts that typically arrive in October will be late for many consumers

Figure 13 2018 Insurer participation changed in Kentucky, Tennessee, and Virginia. State Number of Marketplace Insurers 2017 Kentucky Tennessee Virginia 3 3 8 Detail 2018 2 Humana left Marketplace statewide Anthem reduced service area Caresource no change 3 Humana left Marketplace statewide BCBSTN expanded into areas left by Humana Oscar entered Marketplace (Nashville area) CIGNA no change Aetna left Marketplace statewide UnitedHealth left Marketplace statewide Anthem reduced service area Sentara (Optima) reduced service area CareFirst BCBS no change CIGNA no change Kaiser Permanente no change Piedmont no change 6

Figure 14 Most Marketplace enrollees worry rising deductibles, premiums will make their coverage unaffordable. Percent who say they are “very” or “somewhat” worried that their co-pays and deductibles will become so high that they won’t 33b2 be able to afford to get the health care they need 39% 57% 60% Marketplace enrollees ages 18-64 All non-group enrollees ages 18-64 health insurance premiums will increase so much that they won’t 33a2 be able to afford the plan they have now 35% Employer-sponsored insurance ages 18-64 54% 55% SOURCE: Kaiser Family Foundation Health Tracking Polls (pooled interviews from September and October 2017)

Figure 15 Average medical deductibles in cost sharing reduction plans are much lower than in traditional Silver plans. 4,000 3,609 3,500 Combined Medical and Prescription Drug Deductible 3,276 2,904 3,000 Separate Medical and Prescription Drug Deductible 2,627 2,500 2,000 1,500 1,000 809 645 500 255 172 0 Silver CSR73 (200%-250% FPL) CSR87 (150%-200% FPL) CSR94 (100%-150% FPL) Source: Kaiser Family Foundation analysis of Marketplace plans in the 39 states with Federally Facilitated or Partnership exchanges in 2017 (including Arkansas, Kentucky, New Mexico, Nevada, and Oregon). Data are from Healthcare.gov health plan information for individuals and families available here: https://www.healthcare.gov/health-plan-information-2017/

Figure 16 Though the President stopped reimbursement to insurers, insurers must still provide CSR to consumers. Cost sharing reductions (CSR) are available to eligible individuals in the Marketplace with income 100%-250% FPL – 12,060- 30,150 for individual in 2018 – 24,600 to 61,500 for family of four in 2018 Nationwide, 57% of marketplace enrollees were eligible for CSR in 2017 – 51% in Kentucky; 59% in Tennessee; 60% in Virginia CSR subsidies are delivered only through modified Silver plans. – Silver plan deductibles, co-pays, and other cost sharing amounts are reduced; federal government reimburses insurers monthly for the value of added coverage President Trump’s recent announcement ended CSR reimbursement to health insurers, but insurers are still required to offer CSR to eligible individuals – Most important takeaway for consumers: Insurers are still required to provide reduced deductibles and copays for low-income marketplace enrollees – Second most important takeaway for consumers: While insurers are increasing premiums to offset the loss of payments from the federal government, consumers will mostly be held harmless

Figure 17 Most insurers raised premiums to address the termination of CSR payments Approach to applying CSR premium increases designed to protect consumers – Tennessee: insurers applied premium increase just to silver plans – Kentucky and Virginia: insurers applied the premium increase only on silver plans sold through the marketplace As a result, the premiums for silver plans in most areas will increase much more than will premiums for bronze plans That means the dollar value of premium tax credits will also increase substantially in 2018 Important for consumers to review plan prices during OE – Consumers who continue to buy the benchmark Silver plan – or a cheaper plan – will be able to pay about the same monthly premium in 2018 or less – After taking into account the tax credit, consumers may find the net premiums for bronze or gold plans in 2018 are more affordable than in 2017 – Consumers not eligible for tax credits will likely face higher premiums

Figure 18 2018 premiums in Kentucky are increasing, but subsidy-eligible consumers will pay the same or less. Advance premium tax credit amounts and consumer share of premiums for 30-year old in Louisville, KY with income at 200% FPL ( 24,120 in 2018) Consumer Share of Premium Premium Tax Credit Amount 391 332 269 222 186 247 127 42 195 174 127 101 95 95 95 Lowest-cost Bronze Benchmark Silver Lowest-cost Gold 2017 Monthly Premiums SOURCE: HealthCare.gov for 2017 and 2018 monthly premiums and premium tax credits. 205 205 205 Lowest-cost Bronze Benchmark Silver Lowest-cost Gold 2018 Monthly Premiums

Figure 19 2018 premiums in Tennessee are increasing, but subsidy-eligible consumers will pay the same or less. Advance premium tax credit amounts and consumer share of premiums for 30-year old in Nashville, TN with income at 200% FPL ( 24,120 in 2018) Consumer Share of Premium Premium Tax Credit Amount 732 342 519 481 129 0 372 284 236 353 127 39 353 245 245 245 Lowest-cost Bronze Benchmark Silver Lowest-cost Gold 2017 Monthly Premiums SOURCE: HealthCare.gov for 2017 and 2018 monthly premiums and premium tax credits. Lowest-cost Bronze 390 390 Benchmark Silver Lowest-cost Gold 2018 Monthly Premiums

Figure 20 2018 premiums in Virginia are increasing, but subsidy-eligible consumers will pay the same or less. Advance premium tax credit amounts and consumer share of premiums for 30-year old in Virginia Beach, VA with income at 200% FPL ( 24,120 in 2018) Consumer Share of Premium Premium Tax Credit Amount 850 390 589 129 431 268 313 0 425 245 82 127 186 186 186 Lowest-cost Bronze Benchmark Silver Lowest-cost Gold 2017 Monthly Premiums SOURCE: HealthCare.gov for 2017 and 2018 monthly premiums and premium tax credits. 425 460 460 Lowest-cost Bronze Benchmark Silver Lowest-cost Gold 2018 Monthly Premiums

Figure 21 New enrollment rules may add to confusion. Failure to reconcile – Consumers who received advanced premium tax credits (APTCs) in 2016 and who have not yet filed their 2016 federal income tax return with Form 8962 may be denied APTCs in 2018 – Marketplace eligibility determination notice won’t specify this reason – Consumers can regain eligibility for APTC by filing 2016 federal return with Form 8962 Insurers can require repayment of 2017 unpaid premium debt – Insurers can require payment of back due premiums from prior 12 months before issuing new coverage for 2018 – New rule, effective June 19, 2017, applies to premium debt after that date – Prior notice required in 2017 – Appeals process not yet clearly defined – Contact marketplace, state insurance regulator, in-person assister for help

Figure 22 Start early. Waiting to the last minute risks delays. “Surge” signups as deadline approaches may increase with shorter Open Enrollment period – Healthcare.gov slowdowns, call center waits are possible – Unclear whether “in-line” enrollment will be permitted for those who are unable to complete their enrollment by Dec. 15 deadline Planned maintenance on HealthCare.gov during Open Enrollment Navigator funding reduced 41%, on average, in federal marketplace states – Reductions vary by state: 16% in TN, 49% in VA (Navigators in KY are state-funded) – Response to funding reductions will vary: Staff layoffs, reduced service areas, reduced service hours expected in some areas/programs* Demand for in-person help can exceed capacity in final weeks of Open Enrollment *Kaiser Family Foundation, “Data Note: Changes in 2017 Federal Navigator Funding,” October 2017, https://www.kff.org/health-reform/issue-brief/data-note-changes-in-2017-federal-navigator-funding/

Figure 23 KFF Resources on Open Enrollment Health Reform Frequently Asked Questions https://www.kff.org/health-reform/faq/health-reform-frequently-asked-question s / Marketplace Subsidy Calculator (2018 updates pending) https://www.kff.org/interactive/subsidy-calculator/ Penalty calculator (pending) ACA and You Explainers https://www.kff.org/understanding-health-insurance/ State Health Facts https://www.kff.org/statedata

State-Based Marketplace – Federal Platform Assister Program is required, but 100% State Funded 2 Insurance Issuers for Kentucky, but only 1 per County is available. Anthem available in 59 Counties CareSource available in 61 Counties If you were enrolled in a 2017 plan, You will be Auto-Enrolled into the closest Cross-referenced Plan, even if a different Issuer. #1 Concern – Is your Doctor in Network

https://kynect.ky.gov/General/AgentOrKynector To Find an Assister Near You for Assistance

https://healthbenefitexchange.ky.gov/SiteCollectionDocuments/Nov ember%20Events.pdf To Find a Calendar of Events Throughout KY Where an Assister Is Available Nov. 15th- 12:00-7:00 @ Sun Valley Community Center- 6505 Bethany Ln, Valley Station, KY 40272 Nov. 16th- 1:00-7:00 @ Meade County Extension Office- 1041 Old Ekron Rd, Brandenburg, KY 40108 Nov. 20th- 12:00-7:00 @ Awake Center- 701 Washington St, Shelbyville, KY 40065 Nov. 21st- 12:00-7:00 @ Hardin County Public Library- 100 Jim Owen Dr, Elizabethtown, KY 42701 Nov. 27th- Bullitt County@ Ridgeway Public Library – 127 N. Walnut St., Shepherdsville, KY 40165 Nov. 29th- 12:00-7:00 @ Marion County Career Center- 526 Workshop Lane, Lebanon, KY 40033 Nov. 30th- 12:00-7:00 @ South Central Library- 7300 Jefferson Blvd, Louisville, KY 40219 Dec. 1st- 12:00-5:00 @ Oldham County Public Library- 308 Yager Ave, La Grange, KY 40031 (may be extended to 7:00) Dec. 4th- 2:00-7:00 @ Carroll County Library- 136 Court St, Carrollton, KY 41008 Dec. 5th- 12:00-7:00 @ Breckinridge County Extension Office- 1377 S Hwy 261. Hardinsburg, KY 40143 Dec. 6th- 12:00-7:00 @ St. Matthews Community Center- 310 Ten Pin Ln, Louisville, KY 40207 Dec. 8th- 12:00-5:00 @ Washington County Library- 333 W Main St, Springfield, KY 40069 Dec. 11th- Spencer County@ Spencer County Library – 168 Taylorsville Rd., Taylorsville, KY 40071 Dec. 12th- 12:00-5:00 @ Nelson County Library- 201 Cathedral Manor, Bardstown, KY 40004

TENNESSEE CARRIERS Three carriers: BlueCross BlueShield (everywhere except Greater Nashville and Greater Memphis) Cigna (Tri-Cities area, Greater Nashville and Greater Memphis only) Oscar (Greater Nashville only) All carriers submitted their plans assuming they would cover CSRs This did cause premium increases in order to stabilize the market Consumers who have opted for auto-renewal will be automatically renewed into the plan that is the most similar to the plan that they had in 2017. Because of changes to plans and carriers, this may not be the plan that works best for them. All consumers can pick their own plan during Open Enrollment, even if they have been notified that they have been auto-renewed.

TENNESSEE ENROLLMENT ASSISTANCE Make an appointment with a Navigator anywhere in TN by calling 844-644-5443 or online at http://www.getcoveredtenn.org/ Navigators speak English, Spanish, Arabic, Kurdish, Amharic and language line services are available for other languages

Virginia OE5 Statewide Navigator Program www.enrollva.org Information Appointments Events Calendar 1-888-392-5132 Collaborate with CACs & other partners

Virginia Marketplace for 2018 Fewer carriers participating Seven Companies Most areas have only one carrier But each offers multiple plans 2017 carriers may no longer serve the same areas New provider networks Different hospitals in network Different drug formularies Average rate increases range from 34.5% - 81.8% Companies assumed loss of CSR payments Other federal uncertainty

Number of Issuers by County Yellow – One issuer Green – Two issuers Blue – Three issuers Will there be adequate networks?

Issuer Options by County Red – Anthem Orange – Anthem & Kaiser Pink – Anthem & Optima Light Purple – Optima & Piedmont Dark Purple – Piedmont Yellow – Cigna Light Green – CareFirst, Cigna & Kaiser Dark Green – Optima & Kaiser Brown – Cigna & Kaiser Dark Blue – Optima Light Blue - Kaiser

Tips for Consumers Pay attention to mail from current insurance plan and Healthcare.gov If authorized by consumer, letters will offer automatic renewal into same plan or most similar new plan Consumer can still switch to another available plan – but only during open enrollment (unless SEP eligible) Check new networks – hospital, doctors Check new formularies

Tips for Consumers If eligible, tax credits protect consumers from higher premiums. Income from 100%-400% FPL Silver plans with cost sharing reductions (CSRs) will still be offered Household income under 250% FPL Lower deductibles, lower co-payments Don’t wait to act! Open enrollment is only 6 weeks November 1 – December 15

Figure 36 Questions About Open Enrollment Karen Pollitz, Senior Fellow, Kaiser Family Foundation Email: [email protected] Phone: (202) 347-5270 Jennifer Tolbert, Director of State Health Reform, Kaiser Family Foundation Email: [email protected] Phone: (202) 347-5270 Kelli Cauley, Kentuckiana Regional Planning and Development Agency Online: https ://kynect.ky.gov/General/AgentOrK ynector Phone: (888) 737-3363 Emilie Fauchet, Family and Children’s Service, Nashville Online: http:// www.getcoveredtenn.org Phone: (844) 644-5443 Jill Hanken, ENROLL! Virginia Online: www.enrollva.org Phone: (888) 392-5132

Figure 37 Contact Information Katie H. Smith, Communications Associate Kaiser Family Foundation Email: [email protected] Phone: (202) 347-5270 Facebook: /KaiserFamilyFoundation Twitter: @KaiserFamFound Email alerts: kff.org/email