Understanding Health Insurance Changes for 2019

What's changing about my health insurance for 2018?
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Healthcare reform has been in the news almost non-stop throughout 2017 and 2018, so if you're confused about what's happened and what will happen in 2019, you're certainly not alone. Let's take a look at what's changing, what's staying the same, and what you can expect in terms of your health insurance in 2019

[Note that this discussion mostly applies to individual market health insurance. Although only a small fraction of the US population has individual market coverage, this is where the bulk of the headlines tend to focus, as it's the market that was most affected by the Affordable Care Act.]

ACA Repeal Bills Were Not Enacted

Despite the ever-present headlines about health care reform in 2017 and 2018, most of the proposed changes have withered on the vine. GOP efforts to repeal major portions of the ACA in 2017 were unsuccessful.

That included the American Health Care Act (AHCA) in the House, and the Senate's version, the Better Care Reconciliation Act (BCRA). In fact, Senate Republicans tried to pass three different versions of the bill—"skinny" repeal, the Obamacare Repeal Reconciliation Act, and the BCRA—and none garnered enough support to pass. Neither did the Graham-Cassidy-Heller-Johnson amendment that was considered a few months later.

So although there were numerous pieces of ACA repeal legislation introduced in 2017—and the House did pass the American Health Care Act—none of them were enacted.

The Individual Mandate Penalty Will Be Eliminated in 2019

Although efforts to repeal the ACA were unsuccessful, GOP lawmakers did succeed in repealing the ACA's individual mandate penalty as part of the tax bill that they passed in late 2017.

The penalty repeal takes effect in January 2019. People who were uninsured in 2018 will still owe a penalty (unless they qualify for an exemption) when they file their tax returns in early 2019. But people who are uninsured in 2019 will no longer face a penalty.

The Rest of the ACA Remains in Effect

Other than the individual mandate penalty repeal (and the continuing budget resolution's delay of a few of the ACA's taxes, including the Cadillac Tax), the ACA is still fully in effect, including the premium subsidies, the cost-sharing reductions (aka, cost-sharing subsidies), Medicaid expansion, the employer mandate, protections for people with pre-existing conditions, essential health benefits, medical loss ratio rules, etc.

Cost-sharing subsidies will continue to be available in 2019, despite the fact that the federal government stopped reimbursing insurers for that cost in late 2017. Insurers in most states have incorporated the cost of providing cost-sharing subsidies into the premiums they charge. In most cases, the cost has only been added to silver plan rates, which results in larger premium subsidies for everyone who gets premium subsidies.

Average Premiums Are Increasing Slightly, But Average Benchmark Premiums Are Decreasing Slightly in Most States

Unlike 2017 and 2018, when individual market health insurance premiums increased significantly, average premiums are increasing by less than 3 percent nationwide for 2019.

But average benchmark premiums (the second-lowest-cost silver plan in each area) are actually decreasing slightly across the 39 states that use HealthCare.gov. This is due to a combination of new insurers entering (or re-entering) the individual markets in many states, as well as price reductions from some of the existing insurers.

The slightly lower average benchmark premiums will result in slightly smaller premium subsidies for 2019 in many states, since the subsidies are tied to the benchmark premiums. You can read more here about the issues affecting individual market premiums for 2019.

Changes That Were Implemented for 2018 and Continue to Apply

In April 2017, HHS finalized the market stabilization rule, which implemented several changes that apply to people who buy individual market coverage, on or off-exchange. These changes continue to apply for 2019:

  • In most states, open enrollment will continue to last just over six weeks and will run from November 1 to December 15, with all plans effective January 1, 2019. But there are seven state-run exchanges that have extended the deadline to enroll, so make sure you know how it works in your state.
  • If your policy was canceled for non-payment of premiums in 2018 and you re-enroll with the same insurer (or another insurer owned by the same parent company) during open enrollment, the insurer is allowed to require you to pay your past-due premiums before effectuating your new coverage. In general, it should only be one month of past-due premiums owed, as premiums are not charged after the plan was terminated.
  • The allowable actuarial value range for each metal level of coverage in the individual and small group market was expanded as of 2018. Bronze plans can have a -4/+5 range, while silver, gold, and platinum plans can have a -4/+2 range. Bronze plans have an actuarial value of about 60 percent, silver about 70 percent, gold about 80 percent, and platinum about 90 percent. But they can vary according to the allowable de minimus ranges, which were widened as of 2018. This just means that compared with 2017 and prior years, there can now be more variation from one plan to another within a given metal level, so individuals and small businesses should carefully compare the various options that are available.

    Benefit and coverage changes in the individual and small group market will happen just as they have in past years, with adjustments to deductibles and out-of-pocket limits, along with provider networks and covered drug lists. Don't assume that the plan that you picked last year will still be the best option for you in 2019—it's always wise to compare the options available to you during open enrollment, and make changes if necessary.

    Increased Availability of Short-Term and Association Health Plans

    In 2018, the Trump Administration made changes to the rules that apply to short-term limited duration health plans (STLDI), and to the rules that apply to association health plans (AHPs).

    In both cases, the changes make the plans more readily available as a substitute for regular ACA-compliant individual market health insurance. But buyers need to beware: The cheaper prices that apply to STLID and AHPs are a result of less robust coverage—you get what you pay for.

    Because the new federal rules serve as minimum standards and states are allowed to impose stricter rules, the rules now vary considerably from one state to another, particularly for short-term health insurance. You can click on a state on this map to see how the state regulates short-term coverage.

    Large Group, Medicare, and Medicaid: Normal Annual Changes Apply

    Most of the health care reform debates in 2017 and 2018 have centered around the individual market, the small group market, and Medicaid. For people who get their insurance from large employers, Medicare, or Medicaid (taken together, that's most of the population), the changes for 2019 will generally be the same sort of changes that happen each year.

    Open enrollment for Medicare Advantage and Medicare Part D runs from October 15 to December 7, with all changes effective January 1, 2019. Current plans will change somewhat for 2019—as they do each year—so it's important for enrollees to take time during open enrollment to compare the various available options and select the one that will best meet their needs in the coming year.

    And starting in 2019, there will be a Medicare Advantage open enrollment period from January 1 to March 31. This will replace the previously used Medicare Advantage disenrollment period, and will allow Medicare Advantage enrollees to switch to a different Medicare Advantage plan, or to switch to Original Medicare.

    For employer-sponsored plans, most employers have open enrollment in the fall, with benefit changes effective January 1. If your plan is experiencing changes for the coming year, or if there are new options available to you, open enrollment will be your opportunity to change your benefits if you choose to do so.

    Virginia has opted to expand Medicaid as of January 2019, which will make roughly 400,000 people newly eligible for Medicaid in the state. Maine is expected to expand Medicaid in 2019 as well, after a new governor takes office (residents of Maine voted to expand Medicaid in 2017, but Gov. LePage—who is term-limited and will be replaced in the 2018 election—has been blocking the expansion from taking effect). Several other states have Medicaid expansion on their ballots in 2018.

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