Understanding Health Insurance Changes for 2019

Three young adults talk about health insurance options
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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. And although health care reform (and protections for people with pre-existing conditions) continued to make headlines in 2018, ACA reform was not seriously considered again in Congress.

The Individual Mandate Penalty No Longer Applies as of 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 continue to be available for 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 Increased Slightly for 2019, but Average Benchmark Premiums Decreased Slightly in Most States

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

But average benchmark premiums (the second-lowest-cost silver plan in each area) actually decreased 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 likely resulted in slightly smaller premium subsidies for 2019 in many states, since the subsidies are tied to the benchmark premiums (but actual subsidy amounts depend on the mix of enrollees in each area, since subsidy amounts are larger when enrollees are older and/or have lower incomes, and in areas where the pre-subsidy cost of coverage is higher). You can also read more 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 lasted just over six weeks and ran from November 1 to December 15, with all plans effective January 1, 2019. This is the same schedule that was used in most states for 2018 coverage as well. But ten state-run exchanges 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-enrolled with the same insurer (or another insurer owned by the same parent company) during the 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 apply for 2019 just as they have in past years, with adjustments to deductibles and out-of-pocket limits, along with provider networks and covered drug lists. And there are new insurers offering plans in the exchanges in many states for 2019. All of this annual upheaval makes it particularly important for enrollees to actively compare available plans during open enrollment and select the one that offers the best value, instead of opting for auto-renewal.

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 STLDI 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.

Large Group, Medicare, and Medicaid

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.

But Medicaid work requirements are gaining traction in GOP-led states. Some enrollees in Indiana, New Hampshire, Kentucky, Arkansas, and possibly Wisconsin will have to comply with Medicaid work requirements as of 2019 (the work requirement in Arkansas was already implemented in 2018 for people age 30-49).

Virginia opted to expand Medicaid as of January 2019, making roughly 400,000 people newly eligible for Medicaid in the state. Maine is expected to expand Medicaid in 2019 after Governor-elect Janet Mills takes office (residents of Maine voted to expand Medicaid in 2017, but the outgoing governor blocked expansion from taking effect in 2018). Voters in Nebraska, Utah, and Idaho passed Medicaid expansion ballot initiatives in 2018, so Medicaid is expected to be expanded in those states in 2019 as well.

Open enrollment for Medicare Advantage and Medicare Part D ran from October 15 to December 7, with all changes effective January 1, 2019 (this is the same schedule that's been used for several years). Current plans will change somewhat for 2019—as they do each year—so it was 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 is 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.

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