North Dakota

A couple of weeks ago I posted North Dakota's preliminary 2021 individual & small group policy premium rate filings, which averaged a 7.4% increase on the individual market and a 4.1% unweighted average increase for the small group market.

A few days ago, the North Dakota Insurance Dept. posted the final/approved rate hikes, including several significant reductions over those requested:

BISMARCK, N.D. – Insurance Commissioner Jon Godfread today released the approved health insurance rates for both individual and small group plans for 2021, and encourages consumers to start early, stay informed and shop around.

Here's North Dakota's 2021 individual & small group market rate change filings. Note that all of the small group filings are heavily redacted and the memos aren't available in the SERFF database for any of them, so I can't run a weighted average and had to go with the unweighted 5.0% increase.

For the individual market, Blue Cross Blue Shield's memo isn't available, so I had to plug in an estimate based on the average 2019 enrollment; I'm assuming it's fairly close to that this year as well. Weighted average on the indy market is a 7.4% increase.

Last month I noted that North Dakota had posted their requested 2020 premium rate change requests, including two different filings: One assuming the states' ACA Section 1332 Reinsurance Waiver didn't get approved, the other assuming it did. It was pretty unlikely that their waiver would be denied, however, so the general assumption was that they'd be looking at a significant rate reduction, especially compared with the rate increase if the waiver didn't go through.

At the time, I didn't have access to the actual enrollment figures for the three carriers on North Dakota's individual market, so I had to go with an unweighted average rate change, and came up with a drop of 7.9%.

Since then, however, the state regulators have reviewed and approved the 2020 premium changes, and thanks to Louise Norris, I don't even have to dig up the enrollment data:

Average rates dropping by nearly 6% in 2020 (without reinsurance, they’d have increased by nearly 15%)

MLR rebate payments for 2018 are being sent out to enrollees even as I type this. The data for 2018 MLR rebates won't be officially posted for another month or so, but I've managed to acquire it early, and after a lot of number-crunching the data, I've recompiled it into an easy-to-read format.

But that's not all! In addition to the actual 2018 MLR rebates, I've gone one step further and have taken an early crack at trying to figure out what 2019 MLR rebates might end up looking like next year (for the Individual Market only). In order to do this, I had to make several very large assumptions:

Unfortunately, North Dakota is another state where the carriers have redacted their rate filings. I was able to garner some info about one of the three carriers participating in the Individual Market next year: Medica's filing redaction wasn't done properly, so I was able to extract that they're looking at medical trend of 7.7%, a morbidity reduction of 1.5%, a 2.3% increase due to the reinstatement of the ACA's insurer fee...and a 20% reduction due to the implementation of the state's reinsurance program, which I first reported on last fall and followed up with this spring.

Sure enough, a week or so ago it was made official:

Last September I noted that North Dakota was considering going one of two ways when it comes to making a major change in their individual insurance market: EIther joining over a half-dozen other states in pushing for a reinsurance program (which I strongly support doing), or going the other way and starting to offer weaker policies without some ACA protections the way states like Idaho, Tennessee, Iowa and Kansas either already do or are in the process of doing.

Fortunately, it looks like they ultimately decided to go the former route after all:

A few minutes ago I posted about North Dakota's approved 2019 rate hikes, which are coming in at a mere 3.2% on average (but which would likely be dropping nearly 20 points without both last and this year's #ACASabotage factors).

However, there was something else equally interesting included in the ND DOI press release: Like Montana and several other states, North Dakota is also considering jumping onboard the state-based reinsurance waiver train!

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.

North Dakota was one of only two states (the other one was Vermont) which didn't allow their insurance carriers to add any additional premium load into their 2018 rates to account for Donald Trump's cut-off of Cost Sharing Reduction (CSR) reimbursement payments.

In direct response to this, Medica Health Plans dropped out of the ND on-exchange individual market this year to avoid taking the CSR hit. They hung around the off-exchange market, however, and therefore still have about 600 enrollees in the state.

As a result of this, my estimated impact of ACA sabotage efforts by the Trump Administration and Congressional Republicans has to include the factors from both 2017 and 2018: Cost-Sharing Reduction cut-off (9%) as well as Mandate Repeal and Short-Term Plan expansion (13.8%).

I had actually already written about Vermont doing this back in March, but seeing how it was one of only 2 states (+DC) which didn't allow Cost Sharing Reduction (CSR) costs to be loaded onto premiums at all this year, I figured I should mention it here as well. Once again:

  • 20 states went the full #SilverSwitcharoo route (the best option, since it maximizes tax credits for those eligible for them while minimizing the number of unsubsidized enrollees who get hit with the extra CSR load);
  • 16 states went with partial #SilverLoading (the second best option: Subsidized enrollees get bonus assistance, though not as much as in Switch states; more unsubsidized enrollees take the hit, but they aren't hit quite as hard);
  • 6 states went with "Broad Loading", the worst option because everyone gets hit with at least part of the CSR load except for subsidized Silver enrollees;
  • 6 states took a "Mixed" strategy...which is to say, no particular strategy whatsover. The state insurance dept. left it up to each carrier to decide how to handle the CSR issue, and ended up with a hodge podge of the other three
  • 3 states (well, 2 states + DC, anyway) didn't allow CSR costs to be loaded at all. Their carriers have to eat the loss, which makes little sense, but what're ya gonna do?

Press release from the North Dakota Insurance Dept,, September 28, 2017:

Medica Leaving North Dakota Individual Health Insurance Exchange in 2018
Post date: Sep 28, 2017

BISMARCK, N.D. – Insurance Commissioner Jon Godfread today confirmed that the Insurance Department was informed late Wednesday, Sept. 27, that Medica does not intend to sign an agreement with the federal government to offer coverage on the Affordable Care Act (ACA) Exchange for their individual health insurance in North Dakota for 2018.

“We have had numerous conversations with Medica over the course of the past few months, and given the uncertainty that currently exists around cost sharing reductions, they are unable to move forward in the Federal Exchange,” Godfread said.

In August I wrote that the situation in North Dakota was pretty straightforward: Three carriers on the individual exchange (BCBS, Medica and Sanford), requesting average rate hikes of around 24%, 19% and 12% respectively for an average increase of 23% assuming CSR payments are made, or a bit higher (28%) if they aren't.

Yesterday, however, with the final contract signing deadline having passed on the 27th, Louise Norris reports that one of the three carriers, Medica, was forced to drop out of the market at the last moment...not because they wanted to, but because the ND insurance dept. insisted on carriers pricing 2018 premiums on the assumption CSRs will be paid for the full year.

Medica understandably refused to take that risk (the odds of CSRs being guaranteed are virtually nil, and the odds of them being paid each and every month, as they're supposed to, is only so-so), so they dropped out instead.

North Dakota's numbers are pretty straightforward. Only three carriers, none of whch say anything about CSR or mandate concerns, so I have to assume that their requested rate increases are the best-case scenario. In addition, the KFF estimates suggest only a 5 point additional CSR factor anyway. This results in roughly a 23% average hike if CSRs are paid vs. a 28% increase if they aren't.

Of the 31 states which have expanded Medicaid under the Affordable Care Act, only a handful issue regular monthly or weekly enrollment reports.

I noted in February that enrollment in the ACA's Medicaid expansion program had increased by around 35,000 people across just 4 states (LA, MI, MN & PA).

It's early June now, so I checked in once more, and the numbers have continued to grow. I have the direct links for 5 states now (including New Hampshire)...

Normally I post screenshots from the revised/updated SERFF filings and/or updates at RateReview.HealthCare.Gov, but it takes forever and I think I've more than established my credibility on this sort of thing, so forgive me for not doing so here. Besides, #OE4 is approaching so rapidly now that this entire project will become moot soon enough, as people start actually shopping around and finding out just what their premium changes will be for 2017.

The other reason I'm not too concerned about documenting the latest batch of updates/additional data is because in the end none of it is making much of a difference to the larger national average anyway; no matter how the individual carrier rates jump around in various states, the overall, national weighted average still seems to hover right around the 25% level.

Still, for the record, here's the latest...in four states (Iowa, Indiana, Maine & Tennessee) I've just updated the requested and/or approved average increases. In the other four (Massachusetts, Montana, North & South Dakota) I've added the approved rate hikes as well.

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