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Regulation and Compliance > State Regulation

10 PPACA exchanges with upmarket appeal

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State-based public health insurance exchanges seem to be doing better than the exchanges at attracting consumers who have a choice about where to shop. 

State-based exchanges that use for qualified health plan (QHP) enrollment are somewhere in between.

Analysts at the U.S. Department of Health and Human Services (HHS) have published data supporting those conclusions in a batch of Patient Protection and Affordable Care Act (PPACA) exchange activity for the period from Nov. 15, 2014, through Nov. 16, 2015.

See also: 10 ZIP codes that love PPACA exchange plans

HHS has had a hard time getting the state-based exchanges to report activity data in the same way, and it is missing some types of data, such as data on use of the PPACA premium tax credit program, for several states, including California.

But the report gives some support for the idea that state-based exchanges may be closer to their residents and more effective at outreach in some ways than exchanges run from Washington.

In terms of raw QHP selection numbers, the best exchange QHP markets have been HHS-run exchange states: 1.3 million of the 9.5 million exchange enrollees live in Florida, and 978,890 live in Texas. Both are HHS-run exchange states.

But another performance indicator is the percentage of the exchange QHP enrollees who are buying their coverage without help from the PPACA premium subsidy tax credit and could buy coverage off-exchange. PPACA now imposes the same medical underwriting restrictions on off-exchange coverage as it imposes on exchange QHPs. 

The subsidies are available only to consumers who earn 400 percent or less of the federal poverty level.

The share of exchange QHP business coming from non-subsidy customers has been 13 percent in the HHS-run exchange states, 30 percent in the state-based exchange states, and 19 percent in the states with state-based exchanges that use the enrollment system.

See also: Where PPACA exchanges attract high-income users

In many states, PPACA exchanges have tried to reach out to traditional agents and brokers, and much of the exchange QHP business may be coming in through producers. Producers who are working as exchange agents may happy to build relationships with relatively high-income consumers by helping them buy exchange QHPs. Other producers may object to seeing the PPACA exchanges court relatively high-income customers.

To learn more about where the exchanges have won over higher-income insurance shoppers, read on. 


10. Washington state and Illinois: 22 percent.

Washington state QHP selectors: 117,705.

Illinois state QHP selectors: 286,888.

Washington state has a state-based exchange, the Washington Healthplanfinder exchange, and Illinois ended up having HHS handle enrollment. But officials in both states have supported the exchange program, and the exchanges in both states have attracted an above-average share of non-subsidy customers.

See also: HHS: Florida has 1.2 million exchange plan enrollees


9. Connecticut: 23 percent.

Connecticut QHP selectors: 91,139.

Connecticut’s Access Health CT won a reputation for running enrollment so well that some other state-based exchanges switched to Connecticut’s system. It has attracted an above-average percentage of non-subsidy customers, but not as high a percentage as in some other states with state-based exchanges.

See also: High earners cool to Connecticut PPACA exchange plans

New Mexico road

8. New Mexico: 24 percent.

New Mexico QHP selectors: 43,054.

HHS classifies New Mexico as a state that has a state-based exchange but uses the enrollment system. That exchange does worse at attracting non-subsidy business than some state’s with pure state-based exchanges but better than most of the states with pure HHS-run exchanges.

See also: Escape from New Mexico shops for an enrollment system


7. Arizona: 24 percent.

Arizona QHP selectors: 169,178.

Arizona wavered back and forth between running its exchange and letting HHS do the job. So far this open enrollment period, Arizona has been the HHS-run exchange with the second highest percentage of non-subsidy customers.

See also: Health Net’s earnings: 3 takeaways

6. New Hampshire: 29 percent.

New Hampshire QHP selectors: 46,642.

New Hampshire ended up having HHS run its exchange program. In New Hampshire, HHS is doing better at attracting non-subsidy customers than it is in any other state with an HHS-run or HHS-assisted exchange. 

See also: More carriers flock to PPACA exchanges


5. Maryland: 30 percent.

Maryland QHP selectors: 92,658.

Maryland has given its state-based Maryland Health Connection exchange generous support, and, like Connecticut, Maryland is a state with a relatively high cost of living. Residents there may need a higher level of income to live the way they would in Kansas or Alabama.

See also: 3 PPACA open enrollment surprises

Image: EPA photo/Eric Vance. 

Statue of Liberty

4. New York: 31 percent.

New York QHP selectors: 357,241.

Like the state-based exchanges in Connecticut and Maryland, New York’s state-based NY State of Health exchange may do well on this indicator partly because the system for calculating PPACA premium subsidies is based on the federal poverty level. The poverty level thresholds make no special allowances for residents of New York City.

See also: 5 platinum-budget PPACA exchange programs

Happy office worker

3. Kentucky: 31 percent.

Kentucky QHP selectors: 93,677.

Kentucky’s state-based Kynect exchange was famous for functioning reasonable well even in October 2013, when few other states had a working exchange enrollment system.

See also: McConnell must please Republican base without losing majority

Keep out tape

2. Vermont: 41 percent.

Vermont QHP selectors: 26,009.

Vermont’s state-based Vermont Health Connect exchange has such a high percentage of non-subsidy business because officials did what they could to shut down the state’s off-exchange market.

See also: View: Vermont’s lessons for fans of single-payer system


1. Colorado: 47 percent.

Colorado QHP selectors: 122,381.

Colorado’s state-based Connect for Health Colorado exchange brought in higher-income QHP buyers by doing what it could to work with commercial agents and brokers as well as nonprofit agencies.

See also: 3 PPACA exchange runner nightmares

Non-subsidy QHP selectors as a percentage of all selectors

Colorado 47%
Vermont 41%
Kentucky 31%
New York 31%
Maryland 30%
New Hampshire 29%
Arizona 24%
New Mexico 24%
Connecticut 23%
Washington 22%
Illinois 22%
Idaho 21%
Oregon 21%
Kansas 20%
Oklahoma 19%
Pennsylvania 19%
Virginia 17%
Delaware 17%
New Jersey 17%
Tennessee 17%
Montana 16%
Ohio 16%
Texas 14%
West Virginia 14%
Iowa 14%
North Dakota 13%
Rhode Island 12%
Utah 12%
Arkansas 12%
Indiana 12%
Louisiana 12%
Michigan 12%
Missouri 12%
Nebraska 12%
South Carolina 12%
Alabama 11%
Alaska 11%
Maine 11%
South Dakota 11%
Wisconsin 10%



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