The individual major medical market might look ugly, and expensive, in 2018, but it might continue to exist in much of the country.

Officials at the Centers for Medicare and Medicaid Services recently put out a 2018 Affordable Care Act public exchange plan menu forecast that cast doubt on the sustainability of the exchange system, which provides plans for about 12 million of the 19 million U.S. residents who now have individual coverage. The CMS 2018 exchange menu map showed, however, that most counties in the country outside of central Ohio and western Missouri are likely to have at least one individual exchange plan provider in 2018.

(Related: Iowa’s Individual Health Rescue Proposal, Dissected)

One major source of uncertainty is efforts in Washington to replace the current income-based Affordable Care Act premium tax credit subsidy program with an age-based subsidy.

Some policymakers also want to replace the current Affordable Care Act cost-sharing reduction subsidy program, which helps low-income exchange plan users pay their deductibles, with a new grant program for states.

Some policymakers want to change the current Affordable Care Act benefits coverage mandates and find ways to make other changes in Affordable Care Act individual health market rules.

For issuers of individual major medical coverage, which need precise, detailed information to set rates, the lack of information about the 2018 market creates a cost-forecasting nightmare. 

Would-be 2018 exchange plan issuers were supposed to file their proposed 2018 rates in much of the country by Friday. Regulators in some states can insist on changes in the final rates. The issuers that have filed 2018 rates still have the ability to back out of the 2018 individual major medical market. Issuers may not actually like individual health business enough to be willing to pay agents sales commissions.

The preliminary rate filings do, however, give observers some sense of whether it’s possible that individual major medical insurance could still exist in 2018. 

Here’s what we saw when we looked for 2018 product and rate information for the five states with the highest 2017 Affordable Care Act exchange plan enrollment. Together, those five states account for about 40% of 2017 Affordable Care Act public exchange system enrollment. 

1. Florida

2017 Enrollment: 1.8 million

Florida Blue, Florida’s dominant exchange plan issuer, based in Jacksonville, expects to continue to sell individual exchange plans throughout Florida in 2018, according to the Florida Times-Union. Florida insurance regulators have posted the company’s 2018 form filing on the web, but the 2018 rate information is not yet available to the public.

Molina Healthcare Inc., a Long Beach, California-based carrier, has also filed 2018 rates, and St. Louis-based Centene Corp. has said it hopes to start selling exchange plans in Florida for the first time in 2018.

2. Texas

2017 Enrollment: 1.23 million

At press time, the only issuer with a 2018 individual major medical rate filing posted on the Texas public filing portal was Freedom Life Insurance Co. of America, a unit of Fort Worth-based USHealth Group.

Freedom Life now covers just 18 people in Texas, through bronze-level plans sold outside the Affordable Care Act exchange market. The company expects to increase premiums for those people by 24% in 2018, mainly because of concerns about how external forces might affect the individual health risk pool.

2018 (Photo: iStock)

(Photo: iStock)

The Dallas Morning News is reporting, however, that BlueCross BlueShield of Texas, a unit of Chicago-based Health Care Service Corp., is on track to return to the Texas exchange program menu in 2018. Texas Blue now provides coverage in every county in Texas.

Two other issuers that now serve small parts of Texas, St. Louis-based Centene Corp. and New York-based Oscar Health, have said they hope to expand their service areas in Texas in 2018.

3. California

2017 Enrollment: 1.17 million

Covered California, the agency that runs California’s state-based Affordable Care Act exchange, and state insurance and managed care plan regulators have not yet posted any 2018 form or rate filings.

The exchange has proposed that, if the federal government fails to make Affordable Care Act cost-sharing reduction subsidy program payments, it will try to have issuers increase premiums enough to cover the cost of providing a replacement subsidy program through Covered California.

4. North Carolina

2017 Enrollment: 549,000

Blue Cross and Blue Shield of North Carolina, the state’s Durham-based gorilla, which has about 500,000 individual health enrollees in its state, has filed 2018 rates for all 100 North Carolina counties. The company expects to increase rates for its enrollees an average of 23% for coverage purchased either through the state’s Affordable Care Act exchange program or outside the exchange system.

The carrier says it received an average rate increase of 24% for 2017.

The carrier says much of the increase is the result of the looming return of the Affordable Care Act health insurer tax and the possible end of the health law’s cost-sharing reduction subsidy program.

Another carrier, Bloomfield, Connecticut-based Cigna Corp., now covers about 22,000 people in North Carolina. The company has told regulators that it intends to eliminate a lightly managed plan with just 700 enrollees in North Carolina, but that it may continue to offer a health maintenance organization plan that now has about 21,000 individual and family enrollees. Rates for the individual and family HMO plan might rise an average of about 23%.

5. Georgia

2017 Enrollment: 494,000

Georgia has not yet posted preliminary rate filings on the web.

Blue Cross and Blue Shield of Georgia, a subsidiary of Indianapolis-based Anthem Inc., dominates the Georgia market. The company announced in May that it expects to file 2018 individual rates for all Georgia regions.

Another carrier, Alliant Health Plans of Alpharetta, Georgia, has said it intends to offer individual exchange plans in the state.

Centene already offers individual plans in some parts of Georgia and has said it hopes to expand its service area in the state in 2018. 

— Check out Bucking Trend, Insurer Centene Expands ACA Exchange Coverage on ThinkAdvisor.