Health Insurance Marketplace in Utah
If you live in Utah, you’ll use this website, HealthCare.gov, to apply for coverage, compare plans, and enroll. Specific plans and prices are available now and coverage can start as soon as January 1, 2014. For small businesses and their employees: In Utah, your Small Business Health Options Program (SHOP) is Avenue H. Instead of HealthCare.gov, you’ll use the Avenue H website to apply for coverage, compare plans, and enroll. Visit Avenue H now to apply.
Spanish language speakers can contact cuidadodesalud.gov.`
Choosing the Right Health Insurance Plan
There are 5 categories of Marketplace insurance plans: Bronze, Silver, Gold, Platinum, and Catastrophic.
Plans range from bare bones “bronze” plans which cover 60% of pocket medical costs to “platinum” plans which have greater coverage but come with higher premiums. In general higher premiums mean lower out-of-pocket costs and a wider insurer network of doctors and hospitals.The plans are as listed below:
NOTE: All cost sharing is of out of pocket costs. Please see ObamaCare health benefits for services that are covered at no out of pocket charge on all plans. The maximum out-of-pocket costs for any Marketplace plan for 2014 are $6,350 for an individual plan and $12,700 for a family plan.
Bronze Plan: The bronze plan is the lowest cost plan available. It has the lowest premiums and in exchange has the lowest actuarial value. The actuarial value of a bronze plan is 60%. This means that 60% of medical costs are paid for by the insurance company, leaving the other 40% to be paid by you.
Silver Plan: The Silver plan is the second lowest cost plan, it has an actuarial value of 70%. This means that 70% of medical costs are paid for by the insurance company, leaving the other 30% to be paid by you. The Silver plan is the standard choice for most reasonably healthy families who historically use medical services.
Gold Plan: The Gold plan is the second most expensive plan, it has an actuarial value of 80%. This means that 80% of medical costs are paid for by the insurance company, leaving the other 20% to be paid by you.
Platinum Plan: The Platinum plan is the plan with the highest premiums offered on the Arkansas insurance exchange. The Platinum plan as an actuarial value of 90%. This means that 90% of medical costs are paid for by the insurance company, leaving the other 10% to be paid by you. This plan is suggested to those with high incomes and those in poor health. Although coverage is more expensive up front the 90% coverage of costs will help those who use medical services frequently.
Catastrophic plans – which have very high deductibles and essentially provide protection from worst-case scenarios, like a serious accident or extended illness — are available to people under 30 years old and to people who have hardship exemptions from the fee that most people without health coverage must pay.
Consumer Operated and Oriented Plan Program
Consumer Operated and Oriented Plan (CO-OP) Program are qualified nonprofit health insurance issuers that offer competitive health plans in the individual and small group markets. CO-OP in Tennessee:
Utah has not chosen to expand its Medicaid program at this time. Read “What if my state isn’t expanding Medicaid?” to learn more. You can find out whether you qualify for Medicaid under Utah’s current rules 2 ways: Contact your state Medicaid agency right now or fill out an application for coverage in the Health Insurance Marketplace.
Utah is one of the few states still dithering on whether or not to expand Medicaid to cover people making up to 138 percent of the Federal Poverty Level (FPL), despite the Federal Government’s offer of paying 100 percent of the expansion cost until 2017, and 90 percent of all costs after 2020. (The Feds currently pay 70% of Medicaid costs.) What’s the rationale for not expanding Medicaid in Utah? (Apart from the economic boost it will give the state.) As one government insider told me, it boils down to this: “We don’t trust the federal government.” But this isn’t to say that Utah will not be expanding coverage. While Governor Herbert — and it’s his choice to make — is not considering a full expansion, he is still deciding between three options: do nothing; cover up to 100 percent of the FPL, leaving the rest to shop for federal subsidies on the Federal Marketplace; or partially expand Medicaid to 100 percent, and use Medicaid dollars to subsidize private insurance for those between 101 and 138 percent of FPL. This same government insider opined that option three, a privatization of Medicaid dollars, is the likeliest. This is partially due to the Medicaid Expansion task force being led by Chairman Rep. Jim Dunnigan, R-Taylorsville, who happens to be an insurance broker. His argument is that Medicaid restricts a person’s choice of doctors, while putting those at 100 to 138 percent of FPL into private plans on the Healthcare Marketplace with Medicaid-derived subsidies would benefit both patients and providers with more choices and higher reimbursements. This same government insider said this third option — contingent upon the Feds allowing this flexibility with Medicaid dollars — could be implemented by July 1st.
While I’m a firm supporter of Medicaid expansion, I’m willing to admit option three has some merit, as long as the state subsidies on the Health Marketplace are equal to or greater than what the Federal government provides. The important thing is to make sure everyone is covered. And to do this, the public has to keep the pressure on the governor. Most everyone who has weighed in — the AFL/CIO, League of Women’s Voters, even the Utah Hospital Association — support Medicaid expansion. (The LDS church is strangely silent on the issue.) To support Medicaid extension, write an email to Governor Herbert: http://act.betterutah.org/letter/medicaid_expansion/
Who can help you (the Navigators)
The Utah Health Policy Project is a nonprofit organization dedicated to lasting solutions to the crisis of the uninsured and rising health care costs. The Utah Health Policy Project will lead the Take Care Utah Navigator Hub that will connect nonprofit community-based organizations with resources on health coverage options.
Utah AIDS Foundation (UAF) is the oldest and largest AIDS service organization in Utah, with over 27 years of experience providing effective, culturally-sensitive services to people living with HIV and populations at high risk for HIV in Utah. UAF will hire two full-time staff to serve as Navigators to educate target communities about Exchanges and to help individuals determine eligibility, understand their options, select, and complete all necessary steps to enroll in a Qualified Health Plan.
National Council of Urban Indian Health is the only national, membership-based organization dedicated to outreach and education on behalf of Urban Indian Health. It provides training, technical assistance, outreach, and education to Urban Indian Health Programs.
Who you can contact for more help
Utahhealthmatters.com is a very informative site (see above post on Medicaid expansion) and easy to contact with a quick turnaround for responses.
If you need more detailed analysis, identification of issues, solutions, and implementation of your health insurance plan please let us know with the form below and we’ll get right back to you.
Accountable Care Organizations in Utah
ACOs are profit-driven health innovators primarily serving Medicare patients who are financially rewarded by the government and private insurance companies for delivering medical services that lead to better health outcomes for less money.
- IHC Health Services (Intermountain Health Care) UT – Health Care Innovation Award
- Trustees Of Dartmouth College UT – Health Care Innovation Award
- State of Utah UT – State Innovation Models Initiative: Model Design Awards
Health care facilities where Innovation Models are being tested
- Salt Lake Regional Medical Center Salt Lake City, UT –BPCI Initiative: Model 2
- Nancy Murphy MD Salt Lake City, UT – Innovation Advisors Program
- Sarah Woolsey MD Salt Lake City, UT – Innovation Advisors Program
- Victoria Wilkins MPH, MD Salt Lake City, UT – Innovation Advisors Program
The Insurance Exchange/Marketplace
What has been done, not been done, or left up to the federal government to do.
Establishing the Exchange in Utah
After making health system reform one of the state’s top policy priorities, Utah’s former Governor Jon Huntsman (R) signed legislation in 2008 (HB 133) and 2009 (HB 188) which directed the Office of Consumer Health Services to create the Utah Health Exchange.1 Current Governor Gary Herbert (R) signed into law additional legislation amending provisions related to health system reform in 2010 (HB 294) and 2011 (HB 128); the latter reauthorized the Health System Reform Task Force to evaluate options for bringing the state’s already existing exchange into compliance with the Affordable Care Act (ACA).2 Additional health system reform legislation was introduced in February 2012 (HB 144).3 The Utah Exchange allows small employers to participate in a defined contribution arrangement and compare, select, and enroll in commercial health insurance online. In 2012, the Utah Exchange was renamed to Avenue H.
In early 2012, Governor Herbert stated Utah was in negotiations with the federal Department of Health and Human Services (HHS) regarding the extent to which the state would have to modify its existing health insurance exchange to meet new federal requirements under the Affordable Care Act (ACA). Although the state received conditional approval from HHS in January 2013 for a fully state-run exchange, Governor Herbert subsequently proposed that the state continue running Avenue H as the state’s SHOP exchange for small employers while the federal government operate a federally-facilitated individual exchange in the state.4 HHS granted approval for this proposal in May 2013.5
In March 2011, Governor Herbert also signed HB 354 into law which bans abortion coverage in any private plan sold in the state, including the Exchange, except in cases of life endangerment or severe impairment of the pregnant woman, rape, incest, or fetal abnormality effective January 1, 2012.6
The following describes the structure and governance of Avenue H, the state’s SHOP exchange.
Structure: Avenue H is administered by the Office of Consumer Health Services, which is housed within the Governor’s Office of Economic Development.
Governance: The Office of Consumer Health Services runs Avenue H, and is responsible for ensuring performance and resolving policy issues. State law requires Avenue H to operate with input from two distinct boards: an Exchange Advisory Board and a Defined Contribution Risk Adjuster Board. HB 294 requires Avenue H to create an Advisory Board to counsel staff on the operation of the Exchange and transparency issues. An Exchange Advisory Board met monthly until June 2011, at which time it was replaced by an Executive Steering Committee. Consumer advocates have raised concerns over the lack of consumer representation on the Executive Steering Committee.7
Current Executive Steering Committee members are:
- Greg Bell (Co-Chair), Lt. Governor
- Greg Poulsen (Co-Chair), Intermountain Healthcare
- Richard Broadbent, Utah Association of Health Underwriters
- Marc Bennett, HealthInsight
- Rich McKeown, Salt Lake Chamber’s Health Committee & Leavitt Partners
- Gordon Crabtree, University of Utah
- Pam Gold, United HealthCare
- Pat Richards, SelectHealth
- Jennifer Cannaday, Regence BlueCross/BlueShield
- Howard Headlee, Utah Bankers Association
- David Patton, Department of Health
- Mark VanOrden, Department of Technology Services
- Spencer Eccles, Governor’s Office of Economic Development
- Colleen Mellor, Strategic Employee Benefit Services
- Todd Kiser, Department of Insurance
- Greg Matis, SelectHealth
- Vaughn Holbrook, Regence Blue Cross Blue Shield
- Ernie Sweat, Fringe Benefit Analysts
- Patty Conner, Avenue H, Office of Consumer Health Services
- Norm Thurston, Office of Consumer Health Services
Responsibility for managing the risk sharing mechanisms for Avenue H’s defined contribution market lies with the Utah Defined Contribution Risk Adjuster Board which meets monthly and is composed of up to nine members.8 The Governor appoints between five and seven members, including: three to five members who possess actuarial experience and represent insurers that participate in the defined contribution market in Utah and one to two of whom represent insurers that have a small percentage of lives in the defined contribution market; a representative of an individual employee or employer; and a representative of the Office of Consumer Health Services. The Director of the Public Employees’ Benefit and Insurance Program appoints one member with actuarial experience to represent that program. The Insurance Commissioner (or designee) is the final member and can only vote in the event of a tie.
Current Risk Adjuster Board members are:
- Jim Pinkerton (Chair), Regence Blue Cross Blue Shield of Utah
- John Borer, Public Employees’ Benefit and Insurance Program
- Dave Jackson, First West Benefit Solutions
- Jim Murray, SelectHealth
- Kim Miller, United Health Care
- Norman Thurston, Office of Consumer Health Services
- Tomasz Serbinowski, Utah Insurance Department
Contracting with Plans: Per Utah’s agreement with HHS, the state will maintain oversight of Qualified Health Plans (QHPs) participating in the state’s individual exchange operated by HHS, as well as those participating in Avenue H. On March 28, 2013, the Utah Insurance Department (UID) issued a bulletin providing information on the filing requirements for plans issued or renewing on or after January 1, 2014, as well as the timeline for the QHP approval process.9
Avenue H acts as a market clearinghouse and accepts all insurers meeting minimum standards. HB 128 gives the Insurance Department authority to conduct rate reviews to verify that insurers price plans similarly within and outside of the Exchange. There are currently over 140 plans offered through Avenue H with varying prices, copays and deductible levels. Brokers play an integral role in assisting small employers with selecting plans.
Consumer Assistance and Outreach: By May 2013, 344 employer groups were enrolled in Avenue H with over 8,000 covered lives.10 To increase enrollment, the state is undertaking initiatives to enhance the consumer experience, including improving the user interface and providing education and decision support to consumers.
As part of its agreement to operate Avenue H as the SHOP exchange, the state must run a SHOP-specific Navigator program and fund a minimum of two Navigators. The state has the option of limiting the role of the SHOP-specific Navigators to consumer outreach and education functions only. HHS will finance and run a Navigator program in the individual exchange.
Essential Health Benefits (EHB): The ACA requires that all non-grandfathered individual and small-group plans sold in a state, including those offered through the Exchange, cover certain defined health benefits. States must decide whether to benchmark their EHB plan to one of ten plans operating in the state or default to the largest small-group plan in the state. The Health System Reform Task Force collected public comments on EHB and in mid-August 2012 voted to recommend the Public Employee Health Plan’s Utah Basic Plus as the benchmark.11 The Utah Insurance Department issued a final rule, effective October 25, 2012, designating this plan as the state’s EHB benchmark plan.12
Information Technology (IT): The state already has in place the technology backbone necessary to support Avenue H. Now that the state will not be operating the individual exchange, it will need to develop an interface between the state’s public programs and the federal exchange. Prior to the recent developments, in July 2012, subcontractors completed two reports on exchange design and functionality.13
Financing: Avenue H began with an initial appropriation of $600,000 and ongoing funding is through annual appropriation and monthly fees assessed on every subscriber. Avenue H also receives support from the Governor’s Office of Economic Development for the Exchange’s staff members.
In September 2010, the Governor’s Office of Economic Development was awarded a $1 million federal Exchange Planning grant.
Expansion of Medicaid
From 2014 to 2017, the federal government will pay for 100% of the difference between a state’s current Medicaid eligibility level and the ACA minimum. Federal contributions to the expansion will drop to 95% in 2017 and remain at 90% after 2020, according to the ACA.
As the ACA was originally written, states would lose all Medicaid funding if they refused to expand their program to the ACA minimum.
However, the Supreme Court in June 2012 ruled that the federal government could not withhold Medicaid funding for states that chose not to expand their programs. The decision effectively allowed state officials to opt out of the expansion, and some have said they will do just that.
Utah is considering Medicaid expansion but is more likely to pursue an alternative expansion model.
On May 10, 2013, Utah received approval to operate Avenue H as the state’s SHOP exchange and to perform plan management functions in the federally-facilitated individual exchange.14 The federal government will perform all other functions for the individual exchange.
For more information about Utah’s existing health insurance exchange, Avenue H, visit: http://www.avenueh.com/
- House Bill 133. Health System Reform. 2008 General Session. House Bill 188. Health System Reform- Insurance Market. 2009 General Session.← Return to text
- House Bill 294. Health System Reform Amendments. 2010 General Session. House Bill 128. Health Reform Amendments. 2011 General Session.← Return to text
- House Bill 144. Health System Reform Amendments. 2012 General Session. Introduced February 3, 2012.← Return to text
- HHS letter to Governor Herbert, January 3, 2013.← Return to text
- HHS letter to Governor Herbert, May 10, 2013.← Return to text
- House Bill 354. Insurance Amendments Relating to Abortion. 2011 General Session. Enrolled Copy.← Return to text
- Utah Health System Reform Task Force Meeting Minutes. October 19, 2011. See also: Utah Health Policy Project.← Return to text
- Utah Code: Title 31A, Chapter 42, Section 201. Defined Contribution Risk Adjuster Act. Utah Defined Contribution Risk Adjuster Plan of Operation. As of October 26, 2010.← Return to text
- Utah Insurance Department, Bulletin 2013-4 Health Benefit Plan Market Transition, March 28, 2103.← Return to text
- Avenue H May 2013 Dashboard.← Return to text
- Essential Health Benefits Recommendation. Health System Reform Taskforce. August 16, 2012.← Return to text
- Utah Insurance Department, R590, Utah Essential Health Benefits Package final rule.← Return to text
- Final Report for Solicitation PR11072. Utah Health Exchange Planning Grant. July 12, 2011. PlanSource. Seamless Interface with Public Program Eligibility. Utah Health Exchange- Phase 1 Activity. July 12, 2011.← Return to text
- HHS letter to Governor Herbert, May 10, 2013.← Return to text
Also of interest
Provided by the Henry J. Kaiser Family Foundation