Small Business Health Insurance Pool – Changes in the non-group health insurance market are constant, and recent and upcoming regulatory changes may threaten market stability. So far, these regulatory changes include the elimination of personal mandatory tax penalties; elimination of cost-sharing payments in 2017; reducing funding for ACA navigator services; and eliminating the warranty issue and community assessment provisions of the ACA. 
Health plans not complying with the ACA, the Academy of Actuaries lists in its list of “Top Drivers of Premium Changes in 2019,” could be the biggest factor affecting market stability.  These plans include association health plans (AHPs), short-term limited plans (STLDs), agriculture/farm plans, and religiously based, prepaid coverage plans or “share ministries”. Alternative plans are cheaper than existing products, but they do not cover pre-existing health conditions, maintain minimum medical losses, cover essential health benefits, or vary in valuation based on gender and health status. If the individual mandate tax penalty is used long enough, enrollment in non-compliant plans could increase rapidly.
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We have reviewed each of the plan types that are not ACA compliant and have provided a brief description with current estimates or projected enrollment costs.
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Association Health Plans (AHPs) allow many small employers (including the self-employed) to pool their employees together to purchase health insurance as a large group. In June 2018, the Department of Labor issued new regulations that expanded access to AHPs by dropping the previous requirement that these groups provide “meaningful” union status. The new rules allow sole proprietors and/or small businesses to group together for more open insurance, raising concerns for the individual and small group markets, similar to the individual market regulated by the ACA.
Some ACA rules still apply to AHPs because they are considered large group coverage.  AHPs must meet out-of-pocket maximums and cannot include lifetime limits on coverage. Although AHPs cannot discriminate among those with pre-existing conditions, they can set premiums based on job type, gender, age and geographic location. They are also not required to cover the ten basic health benefits included in the ACA, which requires employers with fifteen or more employees to offer maternity benefits. 
Avalere estimates that 3.2 million people will move from ACA plans to AHPs by 2022, with the rest in the individual market and the rest in the small group market. They also estimate a 3.5 percent increase in premiums for those remaining in the ACA-compliant individual market, which could result in about 130,000 people becoming newly uninsured. 
Many states with large rural populations initially sought regulatory relief through the type of coverage targeted at famine and farm-related businesses. These Farm Bureau plans are similar to AHPs, except members don’t have to be businesses. They can be separated. In some states, members do not have to be farmers or have anything to do with agriculture. Major state Farm Bureau plans include the Tennessee Farm Bureau Health Plans, the Minnesota Agricultural Cooperatives, and the Iowa Farm Bureau Health Plans.
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Despite the implementation of the ACA, Tennessee has allowed its Farm Bureau to sell non-ACA marketplace plans outside of the ACA marketplace. These plans are not required to meet key requirements of the ACA, including providing essential health benefits and providing coverage to people with pre-existing conditions. In fact, these plans are written and sold as they were before the ACA. For several years after the ACA, eligible enrollees had to pay a tax penalty for not enrolling in the plan. However, this penalty does not exist as a deterrent in 2019.
Tennessee Farm Bureau health plans are regulated by the state as “nonprofit membership organizations” and are clearly “not insurance.” This status exempts the Farm Bureau Health Plan from all state insurance laws and insurance regulations established under the ACA.  Farm Bureau plans are written and include a six- to twelve-month waiting period for pre-existing conditions and a nine-month maternity waiting period for families of 2+. Maternity benefits are not available in every plan.
Anyone can join Farm Bureau for $25 a year. Farm Bureau enrollment has grown rapidly since the ACA was enacted. About 73,000 people were enrolled in the Tennessee Farm Bureau plan , with about 209,499 Tennesseans covered by the health insurance exchange in 2018, 90 percent of whom received federal subsidies.  Tennessee also had the highest ACA non-group market premiums in the nation. 
Minnesota passed legislation in 2017 allowing agricultural cooperatives to create self-funded health plans. Unlike in Tennessee, access to the plan is limited to farmers or people in the agricultural industry who can form true cooperatives and self-insurers to provide health insurance to members. Farm co-op plans accept all applicants, but are written to allow higher premiums for people with pre-existing conditions. 
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In 2018, approximately 1,700 Minnesotans were enrolled in two agricultural cooperative health plans – 40 Square Cooperative Solutions and Minnesota Land O’Lakes Cooperative Health Plan.  This was only an estimated percentage of the 166,000 people who purchased coverage in the state’s non-group market.
Iowa passed legislation in 2018 to allow agricultural health cooperatives, but not Minnesota, following Tennessee’s model. The Iowa Farm Bureau has partnered with Wellmark (Blue Cross) on a new self-funding plan. State law requires a health plan to be sponsored by a local nonprofit agricultural organization and clearly defines a plan as “no insurance,” which exempts the plan from most state insurance rules and regulations required by the ACA. As in Tennessee, the Iowa Farm Bureau is not limited to the agricultural community.
Iowa Farm Bureau products were first offered in January 2019 for coverage in the fall of 2018. Iowa Farm Bureau offers three health plan options, including two traditional copay or reimbursement plans and a high-deductible plan with HAS. All beneficiaries are supported in determining the value of their plan. The agency estimates that half of the current 150,000 households should register. They estimate that another 60,000 families could join the agency by paying $55 a year to join their health plan.  If these estimates are correct, the Farm Bureau will enroll more than double the number of people who purchase coverage on Iowa’s health insurance exchange in 2018.
In February 2018, the Department of Health and Human Services proposed that Americans could rely on short-term health plans such as AHPs to receive the benefits and other protections required by the ACA. Short Term Limited Duration (STLD) plans are intended to serve as a bridge plan for coverage when a person transitions from one form of long-term health insurance to another, such as when a person is between jobs. To create more affordable options in some markets, the administration has proposed rules that could extend these plans from the current three-month limit to one year with renewal options.  Final regulations were issued on August 1, 2018, and plans were submitted in October 2019. Despite efforts to overturn the rule in the first half of 2019, it was ultimately upheld by a federal district court.  The final rule allows for up to 36-month extensions and includes a requirement to warn consumers that coverage does not meet the ACA’s “minimum essential coverage” requirements.
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Demand for short-term plans has increased steadily since the implementation of the ACA; Short-term claims accounted for 57 percent of short-term and primary health plan claims received by eHealth in 2017, up from 47 percent in 2016.  According to the National Association of Insurance Commissioners (NAIC), there were at least 160,000. Individuals with short-term policies at the end of December 2016, although the total number may be higher due to the lack of consistent reporting requirements for these types. Bridge plans.
Generally, enrollees in STLD plans tend to be younger and healthier because of underwriting and the ability to limit coverage to those with pre-existing conditions and set lifetime limits. Estimates for the projected adoption impact of expanding the STLD scheme vary. Actuary CMS estimates that 1.7 million people will enroll in short-term plans by 2022,  but the Urban Institute projects 4.2 million.
And RAND estimates that five million will enroll.  Importantly, many of these estimated enrollees are now uninsured—an estimated 500,000,000 people based on CMS’s regulatory analysis. 
Partnership ministries are groups of like-minded individuals who pool resources to help cover health care costs. The ACA and many state laws specify that parts of the ministry are not “insured” and therefore exempt from state and federal insurance regulations.
Membership Organizations And Health Insurance
The Partnership Ministry model is similar to the early 1990s “tripartite” safety net programs, or Local Access to Care Programs (LACPs), where enrollees pay a monthly fee.
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