Iowa Health Insurance

Health insurance in Iowa

● Iowa operates a partnership health insurance marketplace so that residents use HealthCare.gov web to enroll in health insurance plans.

● Open enrollment for 2021 coverage in Iowa runs from November 1 to December 15, 2020. Residents with qualifying events can sign up outside that window.

● Short-term health insurance plans can be sold in Iowa under initial plan terms of up to 364 days, but Iowa has imposed a variety of new requirements on these plans.

● Unlike most states, Iowa has more enrollees in grandparents and grandparents than in ACA-compliant plans.

● Iowa fully implemented the ACA's Medicaid expansion in 2015. The state initially used a privatized approach, but switched to normal Medicaid-run care in 2016.

This page is an overview of health insurance resources and options in the state of Iowa. Includes a summary of how health insurance exchange works for people who purchase their health coverage and information about the open enrollment period for those plans. We've also included an overview of Medicaid expansion in Iowa and links to information about available Medicare plans, state rules for Medicare plans, and how open enrollment works for Medicare beneficiaries.

Iowa Health Insurance marketplace

Each state has a health insurance (exchange) marketplace, created as part of the Affordable Care Act (Obamacare). The marketplace is used by individuals and families who purchase their own health coverage. This includes people who are self-employed, retired before the age of 65 or employed in a small business that does not offer health benefits.

Iowa operates a health insurance marketplace in partnership with the federal government, meaning residents use the HealthCare.gov website to compare and purchase individual medical insurance coverage, while the state is responsible for managing the plan, assisting consumers, and determining Medicaid eligibility.

Two insurance companies, Medica and Wellmark, offer plans in the Iowa exchange, and both have a state-wide service area. For 2021, Medica has proposed a small average premium increase, although Wellmark has proposed an average 42% decrease in premiums.

54,586 people enrolled in health insurance plans through the Iowa exchange during the open enrollment period for 2020 coverage , up nearly 11% from the previous year, when 49,210 people signed up. See a year-by-year enrollment summary at the Iowa health insurance marketplace here.

Out-of-exchange enrollment (directly through health insurance companies) to ACA-compliant Iowa health insurance plans had declined by almost nothing by 2018, due to rising premiums and insurers' exits from the marketplace. Although it rebounded slightly in 2019 after rates fell slightly, enrollment in ACA-compliant plans outside the Iowa health insurance marketplace remains rather low.

But a very significant number of people - about 68,000 - had individual marketplace coverage under plans grandparents and grandparents in 2018. As of 2019, there were still more than 54,000 Iowa residents with Wellmark's grandparents and grandparents plans. Including individual and small-group plans, there were still 72,000 Iowa residents with non-grandma plans as of 2020. Iowa is quite unique in terms of having such a large population on grandparents and grandparents' plans, compared to their enrollment in ACA-compliant plans.

Iowa is allowing the Farm Bureau to sell "non-insurance" health plans (i.e. not regulated as state insurance) that are underwritten from the point of view. Sales started in November 2018 and plans are available year-round, as eligibility is based on an applicant's medical history. This is how individual marketplace health insurance worked in most states (including Iowa) before 2014.

Iowa, open enrollment period and dates

Open enrollment in Iowa for 2021 coverage runs from November 1, 2020 to December 15, 2020. During this window, people can recently sign up for an individual marketplace plan, either through exchange or directly through an insurance company (premium subsidies and cost-sharing subsidies are only available through exchange, so people should generally check there first).

Open membership is also an opportunity for current subscribers to compare options for next year and renew or change existing coverage. Individuals and families who have coverage through the exchange should update the financial information that is on file with the exchange so that their subsidies for 2021 are based on accurate numbers.

Outside of the open enrollment period, membership and plan changes are only possible for Iowans with qualified events.

Medicaid expansion in Iowa

Iowa is among the states that have accepted federal Medicaid expansion. The state initially received a waiver from CMS that allowed it to take a slightly different approach and still receive federal funding, but that approach was abandoned in 2015 in favor of direct Medicaid expansion coverage as required in the ACA.

In 2014 and 2015, Iowa's alternative to Medicaid ACA expansion coverage involved a program called the Iowa Health and Wellness Plan in which residents with family incomes below the federal poverty level were enrolled in a state-run health insurance plan called the Iowa Wellness Plan; some paid modest premiums. Those with incomes of 101 to 138 percent of the federal poverty level purchased marketplace coverage through a program called the Iowa marketplaceplace Choice Plan and their premiums were paid for by the federal government.

In 2015, the state announced that it would move to regular Medicaid expansion coverage as outlined in the ACA, and also move on to using Medicaid-managed care (as most states do). The transition to managed care is 2016.

Average monthly enrollment for Iowa Medicaid plans grew by 40% from 2013 to May 2020.

More information about Iowa Medicaid coverage can be found at the Iowa Department of Human Services.

Short-term health insurance in Iowa

Iowa has agreed to follow federal rules regarding the duration of the short-term health insurance plan, so that plans can have initial terms of up to 364 days and can last up to three years if they are renewable. By mid-2020, the state had approved 364-day plans from seven insurers and at least four of these insurers they were actively marketing these plans, with at least three of them allowing renewals for a total duration of three years.

The state's insurance division implemented new rules for short-term health insurance plans in 2019, with restrictions on performance limits, out-of-pocket limits, and various coverage mandates. The rules are more lenient than the Division had initially proposed in 2018, but stricter than the rules in many other states.

How did Obamacare help Iowa?

Iowa is one of the states that has embraced health care reform for the most part, but most importantly, the state allowed grandma's plans to continue to exist in Iowa, and Wellmark didn't join the exchange until 2017 (and then left in late 2017, though they returned to from 2019). In November 2018, the Iowa Insurance Division reported that about 39,000 people had ACA-compliant individual health insurance marketplace plans in Iowa, while 68,000 people had undercover undercover grandparents and grandparents. This is very different from most states, where enrollment in ACA-compliant plans is far greater than enrolling in pre-ACA plans.

But the state's pre-ACA uninsured rate was relatively low, with a state partnership exchange and Medicaid expansion in place since 2014, its uninsured rate continued to fall through 2016, to a low of just 4.3 percent. The uninsured rate started rising again in 2017, reaching 4.7%, where it remained in 2018. In 2019 it crept up to 5%, but at that point it was still well below the national average of 9.2%.

Premium subsidies in the Medicaid exchange and expansion have made coverage affordable and realistic for many Iowans, but people who buy their coverage and aren't eligible for premium subsidies often find coverage to be completely inaccessible. Iowa had the dubious distinction of having the nation's highest average pre-grant premiums in 2018: a staggering $988/month in writing, compared to a national average of $597/month. Iowa's average premiums fell in 2019 and 2020, and while they are still dramatically above the national average, West Virginia and Wyoming have higher average premiums by 2020.

Premium subsidies are therefore huge in Iowa, but there is no relief for people who are not eligible for benefits. This is an important part of why the state has begun allowing the Farm Bureau to sell medically signed plans that are not regulated by the state as insurance and are therefore exempt from ACA rules. The idea is to allow people to have access to plans that have a lower monthly premium costs, but this is just a solution for people who are healthy. Those who are unable to pass medical underwriting and have to pay the highest prices that go in front of ACA-compliant plans ("get what you pay for" sounds true here, however, as ACA-compliant plans provide much stronger coverage, particularly for people who have pre-existing conditions and need benefits that will cover those conditions).

Iowa and the Affordable Care Act

Iowa Senators Chuck Grassley and Joni Ernst are both Republicans and both oppose the ACA. Both voted yes on all three measures the Senate considered in 2017 to repeal the ACA (the BCRA, "skinny repeal" and the Obamacare Repeal Reconciliation Act), though all three of these measures were not adopted.

In 2009, Grassley introduced an amendment to the ACA to require members of Congress and their staff to use the health insurance marketplace , even though the marketplace was intended for individuals and small businesses. The Grassley Amendment was included in the final bill; Congress and their staff use the D.C. small business exchange to enroll in health insurance coverage (as opposed to the FEHBP plans they once had). Confusion over the amendment led to accusations that Congress was exempting itself from Obamacare.

As of December 2020, the Iowa House delegation includes three Democrats and only one Republican.

Former Governor Terry Branstad, a Republican, was not in favor of the Affordable Care Act. In 2011, Branstad signed with Iowa for the Florida lawsuit challenging the ACA. Branstad declared a preference for a state-based insurance marketplace, but said the federal government had not provided enough information for Iowa to proceed with this option. Iowa currently operates a state partnership marketplace.

Current Governor Kim Reynolds, elected in 2016, is also a Republican and supported the Graham-Cassidy bill to repeal the ACA in 2017 (that measure didn't pass). Reynolds expressed disappointment when the state was forced to withdraw its 1332 waiver proposal that would radically change the ACA within Iowa. Reynolds won re-election in 2018.

Other ACA reform provisions

The ACA's Consumer Operated and Oriented Plan (CO-OP) encourages the creation of consumer-run non-profit health insurance issuers. Twenty-four CO-PO received loans totaling $1.98 billion in January 2013. CoOportunity Health, which operated in Iowa and Nebraska, received $112.6 million.

But CoOportunity Health stopped selling plans in both states at the end of December 2014. It was the first of the nation's CO-OOs to fail, but almost all others failed in 2015 and 2016, leaving only three CO-OOs still operational starting in 2021 (there were four for a few years, but the New Mexico CO-OP is closing at the end of 2020).

Does Iowa have a high-risk pool?

Before the ACA reformed the individual health insurance marketplace, coverage was underwritten in nearly every state, including Iowa. Candidates with pre-existing conditions were often unable to purchase private coverage or were with very limited options that did not cover their pre-existing conditions.

The Iowa Comprehensive Health Association (otherwise known as the Health Insurance Plan of Iowa, or HIPIOWA) was founded in 1987 to offer people an alternative if they were not eligible to purchase private plans because of their medical history.

Under the ACA, all new health insurance policies have become a guaranteed issue as of January 1, 2014. Thanks to this provision on reform, there is no longer an urgent need for high-risk pools. HIPIOWA is still operational, but membership has steadily declined since 2013.

It's important to note, however, that Iowa is one of the states that rely on high-risk pool coverage as an option for disabled Medicare beneficiaries under the age of 65 who are not guaranteed access to Medigap plans. Since Iowa does not require Medigap insurers to offer their products to Medicare beneficiaries who are not yet 65 years old, it is important that the high-risk pool remains operational in order to offer additional coverage to these enrollees (Medicare integration fees through HIPIOWA are available here and here for 2020). But as of 2018, there were only 22 members in HIPIOWA's Medicare integration plans.

The program had 3,002 members as of December 2013 and only 280 members as of July 2018. Operating costs for HIPIOWA were $11.9 million in 2016. Of that amount, about 30% was covered by members' premiums, and the rest was covered by an assessment of insurance companies operating in Iowa. Premiums are based on 150% of the average premiums charged by the top five insurers in the state's individual marketplace, although Medica and Wellmark are the only single marketplace insurer offering plans in Iowa. HIPIOWA awards for 2020 are available here.

Medicare coverage and enrollment in Iowa

There were 637,393 Iowa residents enrolled in Medicare plans as of August 2020. Read more about Medicare enrollment in Iowa, including state rules for Medigap plans.

Our Medicare Open Enrollment Period Guide for Medicare Advantage Plans and Medicare Part D Prescription Drug Plans will provide a variety of useful information to Medicare beneficiaries and their caregivers.