​Since 2014 the government will pay part (or even all) of your individual health insurance premium if your income qualifies. Thousands of business owners leave this money on the table every year because the official explanation is confusing. This is the short, no-BS version.

1. How the subsidy actually works

• You buy a regular individual plan on Healthcare.gov (or your state’s Marketplace)
• The government sends money (your premium subsidy) every month directly to the insurance company
• You only pay the reduced amount (or nothing if the subsidy is big enough)
• You get the savings immediately — not as a tax refund later

2. Basic rules to qualify (most self-employed people check every box)

• You buy the plan on the Marketplace 
• You don’t have affordable coverage from another job or a spouse’s job 
• Nobody claims you as a dependent 
• You’re a U.S. citizen or lawfully present

That’s it.

3. How much money are we talking about?
It’s based on one number: your **Modified Adjusted Gross Income (MAGI)** for the tax year you want coverage.

Quick way to find your MAGI right now: 

• Open last year’s Form 1040 → Look at **Line 11** (Adjusted Gross Income) 
• Your MAGI is usually pretty close to that number (add back in tax-exempt interest, any taxable Social Security, and Foreign earned money — that’s it)

Use this free subsidy calculator — takes 60 seconds: 

• https://www.kff.org/interactive/subsidy-calculator/​

It will show you exactly what you’d pay in 2026 with today’s generous rules and what you’d pay if Congress lets the enhanced subsidies expire after 2025.
​
4. The magic of controlling your MAGI (this is where self-employed people win)
The lower your MAGI, the bigger your subsidy. You have way more control than a W-2 employee.
 
Best legal ways to lower your MAGI in 2026:

• Max out a SEP-IRA, Solo(k), or Simple IRA (you can put away up to $69,000+ depending on income and the type of retirement plan)
• Contribute to an HSA ($4,150 single / $8,300 family in 2026) — note starting Jan 1, 2026, you can now contribute HSA dollars just by being on a Bronze or Catastrophic plan – it doesn’t have to be “HSA-qualified” anymore
• Deduct every legitimate business expense (home office, mileage, equipment, internet, etc.)

Many sole proprietors who gross $100k–$150k end up with a MAGI under $60k after retirement contributions and expenses → resulting in huge subsidies or even $0 premiums.
 
5. The “true-up” at tax time
You tell the Marketplace your estimated 2026 income when you sign up. 

• If your actual MAGI ends up lower → you get extra money back on your taxes 
• If it ends up higher → you'll need to repay some of the subsidy back
  

NOTE: The "original" ACA subsidies (that we will be reverting to as of 1/1/2026 unless Congress acts) had "repayment caps" to mitigate how much you would have to repay if you guessed your MAGI incorrectly.  The Big Beautiful Bill removed those caps. Therefore, you will want to estimate your MAGI conservatively so that you won't have a large repayment at tax time.

You can also adjust your subsidy level mid-year. Just update your income on Healthcare.gov anytime it changes greatly and your monthly payment adjusts automatically for the rest of the calendar year.
 
6. One big caveat about individual plans
Provider networks can be narrower than group plans, especially in some states (Washington is one). Always check:

• Are your preferred doctors and hospital in-network?
• Does the plan cover you if you travel?
• Do you have a kid in college? Check that there are in-network benefits where they live during the school year.

 
YOUR 5-MINUTE ACTION PLAN

1. Pull last year’s tax return
   1. Note Line 11
   2. Add back in tax-exempt interest, any taxable Social Security, and Foreign earned money
2. Calculate your expected 2026 MAGI
   1. Will your retirement deposits change from your last tax filing?
   2. Will your HSA deposits change from your last tax filing? (Note that as of 1/1/2026 you can enroll in any individual Bronze or Catastrophic plan and make HSA deposits - even if that plan is not HSA-qualified.)
   3. Expecting any changes to your income?
   4. What about changes to your itemized “top-line” deductions?
3. Plug your expected 2026 MAGI into the Kaiser calculator https://www.kff.org/interactive/subsidy-calculator/
4. Enroll for an individual medical plan on your state’s Marketplace
   1. Go to: https://www.healthcare.gov/
   2. Open enrollment for 2026 ends January 15th in most states. Enroll by December 15 to lock in a January 1 effective date  or enroll by January 15 to start coverage on February 1.

Still confused? Talk to your CPA or a licensed broker who specializes in self-employed clients (many work on commission paid to them directly by the insurance company, so it’s free to you to access their expertise).

​Bottom line: Your gross revenue doesn’t matter — your taxable profit after "top-line" deductions does. A few smart moves can drop your MAGI enough to qualify for hundreds or thousands of dollars a month in free money from the government.
 
Don’t pay full price for health insurance if you don’t have to.

The government is shut down and the main sticking point is the end of the pandemic-era subsidies at the end of 2025. Here's a look at how the sunsetting will impact people in Washington state.

​When the Affordable Care Act (ACA) was implemented, the law included a premium tax credit to help lower-income individuals afford their individual medical premiums. The tax credit is based on a sliding scale using a person’s Modified Adjusted Gross Income (MAGI) as compared to the Federal Poverty Level (FPL).  

• MAGI for most people is simply line 11 of their Form 1040 tax filing.  (See the government's worksheet to determine your MAGI - page 8 worksheet 1-1 of the IRS instructions.) 
  
• You can find the 2025 FPL (used for the 2026 tax year)  on Healthcare.gov’s website here.

 
To qualify for a premium tax credit, the person needed to be a US Citizen, obtain individual medical coverage on the Marketplace (originally called the Exchange), and have a MAGI of less than 400% of the FPL.  In addition, the person could not be eligible for Medicare, Medicaid (in WA called Apple Health), or the Children’s Health Insurance Plan (federally called CHIP).
 
In 2021, the American Rescue Plan (ARP) increased the premium tax credit that the Federal Government was providing toward healthcare premiums. It also removed the requirement that the person must have an expected MAGI of 400% or less of the FPL. This premium tax credit increase/expansion is set to expire on 12.31.2025. Unless Congress acts to extend these ARP-level premium tax credits, they will revert to the pre-2021 ACA-level premium tax credits.
 
The Sliding Scale
Below is a chart illustrating what the Federal Government expects a household to pay for their "benchmark" Marketplace individual medical plan, based on their MAGI as a percentage of the FPL. The FPL used for tax year 2026 is $15,650 for a single person and increases by $5,500 for every additional person in the household.  For households where their "benchmark: Marketplace premiums are higher than their cap, the Federal government picks up that extra premium – paying the insurance carrier directly each month.

                                                                       * Data from Kaiser Family Foundation, 2025 Enrollment (LINK)

Benchmark Plan
This the the second-lowest cost Silver individual medical plan available to a person through their state Marketplace. This will be different for each person based on the plans sold in their zip code and their household size.  The Federal subsidy for a person is based off of this plan's cost - but the person can choose any Platinum, Gold, Silver, or Bronze plan on the Marketplace and apply their calculated subsidy toward their chosen plan's premium.

How Will Cost Change? Example #1
Let's assume In 2026, a single person expects to earn 150% of the Federal Poverty Level (FPL).
150% of the FPL for a single person for the 2026 tax year is $23,475.

• Under the current 2025 ARP rules, this person would be required to pay 0% ($0 per month) of their household income toward the premiums toward their benchmark plan.
• Under the expected 2026 ACA rules, this person would be required to pay 4.19% ($82 per month) of their household income toward their benchmark plan. 

Let's assume the second-lowest cost Silver plan available to this person costs $764 per month.
Under the current 2025 ARP rules, they would have a subsidy of $764 per month.
Under the expected 2026 ACA rules, they would have a subsidy of $682 per month.
They can purchase any plan on their State's Marketplace and the full premium would be reduced by their subsidy of $682.
 
How Will Cost Change? Example #2
In 2026, a couple expects to earn 250% of the Federal Poverty Level (FPL).
250% of the FPL for a couple for the 2026 tax year is $52,875.

• Under the current 2025 ARP rules, this couple would be required to pay 4% ($176 per month) of their household income toward their benchmark plan.
• Under the expected 2026 ACA rules, this couple would be required to pay 8.44% ($372 per month) of their household income toward their benchmark plan. 

Let's assume the second-lowest cost Silver plan available to this couple costs $1680 per month.
Under the current 2025 ARP rules, they would have a subsidy of $1504 per month.
Under the expected 2026 ACA rules, they would have a subsidy of $1308 per month.
They can purchase any plan on their State's Marketplace and the full premium would be reduced by their subsidy.

​The Bottom Line
In Washington State, more than 250,000 currently receive Federal premium tax credits that help lower their monthly healthcare premiums. The current ARP premium tax credit levels are set to expire at the end of 2025.
 
Unless Congress decides to extend the ARP premium tax credit into 2026, this will revert to the ACA premium tax credit rules. More than 25,000 Washingtonians who are currently receiving individual medical coverage at no monthly cost will need to pay a monthly premium as of 1.1.2026; over $180,00 will see their required monthly premiums increase, and over 40,000 enrollees will no longer receive any assistance at all.
 
The expectation is that a majority of the 25,000+ who will go from $0 to paying a portion of the premium will drop coverage due to not being able to afford the monthly hit to their budget; and that most of the 40,000+ no longer receiving any assistance will also drop coverage – especially those who are older where premiums are well over $1000 a month for a very high deductible plan. So at a minimum, that's at least 65,000 Washingtonians who might not have stable health insurance for the coming year.

The newly enacted "One Big Beautiful Bill" is ushering in positive changes for HSAs. 

Health Savings Accounts (HSAs) have long been touted as one of the most powerful tools in a benefits and retirement planning toolkit. Now, under the One Big Beautiful Bill Act, HSAs will be getting even better.  Here’s a breakdown of what’s in the newly passed legislation and why benefits professionals should pay attention.
 
Removing the Flexible Spending Account (FSA) Prohibition
(effective plan years beginning on or after 1/1/2026)
Currently, an employee is typically not eligible to deposit into an HSA when their spouse is enrolled in an FSA (it would have to be a special type of FSA to allow the employee to then make HSA deposits). The new law removes this barrier, allowing individuals to contribute to an HSA even if their spouse is enrolled in any type of FSA. And even more advantageous, the spouse’s FSA could reimburse the employee's own medical expenses (for example, deductible and copays) and it will not disqualify him from contributing to his HSA.
 
Direct Primary Care and On-Site Clinics
(effective for months beginning after 12/31/2025)
Currently, use of on-site clinics or direct primary care (DPC) models can disqualify someone from contributing to an HSA unless the care is “preventive.” The new law expands HSA eligibility to access these services even if the services aren’t strictly preventive. This removes a key barrier for employers exploring value-based care models and for individuals who might want to sign up for direct care access with a provider. In addition, HSA-eligible individuals can use HSA funds to pay up to $150/month (individual) or $300/month (family) of the DPC membership fees.
 
Telehealth & Remote Care Safe Harbor
(effective plan years beginning on or after 1/1/2025)
During the pandemic, and through to 12/31/2024, high deductible health plans were allowed to provide pre-deductible telehealth care without a member losing the ability to deposit funds into their HSA bank account. This provision sunset as of 12/31/2024. But now under the BBB, this has now been reinstated and is retroactively effective for plan years beginning on or after 1/1/2025.
 
Individual Bronze & Catastrophic ACA Plans
(effective 1/1/2026)
One of the main, very stringent rules, of being able to deposit money into an HSA bank account is that the person must be enrolled for coverage on an HSA-qualified medical plan. These types of plans have high deductibles and do not allow any coverage prior to meeting that deductible other than preventive care. The BBB opens up HSA contributions to more individuals - to also include some individual medical plans. Anyone enrolling on an Affordable Care Act individual medical plan that is classified as either a Bronze level plan or as a Catastrophic plan will now be allowed to open an HSA bank account and make pre-tax contributions. ​

The Bottom Line
 
Now that the bill has passed, HSAs are poised to become even more central to both health and retirement planning.  The changes open the door for more strategic use of HSAs. It also adds flexibility to emerging health delivery models like DPC and strengthens the link between HSAs and long-term financial wellness.
 
Benefits professionals need to understand the new HSA world, particularly as 2026 plan design conversations begin to take shape in the coming months. ​

 A Final Note
 
While several impactful HSA reforms were passed, some proposed changes were not included in the final signed bill. These include:
 
Expanded Eligibility for Medicare Enrollees
Under current law, individuals enrolled in Medicare Part A (even if only involuntarily through Social Security’s automatic enrollment) are prohibited from contributing to an HSA. The proposed law would have allowed individuals enrolled in Medicare Part A to continue contributing to HSAs, but unfortunately was not included in the final signed version.
 
Fitness and Wellness Reimbursement
The proposed law would have allowed tax-free HSA reimbursements for gym memberships, fitness classes, and certain wellness programs, up to $500 per year.  

More Flexibility for Contributions and Catch-Up Rules
Currently anyone age 55+ who qualifies to contribute to an HSA can also deposit up to $1000 in catch-up contributions per calendar year. But while regular contributions can be deposited into either spouse's HSA bank account, the catch-up contribution is specifically limited to only being deposited into that over-age person's named HSA bank account. Original wording under the BBB would have allowed both spouses to deposit catch-up contributions into a single HSA, avoiding the need for separate accounts. 

On-site Employer Clinic Services Exempted from HSA
Some had hoped that employers who offer on-site clinic services to their employees would also be allowed without affecting HSA eligibility, like the OBBBA is going to now allow Direct Primary Care services to be exempted. However, being eligible for an on-site clinic's services, if they provide non-preventive care, will continue to disqualify a person from depositing funds into their HSA bank account.

Allowing HSA Funds to Reimburse Additional Premiums
Currently Medicare A, B, D and Medicare Advantage plan premiums are allowed to be reimbursed from HSA funds. It was originally proposed to expand this to include Medigap/Medicare Supplement plan premiums as well as individual premiums, but these were not added to the approved list of reimburseable premiums.
​

We're getting our first look at carriers' proposed 2026 rates. 

The insurance carriers’ 2026 proposed small group and individual plan premiums have been submitted to Washington’s Office of the Insurance Commissioner (OIC). While it will take at least a few months for the back-and-forth between the carriers and the Commissioner to shake out, the proposed rates give us a starting point for renewal planning.  Individual increases requested range from 9.6% to 37.4%, while small group increases range from 1.9% to 15.8%. We are seeing one new carrier requesting to begin offering individual plans, Wellpoint, while under the small group market United Healthcare of Washington did not submit a filing (although their United Healthcare Insurance Company segment filed).
 
Small Group Plans
We’ll begin with the easier of the two program reviews, small group plans. These plans are for employers who had 50 or fewer employees on average during the calendar year prior to the effective (or renewal) date of the plan. Nine of the 10 insurance carriers have requested to continue offering plans in Washington State. Here’s a quick rundown: 

• United Healthcare of Washington did not file plans for the new calendar year; however, United Healthcare Insurance Company did. With this change, United Healthcare would no longer be offering their plans in Adams, Asotin, Columbia, Douglas, Ferry, Garfield, Kittitas, Lincoln, and Pend Orielle counties.
• None of the other carriers are proposing to pull out of counties where they are currently offering their plans.
• Three carriers propose double digit increases (Kaiser Options at 13.6%, Premera at 14.2%, and United Healthcare at 15.8%).

The carriers’ 2026 requested rates are based on each carrier’s gain or loss at the end of 2024, among other factors. There were 6 of the 9 carriers that were in a loss position for the 2024 calendar year, with the largest being Regence BlueShield (nearly $16M million loss).
 
Individual Plans
Most of the individual carriers are requesting double-digit increases. Regence BlueShield’s increase of 9.6% is the lowest requested; however, interestingly enough, they are the carrier with the highest loss in 2024 (over $14 million). 
 
In 2025, the industry saw subsidy levels reduced due to lower-cost Silver plans new to the marketplace. Most of these are through Ambetter, with just five counties’ benchmark plans being offered through Community Health Plan (Ferry, Kitsap, Kittitas, Lincoln, and Yakima). Both Ambetter and Communnity Health Plan are requesting over 20% increases, 22% and 27.6% respectively.
 
Below is a summary of proposed carrier changes with regard to the counties in which they would offer plans. These changes are not final, as we tend to see at least a few carriers' finalized county lists end up different from what they originally proposed.

• Lifewise wants to remove Lincoln and San Juan counties, but newly offer coverage in Yakima county.
• Premera is proposing to offer coverage in Lincoln county.
• Regence BlueShield would like to no longer offer coverage in Island, San Juan, and Whatcom counties.
• United Healthcare of Oregon wants to expand its reach into Grays Harbor, Spokane and Thurston counties.
• Wellpoint is a new carrier entering the scene, with plans to offer coverage in Grays Harbor, King, and Spokane counties.

 
We began tracking “affected members” for each individual carrier’s program last year. This in effect provides the number of enrolled members under each carrier. Ambetter (Coordinated Care) continues to have the largest number of insureds, at 107,649. Rounding out the top three are Molina (43,346) and Kaiser WA (40,266).

Bottom Line
While these are preliminary renewal numbers for 2026, they provide estimates to begin renewal planning. We expect that final rates will be approved by the Office of the Insurance Commission in October.  

"​The future of virtual healthcare is rapidly evolving, driven by advancements in technology, increased patient demand, and a shift toward more accessible and efficient healthcare solutions."

The Washington State Office of the Insurance Commissioner (OIC) released approved 2025 rates for 11 of the 13 individual carriers who will offer options in the state.  We are still waiting to see final approvals for Asuris NW and Providence Health plan. Currently we have 14 individual medical carriers, so we will be losing one option (PacificSource) as we enter the new year.  While requested increases ranged from 4.5% to 23.8%, the final approvals fall between 5.7% and 23.7%.
 
Carriers Approved
Of the 11 individual carriers that have been approved, many finalized their plans at or below their requested rate adjustment. Four carrier’s rates have been approved at a higher level than initially requested: Community Health Network, Kaiser NW, Kaiser WA, and United Healthcare.

There are five carriers who received a double-digit increase for 2025.

• United Healthcare (23.7%)
• Regence BlueShield (22.8%)
• Regence BlueShield of OR (16.7%)
• Premera Blue Cross (14.9%)
• Bridgespan (14.9%)

For comparison, there were three carriers with double-digit increases in 2024 and six in 2023.

There are no carriers who were approved for a decrease in rates in 2025. For comparison, there were three carriers with rate decreases in 2024 and two in 2023.

To see our 2025 Individual Rate Tracking spreadsheet for more in-depth information about each carrier’ requested rate change and final approval, log in (or create an account) HERE. Scroll down to our Monthly Freebie Section.
 
Changes to County Coverage
In 2025, we will see one carrier exit the individual marketplace in Washington (PacificSource) which currently serves Clark, Pierce, Spokane, and Thurston counties. This will affect roughly 4,000 current customers. Options will remain for these individuals: Clark county will have 7 carriers offering benefit plans, Pierce county 9, Spokane county 9, and Thurston county 8.

Only one carrier, Lifewise, will be eliminating coverage in some counties. They will be dropping Clallam, Jefferson, and Mason counties. They will also be adding coverage in Grays Harbor. Two other carriers will be expanding their county lists. Community Health Network will be adding Lincoln county. And Ambetter (Coordinated Care) will be expanding into Clark, Cowlitz, Island, San Juan, Skagit, and Whatcom counties, becoming the only carrier in 2025 to offer individual coverage state-wide.
​
All counties continue to have at least 3 carriers offering individual medical coverage as we head into 2025. King, Pierce and Spokane counties continue will have the most carriers available, at 9.  A full summary of carrier offerings by carrier and county can be found on our agent website. Log in (or create an account) HERE. Scroll down to our Monthly Freebie Section.
 
Comparing 2025 to Past Years
For the fourth year in a row, at least one carrier has requested an increase of over 16% to their average individual medical rates in Washington state.

​The Washington State Office of the Insurance Commissioner (OIC) released approved 2024 rates for all 14 of the individual carriers currently offering options in the state.  This is one of the least volatile years in terms of carriers offering benefits, and in changes to which counties they will provide their plans. Requested increases ranged from -3.4% to 17.9%, with the final approvals coming in between -7.0% to 17.8%.
 
Carriers Approved
Of the 14 individual carriers, many finalized their plans at or below their requested rate adjustment. Those carriers finalizing rates above their requested changes are only seeing about a 1 – 2% addition to their original request.  

In 2023, there were six carriers who were approved for a double digit increase. In comparison, for 2024, there are only three:

• Kaiser Foundation Health Plan of Washington (17.8%)
• Premera Blue Cross (17.2%)
• Bridgespan (16.4%). 

There was one carrier who was approved for a decrease in 2023. For 2024, there are three carriers falling into this category:

• Asuris Northwest Health (-7.0%)
• Community Health Network of WA (-1.2%)
• UnitedHealthcare of Oregon (-0.5%)

To see our 2024 Individual Rate Tracking spreadsheet for more in-depth information about each carrier’s requested rate change and final approval, log in (or create an account) HERE. Scroll down to our Monthly Freebie Section.
 
Changes to County Coverage
In 2023, we saw one carrier exit the individual marketplace in Washington (Health Alliance), and just one carrier stopped selling their plans in a county (Bridgespan stopped offering plans in Kittitas). However, various carriers added counties to their coverage area. 

In 2024, the market is more robust. No carriers requested to exit counties, which is the first year in quite some time that all individual carriers have retained all their existing coverage areas. In addition, three carriers will expand their territories this coming year.

• Community Health Network of WA – adding Adams, Asotin, Clallam, Columbia, Stevens
• Coordinated (Ambetter) – adding Clallam, Grays Harbor
• Premera Blue Cross – adding Pierce, Spokane, Yakima

All counties will have at least 3 carrier options as we head into 2024. Spokane and Pierce counties continue to have the most carriers available (both growing from 9 to 10).  A full summary of offerings by carrier and county can be found on our agent website. Log in (or create an account) HERE. Scroll down to our Monthly Freebie Section.
 
Comparing 2024 to Past Years
For the third year in a row, at least one carrier has requested over a 16% increase to their average individual medical rates in Washington state. 

​Of note in the filings are the annual cumulative carrier gains/losses in the individual market overall. The carriers evaluate the prior calendar year’s data when setting their rates. For example, the 2024 rate filings were based on the 2022 calendar year. 

• Cumulative Gain/Loss in 2022    $  31,984,912 LOSS
• Cumulative Gain/Loss in 2021    $  58,567,764 LOSS
• Cumulative Gain/Loss in 2020    $102,348,384 GAIN
• Cumulative Gain/Loss in 2019    $207,487,632 GAIN
• Cumulative Gain/Loss in 2018    $131,815,624 GAIN
• Cumulative Gain/Loss in 2017    $  74,370,641 LOSS

The details and implementation of Washington State's long term care program, WA Cares, are still being ironed out in the state legislature. Here is what we know so far.

The LTSS Commission (overseeing WA Cares and providing recommendations to the legislature for changes to the law), met at the end of July. There are workgroups, offshoots of the Commission, that are working to create the specs for an LTCi supplemental product, exemption recertification, benefit eligibility, and portability. During the July meeting, the LTCi group presented to the Commission. The other workgroups will be presenting at the September 13th LTSS Commission meeting.

If you would like snippets of the July meeting, see our Meeting-at-a-Glance section below. Want to delve in deeper? You can watch the July meeting OnDemand and review the minutes, their presentation, or the Supplemental Private LTCi Workgroup Report.
 
Meeting At-A-Glance

Workgroup Reports (the first was presented in July; others will be presented on 9/13)

• Supplemental Private PTCi report
• Private LTC Exemption Recertification report
• Accountability and Self-Employment Income Reporting report
• Benefit Eligibility report and criteria summary
• Portability report

Items/issues reviewed

• Shared Savings Waiver for CMS services – The WA Cares program is expected to reduce Federal funding for Medicare and Medicaid, since WA Cares would pay primary to these programs. The Commission is expected to have a report by December this year regarding whether any of that savings will be passed onto WA state.

• Investment Plan – An update was provided, projecting a median 15-year return of 3.6%. Modeling projects the program will retain positive balances for at least 4 decades (this is lower than Milliman’s solvency recommendation of 75 years).
• The ESD outlined inconsistencies between PFML and WA Cares. They requested changes to the law, to add a collective bargaining agreement deadline and include the authority for the ESD to collect late premiums and levy penalties and interest.

Supplemental Private LTCi (SPLTCI) Workgroup Final Report
These are the main bullet points from this Workgroup’s report:

• Expand and leverage the Statewide Health Insurance Benefits Advisors (SHIBA) program.
• Create a new section of Title 48 to regulate SPLTCI, requiring disclosures to consumers.
• Require that a minimum 3% inflation protection provision be included in the SPLTCI plan.
• Lower the carriers’ time and cost required to develop, price, and support these new products.
• Apply the WA Cares benefit, automatically adjusted for inflation, as the “deductible” required under the SPLTCI coverage to eliminate a “donut hole” between the two plans. This would require the WA Cares statute to change to automatically adjust the lifetime benefit by an annual inflation factor.
• Remove the typical carrier requirement for the client to undergo a functional assessment or satisfy a benefit trigger in order to meet an SPLTCI’s elimination period; allow the carrier to also set a time component to the elimination period (such as 6 months), not to exceed 12 months.
• Allow carriers to set the elimination period for near-retirees at $36,500 or some other lower amount; plans offering a lower cap will reduce the potential of a donut hole for these consumers between the two programs’ benefit payments.
• SPLTCI policies must allow continuity of care from WA Cares, including family providers (unless there is a good-faith reason to believe a care setting or provider is not suitable). If a family provider is not deemed suitable, continuity of care must be provided under the SPLTCI policy for at least 90 days after the transition from WA Cares.
• Support a process of reciprocal administrative notification between WA Cares and SPLTCI carriers, with no health information or claim information being shared.
• Apply statutory changes to facilitate supplemental plans to only these SPLTCI plans, not the rest of the LTCi market.

 

The Bottom Line
Every agent who has clients with LTCi policies or riders should be paying attention to the LTSS Commission meetings and workgroup reports. As we saw last year, the legislature will typically enact most, if not all, of the recommendations that come out of the LTSS Commission. Each meeting has a public comment period, and I highly recommend adding your agent experience to the conversation, since there continue to be no agents, carrier representatives, or WA OIC employees on the LTSS Commission.
​
Next meetings:

• 9/13/2022          1:00 – 4:00        
• 11/10/2022        8:30 – 11:30
• 12/9/2022          1:00 – 4:00

Access all meeting information, including links to the live webinars, here.
 
 

The carriers have submitted 2023 rates to the OIC for review. Let's take a peek at what is in store for next year's individual and small group premiums.

The insurance carriers’ 2023 proposed small group and individual plan premiums have been submitted to Washington’s Office of the Insurance Commissioner (OIC). While it will take at least a few months for the back-and-forth between the carriers and the Commissioner to shake out, the proposed rates give us a starting point for renewal planning. Unfortunately, there are more two-digit increases requested this year than last year.  Small group plans have two carriers (Kaiser WA and Premera) in this category; last year all renewals were in the single digits. Six individual carriers are requesting an increase over 10% (Asuris NW, Bridgespan, LIfewise, PacificSource, Regence, and United Healthcare), whereas last year there was only one (Premera). As with every year, there are a few counties that will be gaining or losing carrier offerings.
 
Small Group Plans
We’ll begin with the easier of the two program reviews, small group plans. These plans are for employers who had 50 or fewer employees on average during the calendar year prior to the effective (or renewal) date of the plan. All 12 insurance carriers providing plans in Washington State today have proposed plans and rates for the coming year, without much upsetting of the apple cart. Here’s a quick rundown:

• Kaiser (both their WA and Options programs) are pulling out of Kittitas county
• None of the other carriers are proposing to pull out of counties where they are currently offering their plans
• Two carriers are proposing double digit increases (Kaiser of WA at 10.2% and Premera at 11.5%)
• Aetna, which is offered statewide, is the only carrier requesting a decrease in rates (at -11.1%) 

The carriers’ 2023 requested rates are based on each carrier’s gain or loss at the end of 2021, among other factors. There were three carriers in a loss position: Kaiser of WA with about a $10.3M deficit, Premera at a $1.6M deficit, and Health Alliance NW at a $198k deficit. The total combined gain/loss of all small group plans offered by all carriers was about an $11M gain in 2021.

Individual Plans
Individual carriers are all requesting increases except Ambetter (requesting -1.2%). Six are requesting double digit increases (Asuris NW at 10.9%, BridgeSpan at 16.1%, Lifewise at 12.5%, PacificSource at 15.4%, Regence at 13.7%, and UnitedHealthcare at 15.3%). Total gain/loss of all individual plans from all carriers was a huge deficit of $58.6M in 2021 (all but three carriers experienced a loss in 2021).  

Coming into 2023, two carriers currently offering individual plans in Kittitas county will no longer do so in 2023: BridgeSpan and Kaiser NW. Three carriers are adding two counties each (Ambetter, Coordinated Care, and Molina) while PacificSource is stretching their service area from 4 to 15 counties. Our county map outlines each of these carriers and counties in more detail.
 
The largest plan offerings are still in King, Pierce, Spokane and Thurston counties, with 9 carriers proposing to provide plans in 2023. San Juan continues to have the fewest (2 carriers) with Clallam, Island, and Whatcom also having few options (3 carriers).

Health Alliance NW Health Plan is not showing any proposed rates for 2023 on the Office of the Insurance Commissioner’s site. This leads me to believe that they will cease offering plans at the end of 2023. They are currently only available in four counties; these four counties would go from 5 carriers to 4 carriers if my supposition is correct.

​Bottom Line
While these are preliminary renewal numbers for 2023, and the final listing of counties per carrier may change, this provides estimates to begin your renewal planning. We expect that final rates will be approved by the Office of the Insurance Commission in October.  

The flurry of announcements out of Olympia in advance of the WA Cares Fund implementation have done nothing to fix the inherent problems of the program, but have created a snowstorm of questions and confusion. Here's our take.

​Governor Inslee’s office has been pushing out press releases and statements with regards to the WA Cares Fund over the last two weeks. Unfortunately, the Governor and legislative representative statements only served to muddy the LTC waters.  Just when agents thought it was safe to celebrate the holidays in peace, the phones started ringing and emails clogged their servers with employers and employees wanting to know what to make of the mixed messages.  

A TIMELINE OF THE STATEMENTS
Those who know me know that I don’t hold back the sarcasm, especially when it is completely warranted. Here’s my take on the messaging coming out of Olympia with regards to the WA Cares Fund taxation.
 
December 17th

• A joint statement from the Governor, Senate Majority Leader Andy Billig, and House Speaker Laurie Jinkins was released.
• The Governor “took measures within his authority” to order the Employment Security Department not to collect the premiums for the WA Cares Fund until April.
  As the original submission date for Q1 2022 was always April of 2022, I am not sure why he felt the need to announce that he was doing anything here. His proclamation of his “authority” changed nothing.
• Senator Billig and Speaker Jinkins announced that the legislature would look at delaying the premium assessment and further stated that they support employers pausing premium collections from employees while the legislature considered tweaking the program.
  What they failed to mention was that only a vote of the legislature can make a change to the start date of the tax collection. Just stating it in a press release does not “make it so”.

 
December 22nd

• The Governor sent a letter to the Employment Security Department directing them not to accept WA Cares Fund premiums from employers in advance of quarterly taxes due in April.
  I am not aware of any employers who would be clamoring to pre-pay their quarterly taxes.
• He goes on to state that “while the legislature lacks authority to direct employers not to collect premiums, legislative leadership has strongly encouraged” employers to pause collection of the tax.
  Isn’t this stating that the legislative leadership has overstepped their authority?
• Now it falls to employers who must “…choose whether to begin collecting premiums on 1/1/2022 according to the current law and returning the premiums to workers following a change in the law, or delay collection in anticipation of this legislative change… If the Legislature fails to change the law, employers will still be legally obligated to pay the full amount owed to [ESD]”.
  Either way, the employer ends up being the bad guy. Begin the payroll deductions and have employees upset because others aren’t seeing a reduction in their paychecks yet or delay the payroll deductions and possibly risk having to collect three months’ worth of taxes from all employees in April to remit to ESD.
• His last statement in the letter reads: “My expectation is that, if the Legislature fails to act to change the…law in early 2022, [ESD] will work with employers who did not assess…premiums during the first quarter of 2022, to develop plans to address potential payment options, consider administrative waivers, or craft other potential remedies in a way that supports the most equitable outcomes for all parties.”
  Um, thanks? An “expectation” is not a guarantee and the Governor has no authority to compel the legislature to act. To me this is another non-statement.

 
December 23rd

• The Governor issued a statement that “There seems to be some inaccurate reporting and misinformation” out there.
  Nice, blame the messenger when the original statements were muddled.
• He went on to say that “The legislature has committed to changing the law in January 2022, including delaying the premium collection timelines.”​
  But have they? I have seen nothing from the legislature stating that they will do this in January. They have stated that they will work on this during the legislative session. The session in 2022 will span from January into March. I am hoping that they quickly vote in January to delay the collection of the tax until at least 4/1/2022, and then deal with the other tweaks during the session. But when have you ever seen a legislative body act that quickly?
• Finally, he delivered the bad news for state employees that “…the state of Washington is following the law and will have to begin collecting money from state employee paychecks as of January 1st.”
  This is contrary to the original press release from Billig and Jinkins, who recommended employers not collect the tax. I understand that the state is required to follow state laws, but do those reading all these statements understand this? Or will they deem this move as the state not having confidence that the tax will be pushed off?
  
  

WHAT YOU REALLY NEED TO KNOW
Unfortunately, all of these statements have caused a great amount of confusion with agents, employers, and employees.  Here is a rundown of what you really need to know:

1. When the state talks about premiums, what they are referring to is the WA Cares Fund tax
2. If you purchased coverage in order to opt out of WA Cares, the delay of the STATE premium collection has nothing to do with your insurance coverage premiums -- you must continue to pay those premiums or your coverage will lapse
3. Whether or not tax collection begins, the WA Cares Fund tax will start accruing on 1/1/2022
4. Withheld January, February, and March taxes have always been, and will (for now), continue to be due in April 2022
5. The only way the start date of the tax can be delayed is if the legislature passes a revision to the WA Cares Fund law and the Governor signs it
6. If an employer starts deducting the tax and the legislature delays the premium start date, the employer can return those deductions to their employees
7. If an employer does not start deducting the tax and the legislature does not delay the premium start date, the employer will need to remit January, February, and March taxes in April (they will either need to cover these taxes for their employees, collect three months of premiums all at once, or some other still unknown “potential remedy”)
8. The WA Cares Fund tax is not being repealed – they are only looking to “tweak” it
9. As far as LTC insurance coverage is concerned
   1. If you purchased coverage prior to 11/1/2021, you can opt out of the state tax
   2. If you drop your coverage, it looks like you’ll end up paying the state tax (since one of their “tweaks” is to require you to continue your insurance coverage in order to continue opting out)

​MY HUMBLE OPINION
I am boggled as to why the original press statement was even released in the first place. It was totally unnecessary. Nothing changed. Except it seems that more constituents are now upset.
 
ESD was already slated to collect Q1 premiums for the WA Cares Fund in April under the current law. If the legislature pushed off the date, then any collected tax in January, February, and March could easily have been paid back to employees by their employers.
 
Anyone following the Long-term Services & Supports Commission knows that they are providing the legislature with recommendations to tweak the WA Cares Fund program. There was no need to restate this.
 
Most importantly, nothing under the current law can be altered until the legislature actually votes to pass a change and the Governor signs it into law.  This was finally outlined in the Governor’s statement on the 23rd.
 
One of the most frustrating things for me is to watch the state continually work within a vacuum with regards to long-term care – both in regard to the development/changes to the law itself and the garbled last-minute communications these past two weeks. The LTSS Commission has rebuffed suggestions and input from agents, brokers, and insurance companies (yours truly included) from the beginning. Heaven forbid, when crafting the law, they gather insight from those who have been working in the long-term care space for decades.
 
To add insult to injury, with these latest statements, it was quite evident that the communications went out without any regard for the practical realities the statements implied or how the news would be construed by an increasingly frustrated public. We in the industry are left to pick up the pieces and answer the mostly unanswerable questions that these proclamations wrought. 
 
In my humble opinion, the original press release was a “feel good” for the Governor and the Democratic Caucus. A perfunctory “we hear you” moment in response to public outcry about the flawed tax’s impending start. Too bad these statements coming out of Olympia are tone deaf and for nearly everyone working in the state, the outcome is still tied up in legislative knots.