5 things to know about Affordable Care Act marketplace in Arizona

• UnitedHealthcare is exiting the marketplace and Blue Cross Blue Shield of Arizona is evaluating options
• Eight counties in Arizona now only have marketplace choices of UnitedHealthcare and Blue Cross Blue Shield

UnitedHealthcare’s decision to leave the health-insurance marketplace in Arizona and most other states will limit choices for consumers.

But the question in Arizona and elsewhere is whether their consumers will have robust choices for health plans.

UnitedHealthcare and Blue Cross Blue Shield of Arizona are the only health insurers that sell Affordable Care Act marketplace plans in every Arizona county. In Pinal, Yavapai, Yuma and five other mainly rural counties, the two insurance giants are the only options for consumers this year.

But Blue Cross Blue Shield, which has reported $185 million in losses on individual plans sold during 2014 and 2015, said that it will evaluate “all options,” including whether to continue selling marketplace plans in every county next year.

If Blue Cross Blue Shield drops those mostly rural counties, it could leave some areas of the state without a marketplace health insurer. That hasn't happened since the state exchanges and federal marketplace began signing up consumers in fall 2013 for coverage that began Jan. 1, 2014.

RELATED: One of Arizona's largest health-care insurers to exit marketplace

Question: When will Arizonans know their marketplace choices for 2017?

Answer: Arizona residents won't know what options they’ll have until later this year. Health insurers that intend to sell marketplace plans in Arizona next year must file paperwork with the Arizona Department of Insurance by May 11.

Federal officials downplayed the possibility that some Arizona counties could be left without a marketplace option.

“I’m not going to speculate on hypotheticals,” said Aaron Albright, a Centers for Medicare and Medicaid Services spokesman. “As with any new market, we expect changes and adjustments in the early years, with issuers both entering and exiting states.”

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Q: Why is it important that consumers have options?

A: Arizonans who seek federally subsidized health plans must purchase plans  through the Affordable Care Act marketplace, healthcare.gov. Consumers who buy "off-exchange" plans — insurance plans sold directly to consumers, not through the marketplace — do not qualify for federal subsidies.

The health-care law requires most consumers to obtain a qualifying health insurance plan or pay a fine. There are more than one dozen exemptions to the health-care law's individual shared responsibility provision, including individuals who can't find affordable coverage, don't make enough to file a tax return, general hardship, religious objectors and those who are unable to renew existing policies.

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Q: Why will UnitedHealthcare discontinue Affordable Care Act plans in most states?

A: UnitedHealthcare said Tuesday it would exit all but a "handful" of the 34 states where it now sells state or federal marketplace plans. The insurer notified the Arizona Department of Insurance that it would not sell individual plans directly to consumers, either on or off the marketplace.

Similarly, UnitedHealth Group CEO Stephen Hemsley cited the "smaller overall market size and shorter-term, higher-risk profile" that has led to $475 million in losses in 2015 and an even larger projected loss in 2016.

UnitedHealthcare sat out Arizona's marketplace in 2014 but has marketed plans the past two years. Its All Savers plan is the only preferred-provider organization (PPO) plan sold on Arizona's marketplace this year, with all other insurers selling HMO plans with smaller provider networks. Some insurers continue to sell "off-exchange" PPO plans.

A Kaiser Family Foundation analysis revealed the potential impact of UnitedHealthcare's decision to drop most states. More than 1.1 million marketplace or state exchange consumers are in communities that have two insurers, which would be reduced to one next year unless another insurer enters the respective market to replace UnitedHealthcare.

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Q: Why is Blue Cross Blue Shield of Arizona evaluating all options for 2017?

A: The Phoenix-based health insurer said it reported losses of $185 million on individual plans during the first two years of the marketplace.

The insurer urges federal regulators to adopt better controls on when people can sign up outside normal enrollment periods.

Blue Cross Blue Shield officials also said the lowest-priced Arizona plans during the first two years of the marketplace were priced too low, which limited subsidy levels for all Arizona consumers and insurers. The health-care law calculates subsidy levels using a formula based on the second lowest-cost "silver" plan in each county. The lower the cost of this benchmark plan, the lower the amount of tax-credit subsidies consumers can collect to offset the cost of their monthly premiums.

Blue Cross Blue Shield of Arizona has said it will evaluate each Arizona county and decide whether to sell insurance plans — and what types of insurance plans — in those areas. The insurer said it recognizes that Arizona consumers need options and choices, but it also said it must financially protect its business.

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Q: Will other insurers expand their offerings in Arizona?

A:  Both Maricopa and Pima counties have a wide selection of health insurers in the marketplace. Aetna, Blue Cross Blue Shield, Cigna, Health Choice, Health Net, Humana, Phoenix Health Plans and UnitedHealthcare's All Savers all sold marketplace plans this year in Maricopa County.

But with UnitedHealthcare pulling out of Arizona, it's unclear whether other insurers will expand their offerings in pockets of the state that have fewer options. More than 30,000 people chose marketplace plans from Blue Cross Blue Shield or UnitedHealthcare in the following eight counties: Cochise, Graham, Greenlee, La Paz, Pinal, Santa Cruz, Yavapai and Yuma.

Federal officials said that each market will have a natural churn each year. In 2016, for example, 39 insurers exited the marketplace or state exchanges in 2016  and 40 insurers joined.

"The marketplace is a reliable source of coverage for millions of Americans with a robust number of plan choices," Albright said. "We have full confidence, based on data, that the marketplaces will continue to thrive for years ahead."

Health experts said they are closely monitoring the coverage options that are available to rural Arizonans.

"It leaves us concerned about what may happen, but there are many unknowns of whether there will be one, two or no marketplace issuers," said Allen Gjersvig, director of navigator and enrollment services for the Arizona Alliance for Community Health Centers.

Aetna officials declined to reveal that company's plans for the Arizona marketplace next year. Likewise, Cigna would not discuss its plans before it files paperwork with state regulators.

A Cigna spokesman said the company has offered plans during all three years of Arizona's marketplace. This year, the company sold two types of plans in Maricopa County.

"We have approached the public exchange market with deliberate focus," Cigna spokesman Joseph Mondy said.  "We believe that the market offers a potential longer-term opportunity for profitable growth through collaborative partnerships with physicians, customers, regulators, and distribution partners."

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