Monday, March 25, 2019

2019 ACA Enrollment: More silver loading effects, CSR enrollment down in SBEs

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CMS released a final enrollment report for the ACA marketplace today, along with the public use files that provide extensive enrollment breakdowns.

The top lines we already knew: Enrollment in was down 3.8% in 39 HealthCare.gov states, up .09% in 12 state-based exchanges (SBEs), and down 2.7% overall.

CMS adds that the percentage of subsidized enrollees rose from 85% to 87%. Translation: unsubsidized on-exchange enrollment was down 12.8%; subsidized enrollment was down just 0.5%. Off-exchange enrollment in ACA-compliant plans was in meltdown in 2017 and 2018; it remains to be seen whether the contraction continued, in the first year in which the Trump administration was actively promoting lightly regulated, medically underwritten short-term plans.

A few more factoids derived from a first look:

1. Enrollment in plans with Cost Sharing Reduction dropped sharply as a percentage of overall enrollment -- but the drop was concentrated in state-based exchanges for some reason. In all states taken together, CSR enrollment dropped from 53.6% to 50.3% of total enrollment -- but it dropped from 51.3% to 41.2% in SBEs, just downticking from 54.4% to 53.6% in HealthCare.gov states.


2. More granular CSR data is available in HealthCare.gov states only. To obtain CSR, an enrollee with qualifying income (up to 250% FPL) must select a silver plan. The highest level of CSR, raising silver plan actuarial value to 94%, is available at incomes up to 150% of the Federal Poverty Level (FPL). In HealthCare.gov states, as a percentage of enrollees with incomes in the 100-150% FPL range, CSR enrollment stayed flat at 88% in 2019 (probably 85-86% in that income range obtained it, as about 2-3% of enrollees have incomes below 100% FPL, a category CMS no longer breaks out*).  At 151-200% FPL, CSR (raising silver AV to 87%) downticked from 76.2% to 74.3% of enrollment. And at 201-250% FPL, where the benefit is weak, raising AV to just 73%, CSR enrollment dropped sharply, from 51% to 41%.

3. For the second consecutive year, enrollment rose at 251-400% FPL in HealthCare.gov states, up .04% at both 251-300% FPL and 300-400% FPL.  Enrollment was down 2.7% at 201-250% FPL, however. Generally, enrollees at the upper income range of subsidy eligibility, 201-400% FPL, are positioned to benefit from silver loading, the pricing in of CSR into silver plans only, which creates discounts in bronze and gold plans (see note below for a quick explanation). At incomes below 200% FPL, the value of the free CSR benefit generally outstrips the value of the discounts created by silver loading. This year, however, despite a further shift out of silver plans at 201-250% FPL, enrollment at that income level dropped more than at 100-150% FPL (where enrollment was down 2.2%), though less than at 150-200% FPL (down 4.7%).

Weedy post, isn't it, without much context. I'll try to digest a bit better later this week.

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* Legally present noncitizens who are time-barred from enrolling in Medicaid can obtain marketplace subsidies if their income is below 100% FPL (or below 138% FPL in expansion states).  In 2016, 3% of enrollees in HealthCare.gov states had incomes below 100% FPL. HHS stopped breakout out that income category separately in 2017.

Silver loadingrefers to concentrating the cost of CSR subsidies (directly reimbursed to insurers by the federal government as stipulated by the ACA until Trump stopped payment in October 2017) in the premiums of silver plans, since CSR is available only with silver plans. Since premium subsidies, designed so that the enrollee pays a fixed percentage of income, are set to a silver plan benchmark (the second cheapest silver plan), inflated silver premiums create discounts for subsidized buyers in bronze and gold plans. And in states that allowed insurers to offer silver plans off-exchange with no CSR load, unsubsidized enrollees were protected from CSR costs, theoretically at least.



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