Thursday, September 16, 2021

Notes from the SEP: On record marketplace enrollment in August 2021

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CMS today released a final enrollment report for the emergency Special Enrollment Period that ran in states from Feb. 15--Aug. 15 this year, and for mostly comparable lengths in the 15 state-based marketplaces. 

The top line: 2.8 million new enrollments nationally in that period. A few quick notes:

  1. Effectuated enrollment in August 2021, 12,199,393, is up 14.6% over 2020, the previous high (10,642,088*), and 22% over enrollment in August 2016, the peak prior to 2020.  Caveat: off-exchange enrollment in ACA-compliant plans dropped by about 3 million from 2016 to 2019, according to KFF estimates. On-exchange enrollment is about 2.2 million above the August 2016 total.

  2. While 2.8 million people newly enrolled in marketplace coverage during the SEP, total enrollment has risen by only 900,000 since February, when effectuated enrollment stood at 11.3 million.  That's steeper attrition than I anticipated when I estimated total enrollment at 12.7 million through July.

  3. In states, which includes all nonexpansion states, 45% of enrollees have income below 150% FPL, and 41% obtained the highest level of CSR silver (94% actuarial value) for free.  In the same period in 2019, 34% obtained CSR-94 (not for free). Nonexpansion states account for 76% of all enrollment (courtesy of Charles Gaba), and the percentages below 150% FPL there are doubtless higher.  

  4. The contrast with 2019 would be a bit sharper if Idaho, Utah, Nebraska and Oklahoma had not expanded Medicaid since 2020. Applicants in the 100-138% FPL range in those states now qualify for Medicaid. 

  5. In states, the percentage of enrollees with incomes in the 100-138% FPL range in 2021 (33%), is actually down slightly from 2020 (36%) and up fairly modestly from 2019, the last pre-pandemic year (30%).  I find that somewhat surprising. Possible factors: 1) the new Medicaid expansion states noted above, and 2) the emergency supplemental unemployment insurance provided by the CARES Act in 2020, which may have pushed a lot of people in nonexpansion states over the 100% FPL threshold for subsidy eligibility.  The new expansion states had just shy of 100,000 new enrollments during the SEP.  Had they not expanded Medicaid, perhaps 30-40,000 with income in the 100-138% FPL range who now qualify for Medicaid may have enrolled in the marketplace.

  6. In state-based marketplaces, all of which are in expansion states, 5% of enrollees had incomes in the 100-138% FPL range. A good percentage of them are likely enrollees who reported receiving unemployment insurance income in 2021 and so, thanks to a provision in the American Rescue Plan, had their incomes deemed to be 138% FPL, qualifying them for free high-CSR silver coverage. Some portion may also be legally present noncitizens time-barred from Medicaid. Unfortunately, CMS does not have an income breakout for 2020 or 2019 in SBMs. Unemployment insurance recipients probably also boosted CSR-94 totals in states, including by qualifying some people with income under 100% FPL for subsidies.

  7. About 225,000 of new enrollees (8%) reported incomes above 400% FPL. That doesn't indicate a huge migration from off-exchange in the wake of the American Rescue Plan ending the income cap on subsidies (which was 400% FPL). I am assuming that the 8 million existing enrollees who selected a new plan or updated their info and received new subsidies does not include off-exchange enrollees who moved on-exchange. 
*  CMS's February early effectuated enrollment report, which as in past years provides monthly enrollment totals for the year, pegs total enrollment in August 2020 at 10,466,271, which would boost this year's increase to 16.6%. The effectuated enrollment file for the SEP, which includes August totals for 2020 and 2019, boosted the tally for August 2020 by some 176,000.  That's a pretty big revision.

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