December 31, 2015 Effectuated Enrollment Snapshot

December 31, 2015 Effectuated Enrollment Snapshot

On December 31, 2015, about 8.8 million consumers had effectuated Health Insurance Marketplace coverage – which means those individuals paid their premiums and had an active policy at the end of December.ⁱ  Of the approximately 8.8 million consumers nationwide with effectuated Marketplace enrollments at the end of December 2015, about 84 percent, or about 7.4 million consumers, were receiving an advance payment of the premium tax credit (APTC) to make their premiums more affordable throughout the year. The average APTC for those enrollees who qualified for the financial assistance was $272 per month.ⁱⁱ

There were 6.3 million consumers with effectuated enrollments at the end of December 2015 through the 37 Federally-Facilitated Marketplaces, including State Partnership Marketplaces and supported State-based Marketplaces that utilize the HealthCare.gov eligibility and enrollment platform (collectively known as HealthCare.gov states) and 2.5 million through the remaining State-based Marketplaces.ⁱⁱⁱ Effectuated enrollment for the 37 states that use HealthCare.gov platform as of September 30, 2015 was 6.7 million, and 2.6 million for the remaining State-based Marketplaces.

 “At the end of 2015, about 8.8 million people had health insurance coverage through the Health Insurance Marketplaces, up from 6.3 million the year before, a nearly 40 percent year-over-year increase,” said Kevin Counihan, CEO of the Health Insurance Marketplace. “This rapid progress in expanding access to coverage through the Health Insurance Marketplace is a major reason why the share of Americans with health insurance rose above 90 percent in 2015 for the first time ever.

CMS releases Marketplace state-by-state effectuated enrollment snapshots on a quarterly basis, detailing how many consumers have an effectuated enrollment, how many are benefiting from financial assistance, and the distribution of effectuated enrollment by qualified health plan metal level. Changes in effectuated enrollment are influenced by many factors and vary from quarter to quarter.

The Marketplace effectuated enrollment snapshot provides point-in-time estimates. CMS expects enrollment numbers will change over time as consumers find other coverage or experience changes in life circumstances such as employment status or marriage, which may cause consumers to change, newly enroll in, or terminate their plans.

The following tables are included in the December 2015 Marketplace Effectuated Enrollment Snapshot:

Table 1: December 31, 2015 Total Effectuated Enrollment and Financial Assistance by State
Table 2: December 31, 2015 Average Advance Payment of Tax Credits by State
Table 3: December 31, 2015 Total Effectuated Enrollment Data by Metal Level by State

December 2015: Total Effectuated Enrollment and Financial Assistance

Of the approximately 8.8 million consumers who had effectuated Marketplace enrollments at the end of December 2015, about 84 percent or about 7.4 million consumers were receiving APTC^{and 56 percent or about 5 million consumers were benefiting from cost sharing reductions (CSRs) to make their coverage more affordable. CSRs are generally available if a consumer’s household income is between 100 percent and 250 percent of the federal poverty level, the consumer is otherwise eligible for APTC, and the individual chooses a health plan from the silver plan category.}

The ten states with the highest rate of consumers who received financial assistance through APTC were: Mississippi (95.5%), Florida (92.2%), North Carolina (91.8%), Alabama (90.6%), Louisiana (90.5%), Georgia (90.4%), Arkansas (89.6%), Alaska (89.4%), South Carolina (88.8%) and Maine (88.7%). The states with the lowest rate of consumers who received APTC are: Washington, DC (8.9%), Minnesota (55.0%), Colorado (56.2%), Vermont (64.2%), New Hampshire (64.3%), Utah (64.5%), Kentucky (67.6%), Maryland (71.2%), New York (72.0%) and Oregon (72.3%).

Table 1: December 31, 2015 Total Effectuated Enrollment and Financial Assistance by State 

Source: February 2016 CMS
* Validated enrollment data was not available for Colorado’s catastrophic plans at the time of publication.

December 2015: Average APTC by State

Consumers with household incomes between 100 percent and 400 percent of the FPL may qualify for APTC, which helps make their coverage more affordable throughout the year by lowering their share of monthly premium costs. Consumers who qualify for APTC may choose how much of the APTC to apply to their premiums each month, up to the maximum amount for which they are eligible.

The overall average APTC Marketplace consumers received was $272 per month at the end of December 2015. Because the amount of APTC an enrollee may receive depends on household income and the cost of the second lowest cost silver plan available to the enrollee, the average APTC ranged from $544 per month in Alaska to $154 per month in Minnesota.

Table 2: December 31, 2015 Average Advance Payment of Tax Credits by State

Source: February 2016 CMS

December 2015: Total Effectuated Enrollment by Metal Level by State

There are generally four “metal levels” of coverage available through the Marketplace, plus catastrophic plans. Plans in each category can be expected to pay different amounts of the total costs of an average person’s care. This takes into account the plans’ deductibles, copayments, coinsurance, and out-of-pocket maximums. The actual percentage a consumer pays in total or per service will depend on the services used during the year.

• Catastrophic: The health plan pays less than 60% of the total average cost of care on average, with consumers paying the balance. These plans are only available to people who are under 30 years old at the beginning of the plan year, or those who have a hardship or affordability exemption.
• Bronze: The health plan pays 60% on average. Consumer pays about 40%.
• Silver: The health plan pays 70% on average. Consumer pays about 30%. Consumers eligible for CSRs can only receive them by enrolling in a silver plan. (Note, American Indians and Alaska Natives can receive CSRs through any metal-level plan.)
• Gold: The health plan pays 80% on average. Consumer pays about 20%.
• Platinum: The health plan pays 90% on average. Consumer pays about 10%.

Of the approximately 8.8 million consumers with effectuated enrollment in Marketplace plans at the end of December 2015, less than half a percent were enrolled in Catastrophic plans, 20% were enrolled in Bronze plans, 68% enrolled in Silver plans, 7% enrolled in Gold plans, and 4% enrolled in Platinum plans.

Table 3: December 31, 2015 Total Effectuated Enrollment Data by Metal Level by State

Source: February 2016 CMS
*Validated enrollment data was not available for Colorado’s catastrophic plans at the time of publication.
**Data needed to be suppressed for Iowa and South Carolina catastrophic and platinum plans due to small totals.

2015 Data Matching

In operating the Marketplaces, we are committed to providing access to coverage and financial assistance to individuals and families who are eligible while maintaining strong program integrity. Throughout 2014 and into 2015, the Marketplaces have worked to resolve consumers’ data matching issues, including for those individuals whose citizenship, immigration status, or household income application information did not match information in our trusted data sources. In 2014, the Marketplace extended the deadline for consumers to submit documentation verifying the information in their applications and conducted an extensive outreach campaign in coordination with local assisters, stakeholders, and insurance companies to contact consumers with data matching issues.

In 2015, the Marketplaces moved to regular monthly action for consumers with unresolved data matching issues who have not provided adequate documentation within 95 days for citizenship or immigration status data matching issues and within 90 days for household income inconsistencies. Consumers who do not submit sufficient documentation to resolve their annual household income data matching issue will have a recalculation of their APTC and/or CSRs based on available tax data. Individuals who have not provided the necessary documentation for their citizenship or immigration status will have their enrollment through the Marketplace terminated. Those individuals whose enrollment through the Marketplace was terminated because of citizenship or immigration status data matching issues are not included in effectuated enrollment totals.

During the time period from October 1, 2015 to December 31, 2015, enrollment in coverage through the Federally-facilitated Marketplaces was terminated for about 30,000 consumers with citizenship or immigration status data matching issues who failed to produce sufficient documentation of their citizenship or immigration status. During the same time period, about 57,000 households with annual household income inconsistencies had their APTC and/or CSRs for 2015 coverage adjusted. In total during 2015, coverage was terminated for about 500,000 consumers with citizenship or immigration data matching issues and APTC and/or CSRs were adjusted for 1.2 million consumers. Data matching issues often impact effectuated enrollment with a lag, because consumers who stop paying premiums after an APTC adjustment have a grace period before their coverage is ended.

If a consumer believes he or she has the appropriate documentation but his or her enrollment through the Marketplace was terminated based on a citizenship/immigration status data matching issue, the individual is able to submit his or her documentation to the Marketplace to resolve the data matching issue and regain enrollment through the Marketplace through a Special Enrollment Period.  
 

ⁱ This snapshot does not include effectuated plan selections from the most recent open enrollment period. Individuals effectuate their enrollment by paying their first month’s premium. This snapshot measures individuals who effectuated their enrollment and have an active policy on the date of the snapshot; it does not measure the rate at which consumers pay their first month’s premium. Active policies include those who have paid for the current month and individuals who may be in a grace period for non-payment. Grace periods can vary by state and issuer. For those individuals receiving APTC, issuers are required to give enrollees a three month grace period. 45 CFR §§ 155.430 and 156.270.ⁱⁱ This data is reported by insurance companies with plans in the Health Insurance Marketplaces as part of the interim payment process. Issuers report total effectuated enrollment counts, and the estimated APTC amounts owed to the issuer for those effectuated enrollments. After CMS validates these amounts, issuers are paid monthly based on these estimates. Each month, issuers are permitted to restate prior months’ enrollment and payment data to reflect enrollee cancellations, terminations, or other fluctuations in enrollment. The data in this snapshot represents issuer estimates of individuals with effectuated enrollment for December 2015 as of February 2016 interim payment process data submission.

ⁱⁱⁱ For 2015, there are 37 HealthCare.gov states; including, Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Louisiana, Maine, Michigan, Mississippi, Missouri, Montana, Nebraska, New Hampshire, New Jersey, New Mexico, Nevada, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin, and Wyoming. New Mexico, Nevada, and Oregon are State-based Marketplaces using the HealthCare.gov platform for 2015. Thirteen states – California, Colorado, Connecticut, Hawaii, Idaho, Kentucky, Maryland, Massachusetts, Minnesota, New York, Rhode Island, Vermont and Washington – plus the District of Columbia – have their own State-based Marketplaces and are using their own technology platform for 2015.