March 31, 2016 Effectuated Enrollment Snapshot

March 31, 2016 Effectuated Enrollment Snapshot

On March 31, 2016, about 11.1 million consumers had effectuated Health Insurance Marketplace coverage – which means those individuals, paid their premiums and had an active policy as of that date.ⁱ HHS continues to project effectuated enrollment of about 10 million people for the end of 2016.

Of the approximately 11.1 million consumers nationwide with effectuated Marketplace enrollments at the end of March 2016, about 85 percent, or about 9.4 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 $291 per month.ⁱⁱ

There were 8.4 million consumers with effectuated enrollments at the end of March 2016 through the 38 Federally-Facilitated Marketplaces, including State Partnership Marketplaces and State-based Marketplaces that utilize the HealthCare.gov eligibility and enrollment platform (SBM-FPs), collectively known as HealthCare.gov states and 2.7 million through the remaining State-based Marketplaces.ⁱⁱⁱ

As of the end of March 2016, about 11.1 million people had health insurance coverage through the Health Insurance Marketplaces, almost a million more than at this point in time a year ago. “This increased level of enrollment demonstrates the strength of the Marketplace over time, as millions of Americans continue to have access to quality and affordable coverage when they need it. As of early this year, 20 million Americans had coverage thanks to provisions of the Affordable Care Act, and the Health Insurance Marketplace is an important contributor to that progress,” said Kevin Counihan, CEO of the Health Insurance Marketplace.

March effectuated enrollment equaled 87 percent of total Open Enrollment plan selections, within the 80-90 percent range that Marketplace issuers have consistently anticipated and the same percentage as last year, despite factors that might have been expected to lower the percentage. For example, a higher proportion of consumers this year signed up for January 1 coverage, creating a longer window between their initial plan selection and March in which they could have gained employer or other coverage.

To date, CMS has released 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, and have been reported based on data gathered by the original payment systems set up when the Marketplace launched.

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.

Moving forward, CMS will be reporting effectuated enrollment data semiannually, once for the first six months of the year and once for the full twelve months of the year, based on the average number of effectuated enrollments over the relevant time period. Average effectuated enrollment provides a more meaningful metric of Marketplace participation, since it captures all enrollments over the time period, rather than only enrollment at a particular point in time.  The new reporting will also facilitate comparisons to projections made by the Congressional Budget Office, which reflect average enrollment throughout the year.  As issuers fully transition to a new payment system using policy-based data, rather than issuer-aggregated workbook-based reporting, the new payment system offers the opportunity to conduct more refined enrollment reporting. We expect to issue the first semiannual effectuated enrollment report in the fall.

Along with this effectuated enrollment report, we are also releasing an addendum (below) providing updated data on special enrollment period activity in 2015, as well as an analysis of the reduction in the number of consumers experiencing coverage terminations or adjustments to financial assistance due to unresolved data-matching issues.

The following tables are included in the March 2016 Marketplace Effectuated Enrollment Snapshot:

Table 1: March 31, 2016 Total Effectuated Enrollment and Financial Assistance by State
Table 2: March 31, 2016 Average Advance Payment of Tax Credits by State
Table 3: March 31, 2016 Total Effectuated Enrollment Data by Metal Level by State

March 2016: Total Effectuated Enrollment and Financial Assistance

Of the approximately 11.1 million consumers who had effectuated Marketplace enrollments at the end of March 2016, about 85 percent or about 9.4 million consumers were receiving APTC,^iv 57 percent or nearly 6.4 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 (FPL), 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 (94.2%), Florida (93.3%), Louisiana (92.6%), Wyoming (92.0%), Alabama (91.9%), North Carolina (91.5%), South Carolina (91.0%), Alaska (90.1%), Nebraska (89.9%), and Arkansas (89.7%). The states with the lowest rate of consumers who received APTC are: District of Columbia (6.9%), New York (55.3%), Colorado (61.9%), New Hampshire (63.4%), Minnesota (63.8%), New Mexico (68.9%), Arizona (69.3%), Washington (69.8%), Vermont (70.2%), and Oregon (72.8%).

Table 1: March 31, 2016 Total Effectuated Enrollment and Financial Assistance by State 

March 2016: 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 $291 per month at the end of March 2016. 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 $750 per month in Alaska to $178 per month in New York.

Table 2: March 31, 2016 Average Advance Payment of Tax Credits by State

March 2016: Total Effectuated Enrollment by Metal Level by State

There are 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 about 60% and consumer pays about 40%, on average.
• Silver: The health plan pays about 70% and consumer pays about 30%, on average. 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 about 80% and consumer pays about 20%, on average.
• Platinum: The health plan pays about 90% and consumer pays about 10%, on average.

Of the approximately 11.1 million consumers with effectuated enrollment in Marketplace plans at the end of March 2016, less than half a percent were enrolled in Catastrophic plans, 22% were enrolled in Bronze plans, 70% enrolled in Silver plans, 6% enrolled in Gold plans, and 2% enrolled in Platinum plans.

Table 3: March 31, 2016 Total Effectuated Enrollment Data by Metal Level by State

2016 Data Matching

In operating the Marketplace, we are committed to providing access to coverage and financial assistance to individuals and families who are eligible while maintaining strong program integrity protections. Throughout 2014, 2015, and into 2016, the Marketplace has 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.For various timing and operational reasons, data matching actions were more concentrated in the first quarter during 2015 than they are likely to be this year. Thus, we do not expect a comparable reduction in data matching issues going forward. Nonetheless, with such a strong start, we do anticipate substantial progress for the year as a whole.

The Marketplace takes 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 January 1, 2016 to March 31, 2016, enrollment in coverage through the Federally-facilitated Marketplace was terminated for about 17,000 consumers with unresolved citizenship or immigration status data matching issues. During the same time period, 73,000 households with unresolved annual household income data matching issues had their APTC and/or CSRs for 2016 coverage adjusted.  Compared to the first quarter of last year, this represents an 85 percent decrease in the number of consumers whose coverage ended because of an unresolved citizenship or immigration data matching issue, and a 69 percent decrease in households with income data matching issues who had their advanced payment of the premium tax credit and/or their cost sharing reduction adjusted.

If consumers believe they have the appropriate documentation but their enrollment through the Marketplace was terminated based on a citizenship/immigration status data matching issue, they are able to submit their documentation to the Marketplace to resolve the data matching issue and regain enrollment through the Marketplace through a Special Enrollment Period.

Addendum Report: Special Enrollment Period Sign ups in 2015 

In the Health Insurance Marketplace, most consumers select a plan during the annual Open Enrollment Period.  Consumers who experience one of six types of life events can also select a plan during a special enrollment period.  For states on the HealthCare.gov platform during 2015, 1.6 million individuals who did not select a plan during open enrollment made a plan selection through a special enrollment period (SEP). 

The majority of these consumers (60 percent) received a special enrollment period for loss of minimum essential coverage. This means the consumer enrolled in Marketplace coverage after losing other health insurance, like coverage from their job. In addition, 18 percent of SEP plan selections were made by consumers who initially applied for coverage during open enrollment but needed to receive an eligibility determination from their state Medicaid agency before they could be determined eligible for Marketplace coverage and/or financial assistance. The tax season SEP for 2015 accounted for 9 percent of SEP plan selections. The tax SEP was not available for 2016. Finally, small numbers of consumers enrolled for other reasons, including birth, adoption, marriage, a move, or other circumstances. 

These figures include only consumers who did not have a plan selection during open enrollment; a consumer who enrolled during open enrollment and used an SEP to change plans is not reflected here. 

ⁱ 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 March 2016 as of the May 2016 interim payment process data submission.ⁱⁱⁱ For 2016, there are 38 HealthCare.gov states; including, Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, 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.  Hawaii, New Mexico, Nevada, and Oregon are State-based Marketplaces using the HealthCare.gov platform for 2016. Thirteen states – California, Colorado, Connecticut, 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 2016.

^iv Consumers reconcile differences between their projected 2016 household income and their actual household income to determine the final premium tax credits they should receive. This reconciliation process ensures individuals receive the correct amount of tax credit, which will be reflected on their tax return: taxpayers may see a smaller refund or owe money back if they underestimated their household income, or they may get a bigger refund if they overestimated their household income.