September 30, 2015 Effectuated Enrollment Snapshot

September 30, 2015 Effectuated Enrollment Snapshot

On September 30, 2015, about 9.3 million consumers had effectuated Health Insurance Marketplace coverage – which means those individuals paid their premiums and had an active policy at the end of September.^[i] HHS’s effectuated enrollment projection continues to be 9.1 million people for the end of 2015.

Of the approximately 9.3 million consumers nationwide with effectuated Marketplace enrollments at the end of September 2015, about 84 percent, or more than 7.8 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 $271 per month.^[ii]

There were 6.7 million consumers with effectuated enrollments at the end of September 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 2.6 million through the remaining State-based Marketplaces.^[iii] Effectuated enrollment for the 37 states that use HealthCare.gov platform as of June 30, 2015 was 7.2 million, and 2.7 million for the remaining State-based Marketplaces.

“The Marketplace is strong and growing. It’s providing millions of Americans with access to quality and affordable coverage when they need it,” said the Health Insurance Marketplace CEO Kevin Counihan. “Since Open Enrollment began on November 1, interest in obtaining coverage continues to increase with millions of new consumers signing up for Marketplace coverage, and even more returning to the Marketplace to renew their coverage for 2016.”

“The Health Insurance Marketplace is giving people choice and access to quality, affordable health care,” Assistant Secretary for Planning and Evaluation Richard Frank said. “As the provisions of the ACA have taken effect, about 17.6 million Americans gained coverage, and the uninsured rate has been reduced by 45 percent since 2010. The third-quarter decline in effectuated enrollment likely reflects our ongoing income data matching efforts, particularly in the second quarter, people gaining other coverage outside of the Marketplace, such as through a new job, and other decisions about continuation of coverage.” 

About 734,000 households with annual income inconsistencies had their APTC and/or cost-sharing reduction (CSR) for their 2015 coverage adjusted in the second quarter of 2015 which often results in decreased financial assistance for enrollees. These adjustments are likely reflected in attrition during the third quarter.  From July 1 to September 30, about 186,000 households with annual household income inconsistencies had their APTC and/or CSR for 2015 coverage adjusted. Resolving data matching issues is an important part of our program integrity commitment and we are continually working to make the process of resolving data issues smoother for consumers.  

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. Our September 30 effectuated total of 9.3 million is consistent with meeting our goal for 2015. 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.^[iv]

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

Table 1: September 30, 2015 Total Effectuated Enrollment and Financial Assistance by State
Table 2: September 30, 2015 Average Advance Payment of Tax Credits by State
Table 3: September 30, 2015 Total Effectuated Enrollment Data by Metal Level by State

September 2015: Total Effectuated Enrollment and Financial Assistance

Of the approximately 9.3 million consumers who had effectuated Marketplace enrollments at the end of September 2015, about 84 percent or about 7.8 million consumers were receiving APTC^{[v]and 57 percent or about 5.3 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 (94.6%), Florida (92.0%), North Carolina (91.6%), Wyoming (91.4%), Arkansas (90.0%), Louisiana (90.0%), Alabama (89.9%), Georgia (89.9%), Wisconsin (88.8%), and Nebraska (88.7%).  The states with the lowest rate of consumers who received APTC are: District of Columbia (10.2%), Minnesota (55.1%), Colorado (57.5%), Vermont (63.4%), New Hampshire (64.5%), Utah (64.7%), Kentucky (66.8%), Maryland (70.4%), New York (71.7%) and New Mexico (72.7%).

Nine of the ten states with the highest rate of consumers receiving financial assistance (all but Arkansas) had not expanded Medicaid programs under the Affordable Care Act as of September 30. As such, residents in those states with household incomes from 100 to 133 percent of the federal poverty level who are otherwise eligible can qualify for coverage through the Marketplace with tax credits. In states that do not decide to expand Medicaid, APTC eligibility ranges from 100 percent to 400 percent of the federal poverty level.

Table 1: September 30, 2015 Total Effectuated Enrollment and Financial Assistance by State 

September 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 $271 per month at the end of September 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 $534 per month in Alaska to $154 per month in Minnesota.

Table 2: September 30, 2015 Average Advance Payment of Tax Credits by State

September 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 9.3 million consumers with effectuated enrollment in Marketplace plans at the end of September 2015, less than 1% were enrolled in Catastrophic plans, 20% in Bronze plans, 68% in Silver plans, 7% in Gold plans, and 4% in Platinum plans.

Table 3: September 30, 2015 Total Effectuated Enrollment Data by Metal Level by State

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 have 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 July 1, 2015 to September 30, 2015, enrollment in coverage through the Federally-facilitated Marketplaces was terminated for about 48,000 consumers with citizenship or immigration status data matching issues who failed to produce sufficient documentation of their citizenship or immigration status.^[vi] During the same time period, about 186,000 households with annual household income inconsistencies had their APTC and/or CSRs for 2015 coverage adjusted.^[vii]

If a consumer believed they had the appropriate documentation but their 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] 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 September 2015 as of November 2015 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.

^[iv] As announced in the 2015 Special Enrollment Period Report, between February 23 and June 20, 2015, nearly 950,000 new consumers selected a plan through HealthCare.gov platform. Supporting these types of changes is an important function of the Health Insurance Marketplace.
^[v] Consumers reconcile differences between their projected 2015 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.
^[vi] An additional 4,886 consumers were previously terminated in the 2015 Plan Year updated their attestation and were terminated again in the time period from July 1, 2015 to September 30, 2015. An additional 3 consumers were terminated twice within the time period of July 1, 2015 to September 30, 2015.
^[vii] An additional 44,255 consumers were previously adjusted in the 2015 Plan Year updated their attestation and were adjusted again in the time period from July 1, 2015 to September 30, 2015. An additional 2 consumers were adjusted twice within the time period of July 1, 2015 to September 30, 2015.