Individual Health Insurance Market Checkup: How Are Minnesotans Experiencing Individual Health Insurance? - A Data Short Take -

Health Economics Program December 2019 Patient History: Background on the individual market

Over the last decade, the individual health insurance market has been a source of insurance coverage for 3 to 5 percent of Minnesotans.

• The individual market provides access to health insurance for Minnesotans who do not have insurance through their employer and who earn too much to be eligible for Medical Assistance or MinnesotaCare.

• Minnesotans also have the option to enroll in the individual market through MNsure, an insurance marketplace which also provides access to premium subsidies to reduce health care costs. The Minnesota Legislature has devoted significant time and resources to support this market. Yet, affording coverage and care in the individual market remains a challenge for some Minnesotans.

2 Checkup Exam: Vital signs examined in this data short take

How do Minnesotans experience the individual health insurance market, and how has it changed? • Pulse  Competition among insurers • Blood Pressure  Enrollment by exchange status, metal level, and age • Temperature  Premiums and health care claims costs incurred • Respiration  Plan benefits offered

3 Pulse: Health insurer competition on MNsure declined in 2017; since then there have been improvements

2014 2015 2016

Number of Insurers Year 1 2 3+ 2014 0 10 77 2015 0 18 69 2016 0 21 66 2017 2018 2019 2020 2017 0 67 20 2018 5 60 22 2019 4 59 24 2020 0 56 31

Source: Kaiser Family Foundation. Insurer Participation on ACA Marketplaces, 2014-2019. https://www.kff.org/health-reform/issue-brief/insurer- participation-on-aca-marketplaces-2014-2019/; Minnesota Department of Commerce’s Health Plan Binders 2020. 4 Note: Companies with related subsidiaries are grouped together as one insurer. Pulse: MNsure products and share of individual market offerings are higher in 2020 relative to 2014

When MNsure (Minnesota’s health insurance marketplace) first opened in 461 2014, 14% of all health plan options were on MNsure. 163

Off Exchange By 2020, that share had grown to 43%.

Number of Health Insurance Products MNsure 122 78

2014 2020

Source: Minnesota Department of Commerce’s Health Plan Binders 2014 and 2020. 5 Blood Pressure: MNsure enrollment—as a percent of individual market enrollment and in absolute numbers—is growing

ACA created MN’s health 350,000 • BCBSM exited individual market insurance marketplace known as • First year without Federal “MNsure.” reinsurance and risk corridors 300,000 program Enrollment on MNsure and • MN established a 1-year 25% subsidy for high-income earners among Individuals 250,000 and a state reinsurance program Receiving Premium Subsidies on MNsure has 200,000 increased since 2014. 150,000 Off-Exchange By the end of 2018, only 100,000 about one-third of the MNsure with subsidies total individual market is 50,000 MNsure without subsidies Off-Exchange enrollment. 0 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 2012 2013 2014 2015 2016 2017 2018

Source: NAIC Health Plan Financial Supplemental Exhibit on Premiums, Enrollment and Utilization 2014 – 2018; MNSure quarterly Marketplace enrollment data 2014-2018. 6 Blood Pressure: Greatest share of MNsure enrollment growth has been in bronze and silver plans

140,000

On MNsure, the greatest share 120,000 of enrollment growth between Platinum 2014 and 2019 has been in 100,000 Bronze and Silver plans. Gold 80,000

Silver Enrollment in Platinum plans 60,000 declined from 2014 to 2015, and Platinum plans have not 40,000 Bronze been offered on MNsure since 20,000 2016. Catastrophic - 2014 2015 2016 2017 2018 2019

Note: Based on enrollment though MNsure only; enrollment in the full individual market may show a different metal level distribution; platinum plans are still available off MNsure. 2014 enrollment was reported as enrollment as of December of that year, 2015 and 2016 as of March, and 2017 through 2019 were as of January. Source: Centers for Medicare and Medicaid Services’ Marketplace Open Enrollment Public Use Files (2015-2019); MNsure quarterly Marketplace enrollment data 2014-2019. 7 Blood Pressure: Age composition of MNsure enrollment has remained generally unchanged since 2016

Age 25 or Under 16% 18% 18% 18% Even as total Age 26-34 14% 15% 14% 14% enrollment on MNsure 13% 13% 13% 14% Age 35-44 has grown, the share of Age 45-54 18% 18% 18% 17% total enrollment by age Age 55+ 38% 36% 37% 37% group has remained

0% 20% 40% 0% 20% 40% 0% 20% 40% 0% 20% 40% stable since 2016. 2016 2017 2018 2019

Note: Based on enrollment though MNsure only; enrollment in the full individual market may show a different age distribution. Source: Centers for Medicare and Medicaid Services’ Marketplace Open Enrollment Public Use Files (2016-2019). 8 Blood Pressure: More Minnesotans are maintaining enrollment through MNsure

140,000 Total Enrollment: Total Enrollment: In 2016, a little over half Total Enrollment: 116,358 120,000 109,974 113,552 of all MNsure enrollees had had a MNsure health 100,000 Total Enrollment: 30% 25% 83,507 insurance plan in the 47% 80,000 prior year. 60,000 45% By 2019, three-quarters 75% 40,000 70% of all MNsure enrollees 53% 20,000 55% had a plan in the prior year. - 2016 2017 2018 2019 Total Reenrollees New Consumers

Note: Based on enrollment though MNsure only; enrollment in the full individual market may show different re-enrollment numbers. 9 Source: Centers for Medicare and Medicaid Services’ Marketplace Open Enrollment Public Use Files (2016-2019). Temperature: Average monthly premiums have increased from 2014 to 2018 despite slower claims spending since 2017

$600

$500 Premiums Average monthly Pre-ACA $481 premiums increased from $400 Claims 2014 to 2018. $379 $300 Average monthly claims

$200 increased from 2014 Monthly Per Capita Capita Per Monthly through 2016 but leveled $100 off beginning in 2017.

$- Q1Q2Q3Q4Q1Q2Q3Q4Q1Q2Q3Q4Q1Q2Q3Q4Q1Q2Q3Q4Q1Q2Q3Q4Q1Q2Q3Q4 2012 2013 2014 2015 2016 2017 2018 PMPM Premiums PMPM Claims

Source: NAIC Health Plan Financial Supplemental Exhibit on Premiums, Enrollment and Utilization 2012 – 2018. 10 Respiration Rate: Average silver-plan deductibles on- and off- exchange increased from 2014 to 2020

Between 2014 and Year Off MNsure MNsure 2020, the average silver 2014 2020 Bronze Silver Gold Platinum Bronze Silver Gold Platinum individual in-network 7K deductible (offered on- or off- MNsure) 6K increased 29%. 5K

The average silver 4K deductible was $3,720 and $3,463 on- and off- 3K MNsure in 2020,

respectively. Indiv 2K

1K On MNsure, platinum 0K plans were not offered 2014 2020 2014 2020 2014 2020 2014 2020 2014 2020 2014 2020 2014 2020 2014 in 2020. Source: Minnesota Department of Commerce’s Health Plan Binders 2014 and 2020. Note: only in-network deductibles for individual plans were used for analysis; plans that only had a combined deductible for in- and out-of-network services were excluded. In 2018, Expanded Bronze plans became available, 11 allowing greater actuarial value variation; Bronze and Expanded Bronze plans are include in the Bronze category. Respiration Rate: All health plans had integrated medical and drug deductibles in 2020

100% Enrollees in plans with deductibles 90% 22% Not Integrated that are Not Integrated pay toward 80% separate deductibles for medical 70% and drug costs. 60%

50% Integrated 100% In 2014, 22% of health plans

40% 78% offered in the individual market had 30% Not Integrated medical and drug deductibles. 20% 10% In 2020, 100% of health plan 0% offerings had Integrated 2014 2020 deductibles.

Source: Minnesota Department of Commerce’s Health Plan Binders 2014 and 2020. 12 Respiration Rate: Almost no 2020 plans limit what enrollees pay for out-of-network care

100%

90%

80% In 2014, half of health plans limited 51% 70% out-of-pocket costs for care Plans with no OON MOOP enrollees received from providers 60% that were out-of-network 50% 97% (OON MOOP).

40% In 2020, almost no plans limited 30% Plans with OON MOOP out-of-pocket costs for care 49% 20% received from out-of-network

10% providers.

0% 3% 2014 2020

Source: Minnesota Department of Commerce’s Health Plan Binders 2014 and 2020. 13 Checkup Exam: Summary

Pulse Competition among insurers on MNsure declined in many parts of the state in 2017, but there has been improvement since then

Blood Pressure Enrollment on MNsure has grown since 2014—particularly among silver and bronze plans—and the age composition has remained stable between 2016 and 2019

Temperature Average per capita premiums and claims went up every year since 2014 until claims slowed in 2017

Respiration Plan benefits offered in 2020 relative to 2014 are more likely to include higher deductibles and less likely to cap out-of- network costs, but deductibles are more likely to be integrated

14 Definitions

Slide 7 Metal Level: Indicates the percent of average medical costs the plan will cover; Catastrophic plans cover about 50%, Bronze plans 60%, Silver plans 70%, Gold plans 80% and Platinum plans 90%.

Slide 10 Premiums: the amount paid to the insurance company every month by an individual/employer to cover the cost of health care services Claims: the amount the health insurance company pays for health care services received by enrollees

Slide 11 Deductible: Amount health plan enrollee pays out of pocket for health care before health plan starts to cover medical costs

Slide 13 Out of Network Maximum Out of Pocket (OON MOOP): Limit on the maximum amount an enrollee will have to pay for health care services received from a provider who is not in their plan’s network

15 Data Sources Used

This Data Short Take draws its analysis from the following data sources. The particular sources used for each slide are noted on a footnote in that slide. • National Association of Insurance Commissioners' quarterly and annual Exhibit of Premium, Enrollment, and Utilization (2012-2018) • Minnesota Statement of Revenue, Expenses & Net Income (2014-2019) • Department of Commerce’s Health Insurance Plan Binders (2014 and 2020) • Monthly enrollment data provided by MNsure • Centers for Medicare and Medicaid Services’ Marketplace Open Enrollment Public Use Files (2016-2019) • Kaiser Family Foundation’s Insurer Participation on ACA Marketplaces Data (2014-2019)

16 Contact and Other Information

Health Economics Program [email protected] 651-201-3550 ______HEP Home Page: www.health.state.mn.us/healtheconomics Health Care Market Statistics: www.state.mn.us/healtheconomics/chartbook A text summary of this presentation is available upon request. 17