Findings in this document are based on publicly available information. Rates for 2014 through 2023 come from the McKinsey Exchange Offering Database, which includes county- and plan-level information from publicly available rate filings and healthcare.gov. The consumer population is defined as the population that has enrolled in any type of individual coverage, including on-exchange and off-exchange plans. Full-year enrollment for 2022 is projected.
The data for prior years in this article is slightly different from the data in last year’s article1Stephanie Carlton, Mike Lee, and Arjun Prakash, “Insights into the 2022 individual health insurance market,” McKinsey, August 3, 2022. because we undertook some additional preprocessing steps (for example, cleaning, quality assessment, validation, and adding missing data). We also refreshed the data to consistently account for M&A activity over the years.
Due to data availability limitations, the analysis excludes the following counties in New York:
- 2020: Herkimer, Montgomery, Orleans, Saratoga, Schuyler, Tompkins, Washington, Wayne, and Wyoming (combined estimated enrollment 12,969)
- 2021: Chemung, Erie, Montgomery, Orleans, Saratoga, Washington, Wayne, and Wyoming (combined estimated enrollment 20,427)
Pricing. Pricing analyses in this document are based on on-exchange plans only; this report does not include off-exchange pricing data. For consistency, premiums were obtained for a 27-year-old nonsmoking individual without family or partner coverage. To understand the premium changes that consumers will see (before the impact of subsidies), we calculated the weighted average rate change in premiums from 2022 to 2023 for the lowest-price silver plan in each rating area and county combination. First, we established a distribution of individuals using individual market plans in each county based on Federal Information Processing Standards (FIPS) codes. Next, we combined this population distribution with data about premiums for lowest-price silver plans in 2022 and 2023. Finally, we used the 2022 and 2023 premiums to calculate weighted average rate changes for all 50 states and the District of Columbia individually and collectively.
Insurer participation. To calculate insurer participation, including the consumer view of insurer participation, we analyzed the number of unique insurer parent companies that are offering plans on exchanges.
Insurer categories. Insurer categories are defined as follows:
- Blues: insurers that are members of the Blue Cross Blue Shield Association
- Consumer operated and oriented plan (CO-OP): a recipient of federal CO-OP grant funding
- Medicaid: an insurer that also operates as a managed care organization (MCO) and whose main line of business outside of individual coverage is in Medicaid
- National: a multistate, non-Blue insurer with a nationwide commercial footprint (for example, Aetna CVS Health, United HealthCare, Cigna)
- Provider: an insurer that also operates as a provider or health system
- Regional/local: a nonprovider, non-Blue insurer with a presence typically in a single state, but that may include a collection of states with regional focus
- Insurtech: a venture capital–backed insurer, typically with an innovative, tech-first value proposition (for example, Bright Health, Friday Health Plan, Oscar Health)
Plan types. Plan types reported here were taken directly from insurer rate filings and summary of benefits and coverage documents. Independent assessment of plan types was not part of the analysis presented in this document. Plan types are defined as follows:
- HMO: A health maintenance organization is a plan typically centered on a primary-care physician who acts as a gatekeeper to other services and referrals. It usually provides no coverage for out-of-network services, except in emergency or urgent-care situations.
- EPO: An exclusive provider organization is a plan similar to an HMO. It usually provides no coverage for any services delivered by out-of-network providers or facilities except in emergency or urgent-care situations; it generally does not require members to use a primary care physician for in-network referrals.
- PPO: A preferred provider organization is a plan that typically allows members to see physicians and get services that are not part of a network; out-of-network services often require a higher copayment.
- POS: A point-of-service plan is a hybrid of an HMO and a PPO; it is an open-access model that may assign members to a primary care physician and usually provides partial coverage for out-of-network services.
Level of plan coverage. Metal levels indicate the share of covered medical costs paid by the plan versus the share paid by consumers in the form of deductibles, copays, and coinsurance. Generally, premiums are higher when the plan covers a larger share of expenses.2“How to pick a health insurance plan: The health plan categories: Bronze, Silver, Gold & Platinum,” healthcare.gov, accessed March 11, 2023.
- Platinum: Plan pays approximately 90 percent of covered expenses.
- Gold: Plan pays approximately 80 percent of covered expenses.
- Silver: Plan pays approximately 70 percent of covered expenses. Some consumers with lower incomes (between 100 and 250 percent of the federal poverty limit) qualify for cost-sharing reductions, which increase the proportion of expenses paid by the plan at no extra cost to the consumer.
- Bronze: Plan pays approximately 60 percent of covered expenses.
- Catastrophic: Plan has very low monthly premiums and very high deductibles, providing protection for high-cost medical situations. Only individuals under 30 or with an exemption based on affordability or other hardship are eligible to purchase catastrophic plans.3“How to pick a health insurance plan: Catastrophic health plans,” healthcare.gov, accessed March 11, 2023.
