Key Takeaways:
The Affordable Care Act Health Insurance Exchange (referred to here as the Exchange) began open enrollment for 2021 health plan coverage on November 1, 2020 and will close enrollment on December 15. This year, there is an increase in the number of plans available across many counties in North Carolina and a decrease in average plan costs. Two new insurers have entered the marketplace - Oscar Health Plan of NC and UnitedHealthcare. One big change from previous years is that a majority of counties in the state (53%) have access to three or more insurance providers on the Exchange (Table 1).
Table 1. Percent of Enrollees with Access to Health Plans Offered by 1, 2, or 3 or More Issuers, 2018-2020 (NC)
| Number of Qualified Health Plan Issuers | Year of Health Plan Coverage | |||
| 2018 | 2019 | 2020 | 2021 | |
| 1 issuer | 85% | 83% | 47% | 4% |
| 2 issuers | 15% | 7% | 41% | 43% |
| 3+ issuers | 0% | 11% | 13% | 53% |
Source: Centers for Medicare & Medicaid Services. Plan Year 2021 Qualified Health Plan Choices and Premiums in HealthCare.gov States. Appendix File. https://www.cms.gov/CCIIO/Resources/Data-Resources/Downloads/2021QHPPremiumsChoiceAppendix.xlsx. Accessed November 9, 2020.
Costs are decreasing, or only increasing slightly, for individuals and families seeking health insurance plans on the Exchange, depending on location. The monthly premium costs for the second-lowest cost silver plan (SLCSP) were down from an average of $460/month (individual) and $1,799/month (family) for 2020 coverage to $423/month (individual) and $1,657 (family) for 2021 coverage [1]. Table 2 shows SLCSP average premiums for individuals and families in three North Carolina counties for coverage in 2019-2021. A majority of individuals who enroll in health plans on the Exchange choose a silver-level plan, with 58% of enrollees in North Carolina doing so for 2020 coverage. The second-lowest cost silver plan is used as the benchmark for calculating premium tax credits that are available based on income.
Table 2. Average Cost of Second-Lowest Cost Silver Plan for Individuals and Families in Three North Carolina Counties, 2019, 2020, & 2021 (NC)
| County | Premium Cost per Month for Average Second-Lowest Cost Silver Plan | |||||||
| Individual1 | Family1 | |||||||
| 2019 | 2020 | 2021 | % Change 2020-21 | 2019 | 2020 | 2021 | % Change 2020-21 | |
| Guilford | $561 | $384 | $345 | -10% | $2,189 | $1,498 | $1,347 | -10% |
| Mecklenburg | $440 | $336 | $348 | 4% | $1,715 | $1,309 | $1,356 | 4% |
| Wake | $385 | $342 | $349 | 2% | $1,539 | $1,387 | $1,367 | -1% |
Median plan deductibles at all metal levels are decreasing for 2021 coverage. Table 3 compares these deductibles for plans from 2019 to 2021.
Table 3. Median Individual Deductible by Plan Metal Level, 2019, 2020, and 2021 (NC)
| Metal Level | Median Individual Medical Deductible | |||
| 2019 | 2020 | 2021 | % Change 2020-21 | |
| Bronze | $7,000 | $7,500 | $7,321 | -2% |
| Silver (standard) | $6,247 | $5,441 | $4,822 | -11% |
| Silver (73% AV CSR) | $3,714 | $4,144 | $3,320 | -20% |
| Silver (87% AV CSR) | $642 | $736 | $724 | -2% |
| Silver (94% AV CSR) | $208 | $205 | $5 | -97% |
| Gold | $2,343 | $2,800 | $2,293 | -18% |
| Platinum | Not Applicable | Not Applicable | Not Applicable | Not Applicable |
AV = Actuarial Value; CSR = Cost Sharing Reduction. Actuarial value refers to the percent of health care costs a plan will pay for. Cost Sharing Reductions refer to discounts that lower the amount individuals pay for deductibles, copayments, and coinsurance.
The majority of people who receive Advance Premium Tax Credits for purchase of plans on the Exchange pay a net monthly premium of $50 or less. Table 4 shows the range of net premiums paid by people who receive APTCs and those who don’t. The majority of people who do not receive APTCs pay between $150 and $500 per month.
Table 4. Net Monthly Premium Within Chosen Metal Level Based on Eligibility for Advance Premium Tax Credits, 2019, 2020, & 2021 (NC)
| Net Premium | Percent Paying Net Premium per Month | |||||||
| Eligible for APTC | Not Eligible for APTC | |||||||
| 2019 | 2020 | 2021 | % Change 2020-21 | 2019 | 2020 | 2021 | % Change 2020-21 | |
| <=$10 | 53% | 51% | 30% | -20% | 0% | 0% | 0% | 0% |
| >$10-$25 | 8% | 11% | 16% | 5% | 0% | 0% | 0% | 0% |
| >$25-$50 | 10% | 10% | 15% | 5% | 0% | 0% | 0% | 0% |
| >$50-$75 | 8% | 8% | 10% | 3% | 0% | 0% | 0% | 0% |
| >$75-$150 | 12% | 12% | 17% | 5% | 0% | 1% | 1% | 0% |
| >$150-$300 | 8% | 7% | 9% | 2% | 13% | 23% | 23% | 0% |
| >$300-$500 | 2% | 1% | 2% | 0% | 33% | 32% | 33% | 1% |
| >$500 | 0% | 0% | 0% | 0% | 53% | 44% | 43% | -1% |
APTC = Advance Premium Tax Credit
Funding for services that help people navigate their health plan options continues to be limited nationwide, with an 84% decrease from 2016 funding levels [2]. For North Carolina, CMS provided $3.4 million for navigation services in 2016, and that has been reduced by 79% to $700,000 in 2020.
This year’s open enrollment period occurs as the COVID-19 pandemic has led to job losses across the country. Recent analysis by Mark Holmes, published in the November-December issue of the NCMJ, estimates that 257,000 North Carolinians have lost health insurance due to job loss during the pandemic. The state’s total uninsured rate is estimated to be 14.3%, up from the 2019 uninsured rate of 11.3%. It remains to be seen whether these newly uninsured individuals may seek coverage through the ACA Exchange.
[1] Plan costs are average premiums for a 27-year-old individual and a family of four defined as two 40-year-old parents with two 0-14-year-old children.
[2] Legal Aid of North Carolina, Inc. is the only organization providing navigation services in the state. These services include outreach, education, and enrollment services. https://www.kff.org/private-insurance/issue-brief/data-note-further-reductions-in-navigator-funding-for-federal-marketplace-states/