The Affordable Care Act (ACA), in section 1402, requires insurers who participate in the marketplaces established under that act to offer CSRs to eligible people who purchase silver plans through the marketplaces. CBO views that requirement as establishing an entitlement for thoseeligible.
To qualify for CSRs, people must purchase a plan through a marketplace and generally have income between 100 percent and 250 percent of the federal poverty guidelines (also known as the federal poverty level, or FPL). The size of the subsidy varies with income.
CSRs reduce deductibles and other out-of-pocket expenses like copayments. For example, in 2017, by CBOs estimates, the average deductible for a single policyholder (for medical and drug expenses combined) with a silver plan varied according to income in the followingway:
The head of the Centers for Medicare and Medicaid Services would not say Thursday if the Trump administration is considering setting limits on how insurers that sell Obamacare plans structure subsidies for their customers.
"I'm not going to comment on the agency's deliberations," CMS Administrator Seema Verma said when asked by the Washington Examiner about rumors that had circulated about the issue. When pressed about whether any conversations had occurred, Verma said, "I'm just going to leave it at that."
NOTE: I've modified the headline to clarify that it's CSR reimbursements which are dead, not the actual CSR subsidies. Those eligible for CSR assistance will still receive it from the insurance carriers..it's just that the carriers aren't/won't be reimbursed for doing so. In response, they've jacked up the premium rates on others to cover their losses.
As I understand it, this means that unless a standalone bill of some sort passes, there will be no significant legislative changes to the ACA exchange/individual market status for the 2019 Open Enrollment Period at the federal level...and that's extremely unlikely to happen this year.
A few days ago I warned Congressional Democrats that while I agree that appropriating CSR reimbursement payments at this point would be a net negative move thanks to the clever Silver Load/Silver Switcharoo workaround developed last year, there's one possible cloud surrounding that silver lining, so to speak: What if the Trump Administration were to attempt to put the kibosh on Silver Loading altogether?
I don't know the legality of such a move, mind you, but It has been thrown around the rumor mill of late, so I figured I should remind them to keep that possibility in mind.
Last year Covered CA's 1/31 total hit 1,556,676 (or just under 15,000 enrollees higher). In 2016 they had their all-time high of 1,575,340, so they'd have to have tacked on about 34,000 more over the final 10 days of Open Enrollment this year in order to beat their record.
According to our CSR Load Load spreadsheet, Hawaii is supposed to be one of the 20-odd states using the full "Silver Switcharoo" strategy. It also has a single Rating Area, and only has two carriers (Kaiser and HMSA) participating in the individual market (on or off-exchange) anyway, making it a pretty easy state to run a full apples-to-apples year over year comparison.
Kaiser is offering a total of 11 plans on the ACA exchange (3 Bronze, 3 Silver, 3 Gold and 2 Platinum), while HMSA lists 10 (2 Bronze, 3 Silver, 3 Gold and 2 Platinum). I couldn't run a perfect comparison to 2017 since each carrier changed a couple of their offerings, but it's pretty darned close.
Until today, I operated under the assumption that my home state of Michigan was among the 18 states which took the "Silver Load" approach to dealing with the Cost Sharing Reduction (CSR) cut-off by the Trump administration. Reviewing the SERFF rate filings of the various carriers participating in the individual market, it looked like most of them were loading the CSR cost onto both on and off-exchange Silver plans. I didn't check every single carrier, but that seemed to be the trend, so I filed the state under "Silver Load".
I'm signing up for a plan off the exchange with Priority Health in Michigan. ON-Exchange, the plan is $365 a month, but off exchange (directly from their website), the price is $300 per month. I don't qualify for a subsidy, but it's still cheaper than my 2017 plan with BCBSM. That was the Multi-State Plan in Region 7 with Dental and Vision.
To summarize (again), this is where someone whose household income is too high for them to qualify for ACA tax credits (400% of the Federal Poverty Line) chooses an ACA-compliant off-exchange Silver plan instead, which is either identical or nearly identical to the same on-exchange policy in every way except that the additional CSR load hasn't been tacked onto it.
Here's a perfect example found by Louise Norris...ironically, this is via Priority Health here in Michigan, which (until today) I thought was a "Silver Load" state, not "Silver Switcharoo". I'll have to do some more research to be sure, but it sounds like at least one MI carrier (Priority) is going full Switch:
I've written a lot in recent weeks about the real world impact that Trump cutting off CSR reimbursement payments will have on 2018 premiums in various states depending on how they choose to load the additional cost. As I've noted repeatedly, there are basically four strategies they can take: They can assume the payments will continue; they can spread the load across all ACA-compliant policies; they can load all of the cost onto Silver plans only; or they can load all of the cost onto on-exchange Silver plans only, while also creating (if one doesn't exist) a special off-exchange-only Silver plan as a backstop for unsubsidized Silver enrollees (aka the "Silver Switcharoo").
Covered California Keeps Premiums Stable by Adding Cost-Sharing Reduction Surcharge Only to Silver Plans to Limit Consumer Impact
In the absence of a federal commitment to continue funding cost-sharing reduction (CSR) reimbursements through the upcoming year, Covered California health insurance companies will add a surcharge to Silver-tier products in 2018.
However, because the surcharge will only be applied to Silver-tier plans, nearly four out of five consumers will see their premiums stay the same or decrease, since the amount of financial help they receive will also rise. Those who do not get financial help will not have to pay a surcharge.
Financial help means that in 2018, nearly 60 percent of subsidy-eligible enrollees will have access to Silver coverage for less than $100 per month — the same as it was in 2017 — and 74 percent can purchase Bronze coverage for less than $10 per month.
California and individual markets across the nation still need a clear commitment that the federal government will continue to make CSR payments to promote lower premiums, save taxpayer money and ensure health insurance companies participate.
I've spent the past two weeks posting about almost nothing besides the Graham-Cassidy debacle, so haven't had a chance to keep on top of the approved 2018 rate changes as I usually do. Fortunately, Louise Norris of healthinsurance.org has stayed on the rate hike job, and reports the final numbers out of Washington State:
2018 rates: 24% approved rate increase, due in large part to federal uncertainty — and higher backup rates will be implemented if CSR funding is cut mid-year
Insurers in Washington had to file rates and plans for 2018 by June 7, 2017. On June 8, Kreidler’s office published a summary of what had been filed (rate filings are available here, and that page will show final rate changes for the individual market once they’re approved), and publicized the filing details on June 19. The average proposed rate increase in Washington, before any subsidies are applied, was 22.3 percent.
As I noted last month with my "Silver Switcharoo" explainer, for carriers which remain in the ACA exchanges next year, there's three potential scenarios which could happen (well, four, actually, if you include "Congress manages to sneak a full CSR appropriation bill into law just under the wire", although that seems pretty unlikely at this point given the time crunch and the fact that it'd need a 2/3 majority in both the House and Senate to avoid being vetoed by Trump anyway):