UPDATE: North Dakota, Vermont, Colorado and Arkansas officially jump on board the #SilverSwitcharoo Express!

I had actually already written about Vermont doing this back in March, but seeing how it was one of only 2 states (+DC) which didn't allow Cost Sharing Reduction (CSR) costs to be loaded onto premiums at all this year, I figured I should mention it here as well. Once again:

  • 20 states went the full #SilverSwitcharoo route (the best option, since it maximizes tax credits for those eligible for them while minimizing the number of unsubsidized enrollees who get hit with the extra CSR load);
  • 16 states went with partial #SilverLoading (the second best option: Subsidized enrollees get bonus assistance, though not as much as in Switch states; more unsubsidized enrollees take the hit, but they aren't hit quite as hard);
  • 6 states went with "Broad Loading", the worst option because everyone gets hit with at least part of the CSR load except for subsidized Silver enrollees;
  • 6 states took a "Mixed" strategy...which is to say, no particular strategy whatsover. The state insurance dept. left it up to each carrier to decide how to handle the CSR issue, and ended up with a hodge podge of the other three
  • 3 states (well, 2 states + DC, anyway) didn't allow CSR costs to be loaded at all. Their carriers have to eat the loss, which makes little sense, but what're ya gonna do?

In 2019, however, assuming CMS Administrator Seema Verma doesn't do the stupidest thing she possibly could (i.e., attempting to force every carrier to "Broad Load" their CSR costs), it looks like most, if not all states will be jumping on the "Silver Switcharoo" bandwagon. Besides Vermont, it now looks like the other "No Load" holdout, North Dakota, will do so as well next year. As Louise Norris reports:

Looking ahead to 2019: North Dakota insurers will add CSR cost to silver plans

For 2018, North Dakota was one of only two states where insurers were not allowed to add the cost of cost-sharing reductions (CSR) to premiums, despite the fact that the Trump Administration stopped reimbursing insurers for the cost of CSR. In most states, the cost of CSR was added to silver plans, either across the full on- and off-exchange market, or only to the on-exchange market. As a result, Medica left the exchange in North Dakota, rather than absorb the cost of CSR without being able to add it to premiums.

Consumers are best protected when insurers add the cost of CSR to on-exchange silver plans, and allow people the option of purchasing off-exchange silver plans that don’t have the cost of CSR added to the premiums. This allows premium subsidies to grow for everyone who gets premium subsidies, including people who purchase non-silver on-exchange plans that don’t have the cost of CSR added. For people who want a silver plan and who qualify for premium subsidies, the subsidies grow to cover the added cost of CSR. And for people who want silver plans but who don’t qualify for premium subsidies, the off-exchange silver plans are a good option, as they don’t have the added premium cost to cover CSR.

About a third of the states took that option for 2018, and North Dakota is joining them for 2019. The state’s rate filing instructions direct insurers to add the cost of CSR to on-exchange silver plans, and to the identical silver plans that are sold off-exchange. But they’re also instructing insurers to file “corresponding” silver plans that will only be sold off-exchange, and that don’t have the cost of CSR added to premiums.

This is the "Switch" part of the Silver Switcharoo: People enrolled in Silver plans who are looking to avoid getting hit with the CSR load will be specifically encouraged to look for special off-exchange Silver plans which will likely be virtually identical in every way to their on-exchange equivalent except for the premium price. In many states, the carrier is even labelling them as such ("Silver Saver" vs. "Silver Saver Off-Exchange", etc.), though I'm not sure how North Dakota or Vermont carriers intend on handling that part of it.

In addition, both Norris and I have also recently reported that Colorado, which is one of the "Broad Load" states this year, is also upgrading to full #SilverSwitcharoo status in 2019. That means the 2019 scoreboard now looks more like this:

  • 23 states: Silver Switcharoo
  • 16 states: Silver Load
  • 5 states: Broad Load
  • 6 states: Mixed Load
  • DC only: No Load

It's worth noting, however, that DC is kind of a special case anyway: In DC, anyone earning up to 200% of the Federal Poverty Line are eligible for Medicaid to begin with (much higher than the 138% FPL cut-off in most states), which lops off the vast bulk of those who would otherwise qualify for CSR assistance anyway. Furthermore, CSR help is much more generous from 100-200% FPL than it is from 200-250%, which means even the few people who do receive CSR assistance only get a small amount. This means that in DC, the CSR load is so nominal that it doesn't really impact premium rates by more than perhaps 1% or so either way.

UPDATE: Louise Norris is kicking butt--she just confirmed that, like Colorado, another state which Silver Loaded this year is "upgrading" to full #SilverSwitcharoo status in 2019: Arkansas:

Looking ahead to 2019: Cost of CSR being added to on-exchange silver plans

Rate filings for Arkansas insurers must be submitted by July 23, 2018. Insurers have been instructed to add the cost of cost-sharing reductions (CSR) to on-exchange (on-marketplace) silver plan rates:

“any premium amounts due to lack of federal Cost Sharing Reduction funding should be attributed to the silver level variants for Marketplace filings.”

For 2018, Celtic’s rate filing clearly stated that the cost of CSR was added to all silver plan rates, both on- and off-exchange. Confining the cost of CSR to only marketplace plan rates is the most beneficial approach for consumers. It results in larger premium subsidies for everyone who qualifies for premium subsidies, since the subsidies are based on the cost of silver plans (specifically, the second-lowest-cost silver plan in each area). People who want a silver plan are protected from the added cost of CSR either by shopping on-exchange if they qualify for a premium subsidy (since the subsidy will grow to compensate for the added cost of CSR) or off-exchange if they don’t qualify for premium subsidies (since the off-exchange silver plans won’t have the cost of CSR added to their premiums).

That makes it:

  • 24 states: Silver Switcharoo
  • 15 states: Silver Load
  • 5 states: Broad Load
  • 6 states: Mixed Load
  • DC only: No Load

I wouldn't be at all surprised to see at least 3 dozen states go full Silver Switch with the rest at least going Silver Load by the time the dust settles this fall.