PNS78 DIFFERENCES BETWEEN ENROLLEES OF INDIVIDUAL VERSUS SMALL GROUP OFF-EXCHANGE HEALTH PLANS UNDER THE AFFORDABLE CARE ACT

Abstract

The Patient Protection and Affordable Care Act (ACA) allows individuals and small businesses to purchase private health insurance through competitive marketplaces. Off-exchange plans are ACA compliant, but sold outside the marketplace, and little is known about the characteristics of enrollees of these plans. This analysis examines member severity and annual cost of enrollees of individual versus small group plans. This study used a national sample of claims data for 2.0m individual and 1.7m small group members enrolled in an off-exchange plan in 2017. Cross sectional descriptive analyses were conducted to examine differences between enrollees of individual and small group plans. Individual plan members were much more likely to enroll in a Silver plan (62% versus 36% small group) while small group members were most likely to enroll in a Gold plan (41% versus 7% individual). Average risk scores were higher among individual members by 20% Silver, 27% Gold, and 66% Platinum. Average PMPM costs were also higher in individual members by >2x Platinum, 36% Gold, and 8% Silver. Cost-risk ratios were also higher in individual members by 23% Platinum and 7% Gold, but were 10% lower in the largest group of Silver members. Risk scores were similar among individual and small group Bronze members, but costs were 33% lower in individual enrollees, and mean cost-risk ratios were 23% lower. Overall, the cost-risk ratio was 7% lower in individual plan members compared to those in small group plans. In general, off-exchange members enrolled in individual plans were less costly (relative to risk score) than those enrolled in small group plans. These findings provide insight into the enrollment patterns and relative risk and cost of individual and small group off-exchange enrollees. The results provide new insights into which individual plan members are more likely to be profitable for off-exchange health plans.