Findings across 50 states and DC

2016 exchange market remains in flux: Plan type trends

PLAN OFFERINGS1

McKinsey Center for U.S. Health System Reform

MARKET VIEWCounting plans at county level

METHODOLOGYThe above findings are based on publicly available, approved 2016 individual market exchange rates as displayed on exchanges for all states and DC, compiled within the McKinsey Exchange Offering Database. Plan types reported here were taken directly from exchange websites and Summary of Benefits and Coverage (SBC) documents. Independent assessment of plan types was not part of the analysis presented in this document.

HMO: a health maintenance organization is a plan typically centered around a primary care physician who acts as 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; however, it generallydoes 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, but out-of-network services often require a higher copayment.

POS: a point-of-service plan is 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.

MARKET VIEWPrices at county level

MARKET VIEWCounting plans at a county level

1. Plan is defined as a health insurance offering in which an individual can enroll, offered by a carrier2. Competitively priced defined as being priced within 10% of the gross premium lowest-price plan in the same county and metal tier3. Gross premium meaning premiums calculated before tax credits4. FL, IN, NJ, NY, and SC have no carriers offering a PPO but at least one carrier offering a POS plan; VT and NM have no carriers offering PPO and POS plans.

Note: These analyses are across all plan offerings and do not reflect enrollment

healthcare.mckinsey.com/reform

McKinsey Center for U.S. Health System Reform

HMO and EPO plans that were competitively priced in 2015 are increasing premiums more modestly than competitively priced PPO and POS plans.

PPOs are becoming less common across silver exchange plans.

MARKET VIEWCounting plans at county level

Most carrier types are shifting towards HMOs and EPOs, most notably the national carriers. Medicaid carriers continue to offer predominantly HMO plans.

% SEEING INCREASE IN PLANS BY METAL TIER

Median 2015 to 2016 percent change in gross3 premium across all competitively priced2 plans

Percentage of silver plan offerings by plan type across years

BRONZE SILVER GOLD PLATINUM

KEY: HMO & EPOPPO & POS

CATASTROPHIC

Percent change in number of PPO offerings by county from 2015 to 2016

9

2014

26

59

6

35

750

8

47

10

35

8

51

14

27

8

17

2015

14

63

6

12

2016

2014 2015 2016

31

952

8

34

851

7

43

13

35

9

2014 2015 2016

877

3

12

2014

858

22

28

2015

14

44

14

50

2016

25

7

18

23

2014

1064

3

22

2015

966

3

29

2016

12

55

4

45

2014

542

8

56

2015

36

6

42

2016

46

8

4

2

55

2014

25

18

51

2015

34

11

63

2016

23

10

44

2

86

2014

14

82

2015

18

70

20168

22

CO-OP NATIONAL BLUE REGIONAL/LOCAL PROVIDER MEDICAID

Percentage of silver plan offerings by plan type across carrier types and years

KEY: HMO EPO PPO POS

KEY: HMO EPO PPO POS

KEY:-100%

-99% to -75%-75% to -50%-50% to -25%-25% to 0%0% to 25%25% to 50%50% to 75%

75%+No PPOs in 2015 and 2016

Competitively priced silver plans2

31% of the PPOs that withdrew in 2016 were priced >35% above the lowest gross silver premium in the same county; 21% of the refiled PPO plans were in that same price category.

As of 1.04.2016

All silver plans

21 8 13

1714

13 12

19 10

40

As HMO and EPO plans are becoming increasingly prevalent, the number of PPO offerings is decreasing; this varies by state. Seven states4 will not have any carriers offering PPO plans on-exchange.