2021 Premium Changes on ACA Exchanges and the Impact of COVID-19 on Rates

Insurers planning to offer health plans on the Affordable Care Act (ACA) marketplaces must submit filings to state or federal regulators detailing their plan offerings and justifying their premiums for the upcoming year. Rates are finalized in early fall (October 15, 2020) ahead of the annual open enrollment period, set to begin on November 1, 2020.

This year, insurers set premiums for 2021 amid the coronavirus pandemic, which has created considerable uncertainty as to what health costs, utilization and enrollment will look like next year. In 2020, many insurers have provided premium relief and/or voluntarily waived cost-sharing for COVID-19 treatment for their members due to excessive profits and low medical loss ratios during the pandemic. In our earlier look at preliminary rate filings in 10 states, we found that while overall proposed rate increases for 2021 appeared modest, most insurers were taking a “wait-and-see” approach, electing to hold off on factoring the pandemic into their premiums for next year until they had more predictability and claims experience.

Now that 2021 rates are being finalized, this brief summarizes the most current premium rate filings in all 50 states and the District of Columbia. We reviewed rate filings for an overall average premium increase across all plans on the individual market, with a focus on the effect of the pandemic on rate changes. We find that the majority of rate changes for 2021 are still moderate, with increases or decrease of a few percentage points. Proposed rate changes range from a -42.0% decrease to a 25.6% increase, though half fall between a 3.5% decrease and 4.6% increase (Table 1). Insurer and state level rates are shown in Table 2.

Table 1: Overall Rate Change and COVID-19 Load Among ACA Marketplace Plans
Overall Rate Change Impact of COVID-19 on Rates*
25th Percentile -3.5% 0.0%
Median 1.1% 0.0%
75th Percentile 4.6% 2.0%
*Among plans that specified an impact of COVID-19. Many filings included COVID-loads that were redacted.
SOURCE: KFF analysis of insurer rate filings to state regulators.

118 of the 273 (43%) filings specified the effect of COVID-19 on their rates for next year. Among these insurers, the impact of COVID-19 on 2021 premiums ranges from a 3.4% decrease to an 8.4% increase, with half of insurers falling between no impact (0.0%) and 2.0% increases (Table 1). Many insurers used similar language to describe their approach to the pandemic, noting that it would put both upward and downward pressure on health costs in 2021 (see examples below).

The most common factors that insurers cited as driving up health costs in 2021 were the continued cost of COVID-19 testing, the potential for widespread vaccination, the rebounding of medical services delayed from 2020, and morbidity from deferred or foregone care. At the same time, many insurers expect health care utilization to remain lower than usual next year as people continue to observe social distancing measures and avoid routine care, especially in absence of a vaccine or in the event of future waves of the virus. At least 53 insurers included a COVID-19 impact of 0% on their premiums because they did not have enough information to confidently alter their premiums or estimated that these factors would offset one another. 29 of the 273 filings (11%) did not mention COVID-19 at all in their rate filings.

The range of COVID-19 loads included in 2021 rate filings partly reflects differences in issuers’ assumptions about the course of the pandemic and individual behavior next year. Below are a handful of representative explanations that insurers provided to justify any impact that COVID-19 had on their overall 2021 rate filings. These examples provide a glimpse of the different expectations that insurers have regarding the availability and distribution of a vaccine, the extent to which pent-up demand for health care services will rebound in 2021, and various other factors.

Pent-up demand and morbidity adjustments. Many insurers expect that health costs will increase in 2021 due to pent-up demand following deferred care, direct costs related to COVID-19 testing and treatment, and vaccination costs, assuming a vaccine will be ready and available to the general public next year. Some insurers also anticipate increased morbidity resulting from deferred care and the impact of that deferred care on chronic conditions, as well as from the impact of the economic downturn on individuals’ health and insurance status.

Fidelis (New York) – 8.4% COVID-load

“Premium rates have been adjusted 8.4% to reflect the estimated impact of the COVID-19 pandemic and secondary effects on the cost to provide healthcare coverage in 2021. The morbidity adjustment reflects the anticipated combined impact of COVID-19-related cost drivers on healthcare utilization and intensity in 2021, including:

  1. Direct cost of acute COVID-19 treatment, testing, and vaccination.
  2. Pent-up demand following social distancing “lockdown” measures
  3. Morbidity impact of economic disruption in the form of job terminations, leading to enrollment shifts from employer sponsored coverage to individual ACA and from individual ACA to Medicaid or uninsured
  4. Morbidity impact of lasting population health changes precipitated by the pandemic, including healthcare complications following recovery from severe cases of COVID-19, and worsened health outcomes due to deferred or avoided preventive care and maintenance care for chronic conditions during social distancing lockdown periods”

Vaccination costs. Some insurers specify loads for a likely vaccine. For instance, MVP Health Care in Vermont loaded an additional 1.0% to premiums in preparation for covering one dose of a COVID-19 vaccination (priced at $75) for 80% of their enrollees. (MVP also loaded another 0.3% for deferred services.)  Other insurers refrained from factoring in COVID-19 vaccine costs, citing a lack of credible information.

MVP (Vermont) – 1.3% COVID-load

“MVP is assuming that a vaccine to prevent the novel coronavirus (COVID-19) will be tested and widely available in 2021. To account for the costs an immunization would add to claim cost, MVP is assuming that an immunization would be covered in full at the cost of $75 per dose. MVP is also assuming that 80% of the population would obtain the vaccine (based on an analysis by Wakely Consulting), which corresponds to a PMPM claim cost of $5.00 PMPM. This factor is increasing the experience period allowed claim cost by 1.0%.”

No adjustments to premiums from COVID-19. Many insurers refrained from specifying any COVID-19 rate impact. Of those that did, several insurers said they would not adjust their rates, citing uncertainty about how the pandemic will affect costs next year. Others expect the upward and downward effects on costs resulting from the pandemic will have a net impact of zero. In some states such as Connecticut, insurers did not apply adjustments due to COVID-19 under the direction of state regulators.

CareSource Indiana, Inc (Indiana) – 0% COVID-load

At the time of this rate filing submission, we acknowledge there is substantial uncertainty regarding the impact of the COVID-19 pandemic on setting premium rates, including whether the pandemic will increase or decrease costs in 2021. Due to this uncertainty, we have chosen not to make adjustment to the 2021 premium rates.”

Expected decreases in premium costs due to COVID-19. Though less common, a few insurers expect that circumstances surrounding COVID-19 will have a net negative effect on their costs.

Maine Community Health Options (Maine) – -1.2% COVID-load

“An adjustment of -1.2% was applied to the 2019 experience to reflect the estimated impact of the COVID-19 pandemic. The adjustment was developed with consideration to the following key drivers of cost impacts:

  1. We have assumed a reduction in total claims experience in 2021 of 1.5% due to deferred and avoided care that will result from a second wave of infections, likely to coincide with the winter flu season.
  2.  We have assumed an increase in claim costs of 0.34% to cover the costs of continuing testing for COVID-19.
  3. No adjustment has been made to account for additional costs related to a potential vaccine. Not enough credible information exists to allow the development of estimates related to the cost and availability of a vaccine.”

Most premium changes on the ACA marketplaces will be modest heading into 2021, even with the uncertainty surrounding the pandemic. Most individual market insurers that specify the impact of the pandemic on their 2021 premiums are loading an extra couple percentage points onto the premium (with the median COVID-19 factor being 1.9%). Thus far during the pandemic, individual market insurers have remained profitable and loss ratios have been low, on average, so large premium increases would have been hard to justify. That said, the range of assumptions that insurers have made about vaccine costs and availability, enrollee utilization, and general morbidity demonstrate just how much uncertainty remains about the state of the pandemic heading into next year.

Data were collected from health insurer rate filings submitted to state regulators. Most rate information is available in the for of a SERFF filings (System for Election rate and Form Filing) that includes a base rate and other factors that build up to an individual rate. This analysis only includes rate filings that were made public on or before October 15, 2020.
Table 2: Rate Change and COVID-19 Load Among ACA Marketplace Plans, By State and Insurer
State/Insurer Rate Change Impact of COVID-19 on Rates
    Blue Cross Blue Shield of Alabama 4.90% Unknown
    Bright Health Insurance Company 25.60% Unknown
    Moda Assurance Company 0.11% No mention
    Premera Blue Cross Blue Shield of Alaska -4.15% No mention
     Blue Cross and Blue Shield of Arizona 1.82% Unknown
     Bright Health Company of Arizona 9.33% Unknown
     Cigna HealthCare of Arizona 1.87% No mention
     Health Net of Arizona -0.80% Unknown
     Oscar Health Plan -6.75% Unknown
    Celtic Insurance Company 4.91% Unknown
    QCA Health Plan 3.05% Unknown
    QualChoice Health and Life Insurance 3.00% Unknown
    USAble Mutual Insurance 2.90% 0.00%
    Oscar Insurance Company New entrant Unknown
    HMO Partners Health Advantage New entrant 0.00%
    Blue Cross of California (Anthem) 6.00% No mention
    Blue Shield of California -2.40% Unknown
    Chinese Community Health Plan -1.30% Unknown
    Health Net 3.40% 1.20%
    Kaiser Permanente 1.00% Unknown
    LA Care Health Plan -4.60% No mention
    Molina Healthcare -3.80% 0.90%
    Oscar Health Plan of California 7.60% Unknown
    Sharp Health Plan -0.50% 0.00%
    Valley Health Plan 9.00% Unknown
    Western Health Advantage -2.60% Unknown
    Anthem (HMO Colorado Inc.) 0.30% Unknown
    Bright Health Insurance Company -5.50% Unknown
    Cigna Health and Life Insurance Company 3.00% 1.00%
    Denver Health Medical Plans -4.60% 6.40%
    Friday Health Plan -5.10% No mention
    Kaiser Foundation Health Plan of Colorado -1.50% 0.00%
    Oscar Health Plan -4.20% Unknown
    Rocky Mountain HMO -10.00% 0.00%
    Anthem Health Plans 1.90% 0.00%**
    Connecticare -0.10% 0.00%**
    Highmark Blue Cross Blue Shield -1.00% Unknown
District of Columbia
    CareFirst HMO (Blue Choice) 0.10% Unknown
    CareFirst PPO 1.00% Unknown
    Kaiser Foundation Health Plan -1.97% Unknown
    AvMed -3.30% 2.00%
    Blue Cross and Blue Shield of Florida 3.70% 2.00%
    Bright Health Insurance Company of Florida 3.70% 2.00%
    Celtic Insurance Company 3.90% 2.00%
    Cigna Health And Life Insurance Company -1.40% 2.00%
    Florida Health Care Plan, Inc. -0.10% 2.00%
    Health First Commercial Plans 4.80% 2.00%
    Health Options, Inc 2.50% 2.00%
    Molina Healthcare of Florida -1.80% 2.00%
    Oscar Insurance Company of Florida 2.90% 2.00%
    Alliant Health Plans 18.34% Unknown
    Ambetter of Peach State 7.43% 0.00%
    Anthem Blue Cross and Blue Shield 10.10% 3.00%
    CareSource Georgia -10.29% Unknown
    Kaiser Foundation Health Plan of Georgia -19.02% 2.50%
    Oscar Health Plan of Georgia 2.11% Unknown
    Kaiser Foundation Health Plan -1.06% No mention
    Hawaii Medical Service Association -3.10% No mention
    Blue Cross of Idaho Health Service -3.50% No mention
    Mountain Health Cooperative 2.00% 0.00%
    Pacific Source Health Plans -7.10% 0.00%
    Regence Blue Shield of Idaho -1.30% No mention
    SelectHealth 5.90% No mention
    Blue Cross Blue Shield of Illinois -0.12% Unknown
    Celtic Insurance Company 0.26% 0.00%
    Cigna HealthCare of Illinois, Inc. 0.89% 1.00%
    Health Alliance Medical Plans, Inc. 0.00% Unknown
    Quartz Health Benefit Plans Corporation -10.05% Unknown
    Anthem Insurance Companies, Inc. -0.30% No mention
    CareSource Indiana, Inc. 4.30% 0.00%
    Celtic Insurance Company -0.55% 1.90%
    Medica Insurance Company 2.45% Unknown
    Wellmark Health Plan of Iowa, Inc. -42.04% Unknown
    Oscar Health Plan of Iowa New entrant Unknown
    Blue Cross and Blue Shield of Kansas 0.70% Unknown
    Cigna Health and Life Insurance 9.96% 1.00%
    Medica Insurance Company 7.78% 5.00%
    Oscar Insurance Company -7.86% Unknown
    Sunflower State Health Plan 4.00% Unknown
    Anthem Health Plans of Kentucky 5.69% 2.60%
    Care Source Kentucky 4.00% Redacted
    CHRISTUS Health Plan Louisiana 7.44% Unknown
    HMO Louisiana 9.50% Unknown
    Louisiana Health Service & Indemnity 7.95% Unknown
    Vantage Health Plan 2.64% Unknown
    Anthem Health Plans of Maine -12.50% 2.50%
    Harvard Pilgrim Health Plan -13.00% 0.00%
    Maine Community Health Options -13.70% -1.20%
    CareFirst Blue Choice -11.90% 0.00%
    CareFirst CFMI -17.10% 0.00%
    CareFirst GHMS -17.10% 0.00%
    Kaiser Foundation Health Plan -11.00% 0.00%
    Optimum Choice (UnitedHealthcare) New Entrant Unknown
    Blue Cross and Blue Shield of Massachusetts HMO Blue 6.17% 0.00%
    Fallon Community Health Plan 3.52% 0.00%
    Harvard Pilgrim Health Care 7.25% No mention
    Health New England 2.23% Unknown
    Tufts Associated HMO 9.03% Unknown
    Tufts Health Public Plans 12.27% 0.00%
    UnitedHealthcare Insurance Company 15.10% Unknown
    BMC HealthNet Unknown Unknown
    AllWays Health Partners Unknown Unknown
    Blue Care Network of Michigan 2.50% No mention
    Blue Cross Blue Shield of Michigan 1.70% No mention
    Oscar Insurance Company 6.00% 4.00%
    McLaren Health Plan Community -2.00% 0.00%
    Meridian Health Plan of Michigan -5.60% 2.00%
    Molina Healthcare of Michigan 0.40% Unknown
    Physicians Health Plan 3.10% 3.00%
    Priority Health Insurance -0.13% 0.00%
    Total Health Care USA -0.39% 0.00%
    Blue Plus HMO 4.21% Unknown
    Group Health Plan Inc 0.67% Unknown
    Medica Insurance Company 2.42% Unknown
    Preferred One Insurance Company 1.05% Unknown
    Quartz Health Plan New entrant Unknown
    UCare MN 1.60% 0.00%
    Ambetter of Magnolia Inc. 11.19% Unknown
    Molina Healthcare of Mississippi, Inc -2.67% Unknown
    Blue Cross and Blue Shield Kansas City New entrant No mention
    Celtic Insurance Company 9.10% Unknown
    Cigna Health & Life Insurance Company 1.40% Unknown
    Cox Health Systems Insurance Company 13.60% No mention
    Healthy Alliance Life Insurance Company -1.44% Unknown
    Medica Insurance Company -7.50% Unknown
    Oscar Insurance Company 6.40% Unknown
    SSM Health Insurance Company -0.49% Unknown
    HCSC (Blue Cross Blue Shield of Montana) 0.00% No mention
    Montana Health Co-Op 0.68% No mention
    Pacific Source Health Plans 5.00% No mention
    Medica Insurance Company 5.36% Unknown
    Bright Health Unknown Unknown
    Friday Health Plans of Nevada New entrant Unknown
    Health Plan of Nevada Incorporated 5.00% Unknown
    HMO Colorado INC D/BA HMO Nevada 3.90% Unknown
    Hometown Health Plan -5.00% Unknown
    Hometown Health Providers Insurance -1.60% Unknown
    Rocky Mountain Hospital and Medical Service 11.00% Unknown
    SelectHealth New entrant Unknown
    Sierra Health and Life Insurance Company 9.80% Unknown
    SilverSummit Health Plan 2.30% Unknown
New Hampshire*
    Celtic Insurance Company -4.50% 0.00%
    Harvard Pilgrim Health Care -13.54% 0.00%
    Matthew Thornton Health Plan (Anthem BCBS) -15.12% Unknown
New Jersey*
    AmeriHealth HMO 11.22% 1.00%
    AmeriHealth Insurance Company of New Jersey 3.82% 1.00%
    Horizon Healthcare Services -1.43% Unknown
    Oscar Garden State Insurance 10.59% Unknown
New Mexico
    Molina Healthcare of New Mexico -0.40% Unknown
    Blue Cross Blue Shield of New Mexico (HCSC) -7.61% Unknown
    True Health -1.40% No mention
    Friday Health Plans New Entrant Unknown
    Western Sky Ambetter New Entrant Unknown
New York
    Capital District Physicians Health Plan 4.30% 0.00%
    Health Insurance Plan of Greater New York (Emblem) 3.80% 2.00%
    Excellus -0.20% 0.50%
    Fidelis (NY Quality Healthcare Corp) 1.60% 8.40%
    Healthfirst PHSP, Inc. -2.50% 0.00%
    Healthnow New York -2.80% 2.00%
    HealthPlus HP 1.00% 5.15%
    IHBC -5.30% 0.00%
    MetroPlus 5.00% 2.10%
    MVP Health Plan 3.80% 1.60%
    Oscar 4.90% 7.40%
    UnitedHealthcare of New York 4.80% 1.00%
North Carolina*
    Ambetter of North Carolina 3.90% 0.00%
    BCBS of NC 4.10% Unknown
    Bright Health Company of North Carolina 1.98% Unknown
    CIGNA HealthCare of North Carolina -10.50% No mention
    Oscar Health Plan of NC New entrant Unknown
    UnitedHealthCare of Wisconsin, Inc. New entrant Unknown
North Dakota*
    Blue Cross Blue Shield of North Dakota 4.42% No mention
    Medica Health Plans 13.16% Unknown
    Sanford Health Plan 20.33% Unknown
    AultCare Insurance Company -4.99% 2.00%
    Buckeye Community Health Plan 1.35% 0.00%
    CareSource 9.30% 0.00%
    Community Insurance Company -3.22% Unknown
    Medical Health Insuring Corp. of Ohio 2.30% 0.00%
    Molina Healthcare of Ohio -0.80% 0.00%
    Oscar Buckeye State Insurance Corporation -0.90% 0.30%
    Oscar Insurance Corporation of Ohio 6.70% -0.10%
    Paramount Insurance Company 8.94% 0.00%
    SummaCare 2.50% 0.00%
    Blue Cross Blue Shield of Oklahoma -0.05% Unknown
    Bright Health Insurance Company 1.84% Unknown
    CommunityCare HMO Inc. -24.40% Unknown
    Medica Insurance Company -5.27% Unknown
    Oscar Insurance Company New entrant Unknown
    UnitedHealthcare New entrant Unknown
    Bridgespan Health Company 11.10% 0.00%
    Kaiser Foundation Health Plan of the Northwest -3.51% 0.00%
    Moda 4.70% 0.90%
    PacificSource Health Plans 4.20% 0.00%
    Providence Health Plan 1.40% 1.00%
    Regence Blue Cross Blue Shield 2.50% 0.00%
    Capital Advantage Assurance Company -14.43% 0.00%
    Highmark Inc. -0.67% 2.50%
    Highmark Benefits Group -3.96% 2.50%
    Highmark Coverage Advantage 3.12% 2.50%
    Geisinger Health Plan -11.28% 0.00%
    Geisinger Quality Options -13.57% 0.00%
    Keystone Health Plan East -3.91% 1.00%
    QCC Insurance Company -3.88% 1.00%
    UPMC Health Options 1.28% 0.00%
    PA Health and Wellness -6.60% 1.40%
    Oscar Health Plan of PA 6.68% 2.10%
Rhode Island*
    Blue Cross Blue Shield of Rhode Island 4.96% Unknown
    Neighborhood Health Plan of Rhode Island 5.60% 2.50%
South Carolina
    Absolute Total Care, Inc 8.50% 0.00%
    Blue Cross and Blue Shield of South Carolina -1.85% Unknown
    Bright Health Company of South Carolina -0.05% Unknown
    Molina Healthcare of South Carolina -3.60% Unknown
South Dakota*
    Avera Health Plans, Inc. 4.29% Unknown
    Sanford Health Plan 0.24% 1.02%
    Celtic Insurance Company -2.50% 2.00%
    Cigna Health and Life Insurance Company -6.01% 1.00%
    Blue Cross Blue Shield of Tennessee 9.82% 1.80%
    Bright Health Insurance Company of Tennessee 3.01% -2.00%
    Oscar Healthcare 9.90% -0.50%
    United healthcare Insurance Company New entrant 0.00%
    Blue Cross Blue Shield of Texas 2.97% Unknown
    Celtic Insurance Company 11.69% 0.00%
    CHRISTUS Health Plan 3.16% Unknown
    Community Health Choice, Inc. 8.65% Unknown
    Molina Healthcare of Texas, Inc. 5.30% Unknown
    Oscar Insurance Company 9.91% Unknown
    Sendero Health Plans, Inc. 8.81% 0.00%
    SHA FirstCare Health Plans 2.81% -3.40%
    Cigna Health and Life Insurance Company 2.20% 1.00%
    Molina Healthcare of Utah -1.63% 0.00%
    Regence BlueCross BlueShield of Utah -7.31% 0.00%
    SelectHealth -1.60% No mention
    University of Utah Health Insurance Plans 3.00% Unknown
    Blue Cross Blue Shield of Vermont 4.20% 0.00%
    MVP Health Care 2.70% 1.30%
    CareFirst BlueChoice, -9.70% 0.00%
    Cigna Health and Life Insurance Company -11.70% 1.00%
    Group Hospitalization and Medical Services 5.20% 0.00%
    HealthKeepers -7.70% Unknown
    Kaiser Foundation Health Plan of the Mid-Atlantic States -13.00% 0.00%
    Optima Health Insurance Company -2.00% Unknown
    Optima Health Plan – HMO 7.74% 0.90%
    Optimum Choice, Inc. New entrant Unknown
    Oscar Insurance Company 2.20% 0.20%
    Piedmont Community Healthcare HMO, Inc. -3.40% Unknown
    Bridgespan Health Comapny -0.17% Unknown
    Community Health Network of Washington New entrant No mention
    Coordinated Care Corporation 0.93% Unknown
    Kaiser Foundation Health Plan of the Northwest -1.87% No mention
    Kaiser Foundation Health Plan of Washington -4.86% Unknown
    Lifewise Health Plan of Washington -2.06% Unknown
    Molina Healthcare of Washington Inc. -3.19% 3.20%
    Pacific Source Health Plans 7.63% Unknown
    Premera Blue Cross -8.67% Unknown
    Providence Health Plan 3.18% No mention
    Regence Blue Cross Blue Shield of Oregon -4.08% Unknown
    Regence BlueShield -5.35% Unknown
    UnitedHealthcare of Oregon New entrant 2.50%
West Virginia*
    CareSource West Virginia Co. 6.26% Unknown
    Highmark Blue Cross Blue Shield West Virginia 4.34% Unknown
    The Health Plan of West Virginia, Inc. 3.67% No mention
    Aspirus Arise Health Plan of Wisconsin, Inc -12.89% -2.20%
    Children’s Community Health Plan -7.47% Unknown
    Common Ground Healthcare Cooperative -6.25% Unknown
    Dean Health Plan -2.27% Unknown
    Group Health Cooperative of South Central Wisconsin -6.81% Unknown
    HealthPartners Insurance Company -3.40% Unknown
    Medica Community Health Plan 5.87% Unknown
    MercyCare HMO, Inc. -1.39% Unknown
    Molina Healthcare of Wisconsin, Inc. -3.50% Unknown
    Network Health Plan 3.34% Unknown
    Blue Cross Blue Shield of Wyoming -10.2% Unknown
*Indicates that the rates shown for the state have not been finalized.
**Connecticut Insurance Department instructed insurers to include a COVID-impact of 0%
NOTE: ‘Unknown’ includes plans where the rate change or impact of COVID-19 on rates was redacted or otherwise unavailable for some reason.
SOURCE: KFF analysis of insurer rate filings to state regulators.

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