Subscriber continuity in health insurance plans: factors associated with re-enrollment and coverage changes

Aims: This study examined the extent to which Marketplace health insurance subscribers re-enroll a second year. Among re-enrollees, we sought to examine movement to more and less generous insurance plans (based on actuarial value), and the extent to which adverse selection, adverse retention, and aging in place are evident from re-enrollment choices made.Methods: Re-enrollment from 2015 to 2016 and 2016 to 2017 and movement to more and less generous insurance plans was examined using enrollment and insurance claims data from two US Federally-facilitated Marketplace insurance carriers operating in the state of New Mexico for 2015-2017. Insurance plans are assigned to metal levels based on estimated plan actuarial value: Bronze (60%), Silver (70%), and Gold (80%). Odds ratios (ORs) and 95% confidence intervals (OR CI) were estimated using logistic regressions for subscribers with base-year healthcare utilization. ORs were estimated for (1) re-enrollment in the year following the base year, and (2) movement to a higher or lower actuarial value plan.Results: Approximately 50% of subscribers re-enrolled with the same carrier for 2016 and 60% for 2017. Being enrolled 12 months was the strongest predictor for second year re-enrollment. Older individuals were more likely to re-enroll. Re-enrollment was lower for the insurance carrier with higher second year premium changes. Chronic condition utilization characteristics were positively associated with re-enrollment. Approximately 12% of Bronze subscribers moved to Silver or Gold, and had higher utilization after re-enrollment. Among Silver subscribers, 6% moved to Gold and 6% to Bronze. Approximately 37% of Gold subscribers moved to Silver or Bronze.Discussion: Re-enrollment was similar to published non-group insurance rates. Adverse selection and aging in place were observed. Evidence was weak for adverse retention. Some coverage change choices were rational, while others suggest subscribers may have difficulty making insurance choice decisions.