An Analysis of Profitability for the Individual and Small Group Health Insurance Markets in 2024
July 1, 2025
Health plans across the country submitted their Supplemental Health Care Exhibits (SHCE) on April 1, 2025, as part of the 2024 National Association of Insurance Commissioners’ (NAIC) annual financial statements. The SHCE contains financial performance metrics, membership, and preliminary Affordable Care Act’s (ACA’s) Medical Loss Ratios (MLRs) – at the state level. Subscribers to Mark Farrah Associates’ (MFA's) Health Coverage Portal or the SHCE & MLR Data have access to this important information. In this Business Strategy Report, MFA presents key findings from its latest analysis of the SHCE data, focusing specifically on performance within the Individual and Small Group comprehensive health/medical insurance segments, as plans in these two segments face the added constraint of a standard (minimum) MLR.
Segment Profitability Overview
Beginning with the Individual segment, year-end 2024 membership was nearly 21.5 million members, up from 17.7 million members in 2023. This is primarily due to former Medicaid recipients moving into heavily subsidized Marketplace/ACA Exchange plans. Individual segment for health insurance companies remained profitable in 2024, with a $2.4 billion underwriting gain, or 1.7% of adjusted premium revenues for the Individual market.
While the declines for Small Group membership continued in 2024, down year-over-year by 7.0% to 7.9 million, the segment remained more profitable per member than the Large Group segment. Small Group plans reported an underwriting gain of $256.9 million for 2024, down from $1.3 billion in 2023 and a decline of 80.2%. In comparison, Large Group profitability declined 114.8%, to a loss of $253 million, for the same period.
Individual Comprehensive Segment
After reporting an underwriting (profit) margin of 3.0% in 2023, the Individual segment reported a gain of $2.4 billion in 2024, a modest 1.7% of adjusted premium revenue. The segment also experienced enrollment growth of 21.0%, expanding to 21.5 million members for 2024. Adjusted Premiums Earned PMPM (per member per month**) increased 1.8% to a segment average of $559 PMPM. The average incurred medical claims expense of $493 PMPM for 2024 was an increase of 2.3% on a PMPM basis from 2023. While focusing on segment leaders for this analysis, MFA looked at four-year trends in membership, medical claims incurred PMPM, adjusted premium PMPM, and SHCE-reported MLR**.
Segment leadership is based on 2024 SHCE-reported membership by company. After nearly doubling enrollment from 2022 to 2023 market leader, Centene’s, Individual enrollment, increased an additional 12.9% in 2024 to over 4.1 million members. UnitedHealth reported the largest increase; it gained over 1.1 million members, and this moved the company into the top tier carriers. Oscar Health, with a gain of 708,303 Individual members, also joined the leading carriers this year. The entire Individual segment grew by over 3.7 million members in 2024.
Health insurers reported a 30.2% increase in total spending on medical costs for the 2024 Individual segment. In contrast, the average incurred claims PMPM increased from $482 in 2023 to $493 in 2024, a 2.3% change. For the top Individual carriers, CVS Health experienced the largest increase, rising 16.2% to $444 PMPM in 2024, up from $382 PMPM in 2023. Health Care Service Corporation (HCSC – which operates Blues plans in five states) continues to have the highest incurred claims PMPM at $530, among the top five Individual health insurers.
Nationwide average Individual Premiums PMPM grew by 1.8% in 2024 to a peak of $559 PMPM. UnitedHealth vaulted into the top five plans for 2024 with the lowest premium PMPM among them. Both HCSC and Oscar lowered their average premium PMPM, with declines of -12.4% and -0.7%, respectively.
The Medical Loss Ratio (MLR) illustrates the relationship between premiums and medical costs. For the segment leaders, four of the five leading carriers had increased weighted average MLRs in 2024. Centene experienced a large decrease in their 2024 average MLR due in part to significant risk corridor revenue (from previous years) that was recognized in 2024, leading to an abnormally low MLR.
Please Note: MFA is reporting all data as filed with the NAIC in the annual SHCE. We are not adjusting the data to account for differences in the number of reporting plans between 2021 and 2024. For this analysis, MFA has calculated a weighted average MLR** based upon adjusted premiums.
Small Group Comprehensive Segment
Overall, the Small Group segment profitability remains strong; though the segment continues to lose membership - down another 7.0% for 2024 with small businesses opting to self-insure, through level-funded plans; switch to Individual Coverage Health Reimbursement Arrangements (ICHRAs); or drop health insurance coverage for their employees. Focusing on the segment leaders for this analysis, MFA looked at four-year trends in membership, claims incurred PMPM, adjusted premium PMPM and segment leaders’ SHCE-reported MLR.
The five Small Group segment leaders, based on membership, remained unchanged since 2021. These carriers are UnitedHealth and four Blue Cross Blue Shield (BCBS) entities: HCSC, Elevance, BCBS of Michigan (BCBS MI) and CareFirst. BCBS MI did move ahead of CareFirst in 2024. UnitedHealth experienced the largest decrease in membership of the top plans, reporting a 11.1% drop in enrollment. Overall, segment membership is down over 1.6 million members since 2021.
Average claims incurred PMPM increased from $495 in 2023 to $537 in 2024, an 8.4% increase. CareFirst reported the lowest increase in claims incurred PMPM among the segment leaders with a 4.3% year-over-year change. BCBS MI reported the lowest claims PMPM at $473, with a 10.7% change for the period. UnitedHealth reported the highest percentage increase among the top plans at 13.3%.
Average adjusted premium PMPM for the segment rose from $580 in 2023 to $615 in 2024, a 6.1% increase. Since 2021, and despite significant changes in the last four years, Small Group PMPM premiums have increased an average of 6.9%, year-over-year. All five segment leaders reported increases in premiums PMPM for 2024. BCBS MI continues to report the lowest premiums PMPM among its top five peers.
The ACA requires health insurers in the Individual and Small Group markets to spend at least 80% of their premium revenues on clinical care and quality improvements. Overall, the leading plans have been able to better manage MLRs within the Small Group segment as compared to larger challenges within the Individual segment. For 2024, the most notable among the segment leaders was CareFirst’s 79.1% and BCBS MI’s 92.1% weighted average MLRs, with premiums PMPM of $612 and $519, respectively.
Conclusion
For both the Individual and Small Group comprehensive medical coverage segments, underwriting gains have continued to fluctuate; however, both remain profitable. Premium PMPM growth for the Individual segment has stabilized with low single digit changes since pre-2020, which is good news for consumers. On average both segments did experience higher MLRs between 2023 and 2024. The growth of enrollment in the Individual segment that began in 2020 continued through 2024, with Small Group enrollment continuing to fall. Available data for the first quarter of 2025 shows this growth trend continuing. Mark Farrah Associates will have more to report on 2025 enrollment and profitability trends in the coming months.
* PMPM– Per Member Per Month is an amount divided by member months; one member enrolled for 12 months equals 12 member months.
** Weighted Average MLR – For analysis purposes, Mark Farrah Associates calculated average preliminary MLRs weighted on the adjusted premiums for each company by segment. The MLRs used in the calculation are average ratios based upon 2021 – 2024 as reported in the NAIC’s Supplemental Health Care Exhibit.
About the SCHE Data
The data used in this Business Strategy Report was obtained from Mark Farrah Associates' Health Coverage Portal TM using Supplemental Health Care Exhibit (SHCE) data, for medical (non-specialty) plans, as reported in the NAIC Annual Financial Statement. CA managed care plans do not file the SHCE. CHIP enrollment is reported under government business in the SHCE. Each year, MFA updates its products with the latest SHCE data. Additionally, MFA maintains financial data as well as enrollment and market share for the health insurance industry in the subscription-based Health Coverage Portal TM.
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About Mark Farrah Associates (MFA)
Mark Farrah Associates (MFA) is a leading data aggregator and publisher providing health plan market data and analysis tools for the healthcare industry. Our product portfolio includes Health Coverage Portal™, County Health Coverage™, 5500 Employer Health plus, Medicare Business Online™, Medicare Benefits Analyzer™, and Health Plans USA™. For more information about these products, refer to the informational videos and brochures available under the Our Products section of the website or call 724-338-4100.
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