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DEEP DIVE 📚

A few weeks ago we pulled apart the last two AEP cycles of plan terminations.

One thing kept showing up. Plan terminations hit PPOs hard, and it hit rural markets hard.

That got us wondering whether that was a one-year story or something structural.

So we went back to county-level enrollment data and pulled in the USDA's Rural-Urban Continuum Codes, which classify every county in the country by population size and by whether it touches a metro area. Six years of it, December 2019 through August 2026.

What we found changes the question. It's not really about population size. It's about whether a county is adjacent to a metro area at all. Two counties can be the same size, but the one that touches a metro market looks structurally different from the one that doesn't, on nearly every measure we could pull.

Here's what that looks like, piece by piece.

Penetration has climbed everywhere since 2019.

What's notable is the shape of the climb. Counties not adjacent to a metro area have consistently trailed both metro counties and adjacent nonmetro counties by double digits, and that gap hasn't meaningfully closed.

More striking: growth in the non-adjacent group has essentially stalled since early 2024. It sat at 29.8% in February 2024 and 31.1% in August 2026, two and a half years to move a point and a half. Metro and adjacent-nonmetro counties have plateaued too, but from a higher base, and with less room left to run.

Choice has expanded everywhere too, which sounds like good news until you look at the gap.

Metro counties now average 42.2 shoppable plans. Non-adjacent counties average 16.4.

HMO share has grown steadily in the least-connected markets, from 32.1% in 2019 to 42.8% today.

Carriers are building HMO networks into places that used to be PPO-only territory.

But the gap to metro hasn't closed, because metro moved too. And metro's line isn't flat along the way. HMO share in the biggest metro markets drifted down through 2024, bottoming near 66%, before recovering to 68.8% over the past year and a half.

Non-adjacent counties still lean far more heavily on PPO than anywhere else in the country, and PPO is exactly the product type that's proven most exposed to the current disruption.

This is where it gets concrete. Combining outright plan terminations with service area reductions, non-adjacent counties absorbed 12.6% of their enrollment in disruption heading into the 2025 AEP, and 17.3% heading into 2026.

Metro counties saw 6.2% and 8.5% over the same two cycles. Adjacent nonmetro sits in the middle, as it does everywhere else in this piece.

Most of this is driven by Service Area Reductions.

Outright terminations are fairly even across all three groups, 6.8% in metro versus 8.3% in non-adjacent counties.

Service area reductions are where the real gap lives: 1.7% in metro versus 9.0% in non-adjacent counties, more than five times the rate. Carriers generally aren't killing these plans outright. They're pulling the map back so the plan no longer covers the county. The product survives. The county doesn't.

Non-commissionable enrollment has roughly doubled everywhere between December 2025 and August 2026, and non-adjacent counties have carried a consistently higher share of their enrollment in these plans throughout, 9.8% versus 6.1% in metro at the end of 2025, 19.8% versus 13.5% in metro by August 2026.

If MA is getting harder to navigate in these counties, where does that leave people?

Original Medicare enrollment gives an answer. It declined steadily for years in every group as MA absorbed more of the market, bottomed out in early-to-mid 2024, and has ticked back up since, non-adjacent counties included. Those counties still have 59.9% of their eligible population in Original Medicare, by far the highest share in the country, and that share is no longer shrinking.

This points to the following: a real share of people leaving MA in these counties are landing back on the traditional program, most plausibly with a Medicare Supplement policy and a standalone Part D plan.

Counties that aren't adjacent to a metro area already have less MA penetration than the rest of the country, and that gap has stopped closing. They have a quarter of the plan choices that metro counties have, and that gap keeps widening. They lean more heavily on PPO, the product type most exposed to the current disruption. They're absorbing disruption at roughly double the metro rate, driven mainly by carriers pulling service areas back rather than killing plans outright. And they carry a disproportionate share of enrollment sitting in plans that have gone non-commissionable.

And we know where some of that pressure goes. Original Medicare enrollment in these counties stopped shrinking right as everything else here turns, and it's climbing again for the first time in years, most likely beneficiaries opting out of MA entirely for the traditional program with a Medigap policy and standalone Part D.

For distributors with books concentrated in these counties, that's not a future risk. It's the current environment, and it's already costing MA enrollment outright, not just shifting it between plans.

If you’re ready, here are some ways we can help you: