- COVID-related enrollment window continues through August 15, 2021.
- Rate changes for 2021: Decrease for Molina, increase for Ambetter (and a slight decrease for BCBSMS, available only outside the exchange). Broad loading the cost of CSR across all plans continues in 2021, and Molina expanded to offer coverage statewide.
- Short-term health plans can be sold in Mississippi with initial plan terms up to 364 days.
- Nearly all Mississippi exchange enrollees receive premium subsidies.
- Almost 111,000 people enrolled for 2021, for a third straight year of increasing enrollment and a record-high enrollment total (in most other states, enrollment grew in 2021 but is still lower than it was in 2016).
Mississippi exchange overview
Mississippi uses the federally run exchange for individual market plans, so residents who buy their own health insurance enroll through HealthCare.gov.
The state initially ran its own SHOP exchange for small businesses, dubbed One Mississippi, but had switched to the federally-run SHOP exchange by 2018 (and the federally-run SHOP exchange had switched to a direct-to-carrier enrollment model by that point).
Blue Cross Blue Shield of Mississippi has a strong presence in the Mississippi individual market, but they do not participate in the exchange. Magnolia/Ambetter/Centene offers plans statewide in the Mississippi exchange, and became the only insurer offering exchange coverage after Humana exited at the end of 2017. But Molina joined the exchange in 19 counties for 2020, giving residents in those counties a choice of two health plans. As of 2021, Molina expanded their coverage area statewide, so all marketplace enrollees in Mississippi can choose from among plans offered by both insurers.
Highest percentage of subsidy-eligible enrollees in the country
Almost all of Mississippi’s exchange enrollees — 97 percent — received premium subsidies in 2020 (that’s the highest rate in the nation; the nationwide average was 86 percent; this is unsurprising, since subsidy eligibility is based on income, and Mississippi has the lowest average household income in the US).
When can I enroll in health insurance in Mississippi?
Although open enrollment for 2021 health plans ended in mid-December 2020, the ongoing COVID pandemic has changed the rules regarding access to health insurance. Normally, plans can only be purchased (on-exchange or directly from an insurer) during open enrollment or a special enrollment period triggered by a qualifying event. But a six-month COVID-related enrollment window is available in 2021.
During this window, which has been extended through August 15, 2021, Mississippi residents can enroll in a plan through the marketplace regardless of whether they have a qualifying event. This is an opportunity for uninsured residents to sign up for coverage, and also for people who already have a plan to pick a different one if it better fits their needs. This is especially important given the enhanced premium subsidies that are available as a result of the American Rescue Plan. The additional subsidies are retroactive to January 1 for people who are already enrolled in a plan through HealthCare.gov, and will show up on HealthCare.gov as of April 1, 2021.
After August 15, Mississippi residents will need a qualifying event in order to enroll in a health plan before the start of open enrollment. Open enrollment will begin again on November 1, 2021, for coverage effective January 1, 2022.
2021: Molina decreased premiums and expanded statewide; Ambetter increased premiums; Broad loading continues for the cost of CSR
In 2021, Mississippi continues to be one of three states (the others are Indiana and West Virginia) where the cost of cost-sharing reductions is spread across plans at all metal levels (broad loading), instead of being added only to silver plan rates (silver loading). Although the rate filing memo for Molina’s 2021 plans in Mississippi indicated that the cost of CSR was going to be added only to silver plan rates, the Mississippi Insurance Department confirmed that was an error (Molina uses silver loading in other states, but not in Mississippi and that part of the filing had not been adjusted for Mississippi). When broad loading is used, enrollees are less likely to see the sort of bargains on non-silver plans that are available in areas where silver loading is used.
There continue to be two insurers offering plans in Mississippi’s exchange for 2021, and Molina, which offered plans in just 19 Mississippi counties in 2020, expanded its coverage area to the entire state for 2021. So all Mississippi residents have access to plans from both insurers for 2021. Mississippi’s exchange insurers have implemented the following average rate changes for 2021 (in both cases, the final rates are lower than the insurers initially proposed):
- Molina: 3.5% average decrease. Molina’s plans are available statewide for 2021
- Ambetter/Magnolia: 6.4% average increase (filing notes that Ambetter expected 100 percent of its members to enroll on-exchange, indicating that their plans are not marketed off-exchange).
Blue Cross Blue Shield of Mississippi implemented a slight average rate decrease (0.45%) for its individual market plans, all of which are sold only outside the exchange.
For perspective, here’s a look at how premiums have changed in prior years:
- 2020: Average rate decrease of 1.1%, plus a new insurer. Magnolia/Ambetter offered plans statewide in the Mississippi exchange in 2020. According to the federal rate review site, Ambetter decreased their average prices by 1.1 percent for 2020. And in 19 Mississippi counties, Molina joined the exchange for 2020 (as noted above, Molina expanded statewide for 2021).
- 2019: Average rate increase of 0.27%. Ambetter/Magnolia was the only insurer offering plans in Mississippi’s exchange for 2019. Average premiums for Ambetter plans were mostly unchanged for 2019, with an average rate increase of just 0.27%.
- 2018: Average increase of 47.3%, due to elimination of federal CSR funding. For 2018, Magnolia/Ambetter initially proposed average rate increases of 18 percent for their standard individual market plans, and 21.4 percent for their plans that include adult dental and vision coverage. The rate filing was heavily redacted, but it did note that the proposed rates were based on the assumption that the federal government would continue to fund cost-sharing reductions (CSR), and that larger premium increases would be necessary if CSR funding were to end.Ultimately, the Trump administration did eliminate federal funding for CSR in October 2017, but Ambetter/Magnolia had already filed revised rates over the summer with the assumption that CSR funding would end. The revised rate proposal, which was approved by regulators, called for an average increase of 47.3 percent — more than two and a half times as large as the originally proposed increase.The dramatic increase in the revised rates is because CSR is a larger expense in Mississippi than it is in other states. 86 percent of Mississippi exchange enrollees were receiving cost-sharing reductions at that point — the highest percentage in the nation, and well above the national average of 53 percent. Eligible enrollees have continued to receive CSR benefits, but the federal government is no longer reimbursing insurers for providing that benefit. So insurers in nearly every state added the cost of CSR to their premiums starting in 2018. In most states, the cost of CSR was added only to silver plans, which is beneficial for most enrollees, since premium subsidies are based on the cost of a silver plan, and larger silver plan premiums mean larger subsidies.
But in Mississippi, Ambetter/Magnolia’s revised rate filing noted that the cost of CSR was added to the premiums of all ACA-compliant plans, including those sold outside the exchange. Only a few other states took this “broad load” approach in 2018 (Colorado, Delaware, Indiana, and West Virginia). Premium subsidies were much larger in Mississippi for 2018 than they were for 2017, since premiums increased by an average of 47.3 percent. But since plans at all metal levels are sharing the burden of the cost of CSR, the free or ultra-low-cost bronze plan premiums (after subsidies) that became available in some areas of the country were not available in Mississippi (and Mississippi has continued to use the “broad load” strategy ever since).
- 2017: Average increase of about 16%. The approved rate increases were 43% for Humana (about 13,000 enrollees) and 7% for Magnolia/Ambetter (about 40,000 exchange enrollees).
- 2016: Modest increase for UHC, decreases for Magnolia and Humana. Premium changes were generally quite modest in Mississippi for 2016. According to the Mississippi Business Journal, average rate changes for 2016 were:
- Magnolia Health/Ambetter: average decrease of 2.9% (18,000 enrollees as of November 1, 2015)
- Humana: average decrease of 0.2% (16,915 enrollees as of November 1)
- UnitedHealthCare: average increase of 6.6% (26,000 enrollees as of November 1)
Once all of the plan selections for 2016 had been finalized, 90 percent of Mississippi exchange enrollees qualified for premium subsidies. Their average pre-subsidy premium was $388 per month (a little lower than the $396/month average across all states that use Healthcare.gov), and their average after-subsidy premium was $91/month (the average after-subsidy premium across all Healthcare.gov states was $106/month that year).
- 2015: Average decrease of 19%. In 2015, according to an analysis published by The Commonwealth Fund, average premiums in Mississippi were 19% lower than they had been in 2014. The weighted analysis looked at premium amounts, differences in premiums between urban/suburban/rural areas within states, and insurer participation. A similar analysis from PricewaterhouseCoopers found an average rate decrease of 9.3 percent from 2014 to 2015 — still a significant rate decrease, but not as substantial as the Commonwealth Fund’s result.
- 2014: Fifth-highest premiums among states using HealthCare.gov. For 2014, individual market health insurance premiums were essentially actuaries’ best guesses, as there was no market experience on which to base the rates (prior to 2014, individual market coverage was medically underwritten, so there was a seismic shift in 2014 in terms of claims experience). In 2014, Mississippi’s pre-subsidy average premium was $438/month — the fifth-highest among the 36 states that used Healthcare.gov.
Mississippi exchange enrollment: 2014-2021
Mississippi exchange enrollment grew from 2014 through 2016, then dropped sharply in 2017. It dropped again in 2018, but has increased since then, reaching a record high in 2021, with nearly 111,000 people enrolling during the open enrollment period that ended in December 2020. The extended COVID-related enrollment window in 2021 will likely result in a further increase in enrollment throughout 2021. Here’s a summary of how enrollment has changed over the years in Mississippi’s exchange:
- 2014: 61,494 people enrolled (most enrolled in a plan from Humana, which was the only insurer in all but four counties)
- 2015: 104,538 people enrolled
- 2016: 108,672 people enrolled (effectuated enrollment stood at 77,747 by March 31, 2016 — that’s an attrition rate of 28 percent, which was more than double the national average rate of attrition during the first quarter).
- 2017: 88,483 people enrolled. President Trump took office less than two weeks before the end of open enrollment that year, and immediately eliminated an advertising campaign that had been designed to direct people to HealthCare.gov to enroll in coverage. Across all states that use HealthCare.gov, enrollment dropped by about 5 percent in 2017, but in Mississippi, it dropped by almost 19 percent.
- 2018: 83,649 people enrolled
- 2019: 88,542 people enrolled. In most states that use HealthCare.gov, enrollment continued to decline in 2019, but that was not the case in Mississippi. Among the 39 states that use HealthCare.gov, only six saw their enrollment grow in 2019, and only Oklahoma had a higher percentage increase in enrollment than Mississippi.
- 2020: 98,892 people enrolled. This was nearly a 12 percent increase over 2019’s enrollment, which was the largest percentage increase in the country. That could be partially due to the fact that enrollment had dropped so precipitously in 2017 (more so than the rest of the country), and also partially due to a new insurer joining the exchange in some areas of the state.
- 2021: 110,966 people enrolled, reaching a record high for the state’s marketplace.
Insurer participation in Mississippi’s exchange: 2014-2020
In 2011 and 2012 — back when Mississippi was considering creating its own State-run exchange — Blue Cross Blue Shield of Mississippi (which had more than 80 percent of the market share in Mississippi) had told Insurance Commissioner Mike Chaney that they would participate in the exchange. But due to conflicts among the state’s leadership, HHS rejected Mississippi’s exchange application (more details below), and at that point, BCBS of Mississippi pulled out.
That left Humana and Magnolia Health Plan as the only two carriers for 2014. But leading up to the federally-run exchange’s fall 2013 debut, Mississippi had a problem. The two carriers had selected the counties in which they wanted to operate, and 36 of the state’s 82 counties had no participating carriers at all. Humana ultimately decided to go ahead and offer coverage state-wide in 2014, but only four of the state’s counties had plans available from both carriers in 2014.
In 2014 and 2015, plans were available in Mississippi’s exchange from Humana and Magnolia Health Plan (Ambetter/Centene).
For 2016, UnitedHealthcare joined them, bringing the total number of insurers on the individual exchange to three. United was the only carrier in the Mississippi exchange that offered coverage in all 82 counties in the state in 2016. Residents in every county in the state had at least two carriers from which to choose that year, and 32 counties had plans available from all three carriers.
But for 2017, United left the state (as was the case in most states where United had been offering exchange plans), and Mississippi’s exchange was back to just Humana and Magnolia (Mississippi Insurance Commissioner Mike Chaney had reported in August 2016 that a third health insurer had proposed joining the exchange state-wide, but had been rejected by HHS due to “lack of an adequate network and specialists in each county”).
Although Humana exited the exchanges in several states at the end of 2016, they stayed in Mississippi for 2017. There were 32 counties where both insurers offered plans that year, and 50 counties where the only carrier offering plans in the exchange was Magnolia (Magnolia had expanded to offer coverage statewide as of 2017).
Humana’s decision to remain in the exchange was short-lived, however, as they announced in February 2017 that they would no longer offer individual market plans in any state after 2017. But Centene (Magnolia/Ambetter in Mississippi) continued to offer coverage. In April 2017, Centene announced that they were planning to remain in the exchanges in 2018 in the states where they were already participating, which was in contrast to quite a few other insurers’ decisions to exit the exchanges in various states at the end of 2017. According to Centene Chairman and CEO, Michael Neidorff, “Centene’s exchange experience continues to be favorable, and we are achieving margins at the higher end of our targeted range.”
So as of 2018, Magnolia/Ambetter was the only insurer offering plans in Mississippi’s exchange, and that continued to be the case in 2019.
For 2020, however, Molina joined the exchange in 19 counties. And for 2021, Molina expanded their coverage area to include the whole state, giving all Mississippi residents a choice of two marketplace insurers.
King v. Burwell: Chaney had a plan in case SCOTUS ruling had been different
In June 2015, the Supreme Court ruled that subsidies are legal in every state, regardless of whether the exchange is run by the state or the federal government. That was great news for Mississippi residents, insurers, and healthcare providers; 98 percent of the people enrolled in private plans through the Mississippi exchange in 2019 were receiving premium subsidies.
The Mississippi Business Journal reported that Insurance Commissioner Mike Chaney had a contingency plan to protect subsidies for state residents if the Supreme Court had eliminated them. Rather than creating a state-run exchange, “it would entail funneling federal money through the existing Mississippi Comprehensive Health Insurance Risk Pool Association to private insurers.” But the Journal noted that the plan would have been contingent upon approval from the Governor, Lt. Governor, and the Speaker of the House (Chaney had worked to establish a state-run exchange back in 2011 – 2012, but was foiled by the Governor and the legislature).
Politico also reported that the state had a back-up plan, but they explained that Chaney wanted “Mississippi to use existing private health insurance exchanges to enroll people, qualifying for subsidies while avoiding the federal government’s technology.”
The Mississippi Comprehensive Health Insurance Risk Pool is the state-run high-risk pool that pre-dates the ACA. Private health insurance exchanges are not run by the government — rather, they’re set up by health insurance carriers, brokers and benefits managers to provide a platform for people to shop for coverage. Mississippi’s Insurance Department did not return phone calls to clear up the discrepancy, but it did appear that in early 2015, the state was working on a back-up plan that could have been put in place if the Supreme Court had eliminated subsidies. In many states, there were no such contingency plans, and enrollees would have had few options but to terminate their coverage if subsidies had been eliminated.
The University of Mississippi Medical Center got the majority of the Navigator grants that were awarded by the federal government in August 2013 to fund enrollment efforts in Mississippi for 2014. Of $1.1 million that Mississippi received, $832,000 went to UMMC. Oak Hill Baptist Church got the remaining Navigator funding that year, but by 2015, Oak Hill had become the primary Navigator grant recipient in Mississippi, receiving $547,867 to assist with enrollment efforts for 2016 (another $415,224 was awarded to the University of Southern Mississippi in September 2015).
Navigator funding has been drastically reduced under the Trump Administration, however. In 2018, total Navigator grants in Mississippi came to less than $188,000. My Brother’s Keeper received $100,000 and Oak Hill got about $88,000. But navigator funding increased in Mississippi in 2019: My Brother’s Keeper got another $100,000, but Oak Hill got nearly $200,000.
Exchange creation battle in Mississippi
State Commissioner of Insurance Mike Chaney clashed with two governors as to what form a health insurance exchange should take in Mississippi. Chaney, former Gov. Phil Bryant, and former Gov. Haley Barbour are all Republicans and on record as opposing the Affordable Care Act. However, Chaney consistently maintained that the state would be better off running its own exchange.
Chaney pushed hard for a state-run exchange. In 2011, he announced that the Mississippi Comprehensive Health Insurance Risk Pool Association would operate an exchange. The Risk Pool Association developed a plan in which the exchange would be developed in four phases, with work outsourced.
Early exchange planning was carried out by the board of directors of the Risk Pool Association and an advisory board appointed by Chaney. The Risk Pool Association, the advisory board, and the insurance department continued working throughout 2012, and in November, Chaney notified the U.S. Department of Health and Human Services (HHS) that Mississippi intended to implement a state-run exchange. However, Bryant told HHS in December 2012 that Chaney had overstepped his authority.
It was also in 2012 that anti-ACA influences from outside Mississippi (including the Koch Brothers and the Cato Institute) began pressuring Cheney to give up his push for a state-run exchange. But One Mississippi, the state-run exchange that Cheney created, opened in October 2012, a year before the ACA-sanctioned exchanges nationwide. One Mississippi didn’t have any premium subsidies (those wouldn’t be available until the first ACA open enrollment period began in October 2013), but it did have coverage for sale. The task at that point switched to obtaining federal approval to have One Mississippi be the state’s official ACA exchange.
But ultimately, Governor Bryant’s opposition to the exchange was its downfall. In February 2013, HHS rejected Mississippi’s exchange blueprint, telling Chaney that it simply wouldn’t work without the Governor’s support. The exchange would have needed to work with the Mississippi Medicaid program — overseen by a Bryant appointee — and there were too many concerns that Bryant would be able to derail the exchange via funding or hiring decisions. The federal government said at the time that they “didn’t feel that [they] should get involved in a battle between two elected state officials.”
Mississippi was the only state whose exchange blueprint was rejected by the federal government, and in February 2013, One Mississippi shut down. The federal government ran the individual exchange in Mississippi from the start, but One Mississippi opened back up as the state-run SHOP exchange in the spring of 2014, offering health insurance options for small businesses. By 2018, however, Mississippi had opted to return to the federally-run exchange for small businesses. And even the federally-run small business exchange had switched to a direct-to-carrier enrollment model (instead of an enrollment portal on HealthCare.gov) by that point, as small business enrollment in the exchange had been quite low throughout most of the country.
Several factors constrain marketplace enrollment in the Magnolia State. Political opposition to the Affordable Care Act is very strong, many residents are distrustful of government assistance, and outreach efforts are limited. In a state with a 22 percent poverty rate, many people find premiums too expensive — even with subsidies factored in. And the Medicaid coverage gap is significant in Mississippi: Kaiser Family Foundation estimates that 100,000 Mississippi residents are in the coverage gap — ineligible for Medicaid (because the state has refused federal funding to expand Medicaid) and ineligible for subsidies in the exchange because their income is under the poverty level.
Mississippi health insurance exchange links
State Exchange Profile: Mississippi
The Henry J. Kaiser Family Foundation overview of Mississippi’s progress toward creating a state health insurance exchange.
Health Help Mississippi
Assists people insured by private health plans, Medicaid, or other plans in resolving problems pertaining to their health coverage; assists uninsured residents with access to care.
(877) 314-3843 / firstname.lastname@example.org
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.