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Missouri health insurance marketplace: history and news of the state’s exchange

Blue KC returned to marketplace in western Missouri for 2021; Medica, Anthem expand coverage areas; COVID-related enrollment window continues through August 15

Roaring River State Park, near Cassville, Missouri | Image: Kyle Spradley / stock.adobe.com

Highlights and updates

Missouri exchange overview

Missouri uses the federally facilitated marketplace, which means residents enroll through HealthCare.gov if they want a plan through the exchange. Eight insurers offer plans in the Missouri marketplace as of 2021, and 215,311 people enrolled in plans through the marketplace during the open enrollment period for 2021 coverage.

When can I enroll in health insurance in Missouri?

Normally, enrollment is only available during the annual open enrollment period in the fall, or during a special enrollment period triggered by a qualifying event. But there is a one-time COVID-related enrollment period in 2021, which continues through August 15.

Missouri residents can use this window to enroll in coverage for the first time, transition from an off-exchange plan to an on-exchange plan, or switch from one exchange plan to another. Any of these might be necessary in order to best take advantage of the premium subsidy enhancements made by the American Rescue Plan, as subsidies are larger and more widely available in 2021 than they were in past years.

2021 rates and plans: Average rate increase of about 4.7%, plus Blue KC returned to the individual market and other insurers expanded coverage areas

As described below, Blue KC (Blue Cross Blue Shield of Kansas City) previously offered individual market coverage in Missouri, but exited the entire ACA-compliant individual market (on- and off-exchange) at the end of 2017, keeping only grandmothered and grandfathered plans in force. For 2021, however, Blue KC returned to the individual market in Missouri, both on-exchange and off-exchange. They are offering plans in the same 30 counties in western Missouri where they previously offered individual market coverage.

Medica also drastically expanded its coverage area for 2021, and is offering plans in 46 counties (up from just 13 in 2020).

Anthem (Health Alliance Life Insurance) expanded into the St. Louis area for 2021. You can see a map of their 2020 coverage area (blue) versus their 2021 coverage area (red).

The following average rate changes were implemented for 2021 for the eight insurers in Missouri’s individual market, all of which offer plans both on-exchange and off-exchange:

  • Anthem (Healthy Alliance Life Insurance): 1.4% decrease
  • Cigna: 1.3% increase
  • Ambetter/Celtic (Centene): 9.1 percent increase
  • Medica: 7.5% decrease
  • SSM/WellFirst: 0.5% decrease
  • Cox: 13.6% increase
  • Oscar: 6.4% increase
  • Blue KC (Blue Cross Blue Shield of Kansas City): New to the marketplace for 2021, so no applicable rate change

The overall average rate change for 2021 was a 4.7% increase for individual market premiums. A map of anticipated insurer participation for 2021 is available here, and a list of counties showing each insurer’s service area is available here.

As is always the case, premium changes refer to full-price premiums, before subsidies are applied. Most Missouri marketplace enrollees receive premium subsidies, however, which offset some or all of the cost of their coverage. And subsidies are larger and more widely available in 2021, thanks to the American Rescue Plan.

For perspective, here’s a summary of how premiums have changed in Missouri’s marketplace in prior years:

  • 2016: Average increase of 13.9% According to Healthcare.gov’s rate review tool, average rate changes for 2016 in Missouri’s exchange ranged from a decrease of about 2% to an increase of about 30%, amounting to an overall average increase of 13.9 percent.
  • 2017: Average increase of 25.5% The four carriers that offered plans through the Missouri exchange had average rate increases that varied from 9% to almost 41%, amounting to an overall average increase of 25.5 percent.
  • 2018: Average increase of about 40% Prior to 2018, Missouri deferred to the federal government for rate review of ACA-compliant individual market health insurance. But that changed in 2017 with new state law, and 2018’s rates were reviewed and approved by the state insurance department. Missouri’s exchange participation dropped to three insurers for 2018 (Humana and Blue KC exited the marketplace, but Celtic/Ambetter joined). The overall average rate increase for the two existing insurers (Cigna and Anthem) amounted to an overall average increase of about 40 percent.
    All three insurers indicated in their rate filings that they based their 2018 rates on the assumption that federal funding for cost-sharing reductions (CSR, aka cost-sharing subsidies) funding would be eliminated by 2018 (this proved to be a correct assumption, as the Trump Administration cut off CSR funding in October 2017). Insurers still have to provide cost-sharing reductions to eligible enrollees, but the cost of doing so was incorporated into premiums for 2018, since the federal government is no longer covering this cost for insurers.

    But because the cost of cost-sharing reductions (CSR) was added to Silver plan premiums (this continues to be the case in 2019), and because premium subsidy amounts are based on the cost of a Silver plan, premium subsidies were much larger in 2018 than they were in 2017.

  • 2019: Average increase of 1.6% The Missouri Department of Insurance posted a summary of the average rate changes for 2019. In the individual market, all four insurers offered plans both on- and off-exchange for 2019, with average rate changes that ranged from an 8.6% decrease to a 7.3% increase. The overall weighted average rate increase of just 1.6% — but rates would likely have dropped by about 10 percent if the individual mandate penalty hadn’t been eliminated and if short-term and association health plans hadn’t been expanded (all of those factors result in fewer healthy people having coverage in the ACA-compliant risk pool, which causes higher premiums).
  • 2020: Average decrease of 2% Missouri established a task force in 2019 aimed at making the state’s insurance market more robust and affordable, but even before the task force convened, several insurers had filed plans to join the state’s exchange or expand their existing coverage area for 2020. And the insurers that already offered plans in Missouri’s exchange implemented a small overall rate decrease for 2020. Missouri had four insurers offering plans in the exchange in 2019, and that grew to seven for 2020. Anthem (Healthy Alliance Life Insurance), Cigna, Ambetter/Celtic (Centene), and Medica offered coverage in various areas of the state in 2019, and their overall average premiums decreased by about 2% for 2020. In addition, Oscar Health, SSM Health Insurance, and Cox Health Systems joined the exchange.

Missouri exchange enrollment: 2014-2021

215,311 people enrolled in private plans through the Missouri exchange during the open enrollment period for 2021 coverage, up from 202,750 the year before (but still quite a bit lower than the more than 290,000 who enrolled in coverage for 2016). Enrollment is likely to increase throughout much of 2021, due to the one-time COVID-related enrollment window that continues through August 15.

For perspective, here’s a look at prior enrollment numbers in Missouri’s exchange:

Nationwide, there was an enrollment drop of about 5% in 2017, although Missouri’s enrollment dropped more sharply, by about 16%. The enrollment declines in 2017 and 2018 were due to a variety of factors, including uncertainty about GOP efforts to repeal the ACA, the Trump Administration’s decision to sharply reduce funding for exchange marketing and enrollment assistance, and sharp premium increases for people who aren’t eligible for premium subsidies (those rate increases were partially due to the market instability caused by GOP efforts to repeal the ACA). There was another nationwide average enrollment decline in 2018 of about 5%. Enrollment trended upwards nationwide in 2021 for the first time in several years, and that was the case in Missouri as well.

Changes in insurer participation in Missouri’s exchange over time

Aetna subsidiary Coventry offered plans in the Missouri exchange until the end of 2016, but abruptly exited the exchange market two weeks before the start of open enrollment for 2017 coverage. I talked with the Missouri Department of Insurance about Coventry’s market share in 2016, and they said that the size of the individual market had “exploded” in Missouri, and that Coventry had picked up a disproportionate number of the new enrollees, since their rates had been among the lowest in the state.

UnitedHealthcare also exited the exchange in Missouri at the end of 2016, and stopped selling any ACA-compliant individual market plans, on- or off-exchange.

So Missouri’s exchange had four participating insurers for 2017. But two of them — Humana and Blue KC — announced that they would exit the exchange at the end of 2017, and did not offer plans for 2018. The other two — Anthem (Healthy Alliance Life) and Cigna — continued to offer coverage in the exchange (Cigna’s participation was limited to 10 counties in the St. Louis area and five counties in the Kansas City Area).

In 25 counties in western Missouri, Blue KC’s impending exit initially meant that there were no insurers slated to offer exchange coverage in 2018 (all but the five Kansas City-area counties where Cigna also offered coverage). Blue KC noted in their announcement that they had lost more than $100 million on their ACA-compliant individual market plans through 2016, calling the losses unsustainable.

Blue KC sought, and obtained, an exemption from the five-year ban on re-entering a market after exiting (the ban on re-entry is a HIPAA regulation that long pre-dates the ACA). Because Blue KC continued to renew their grandmothered and grandfathered plans, their exit from the ACA-compliant individual market was not considered a full market exit, allowing them to begin selling individual market plans again at any point in the future (they are rejoining the individual market for 2021, both on-exchange and off-exchange).

In June 2017, Missouri Insurance Director Chlora Lindley-Myers announced that Ambetter/Celtic Insurance (a Centene company) would be joining the exchange for 2018, and would offer coverage in all 25 of the counties that would otherwise have been left without an insurer in the wake of Blue KC’s exit. In total, Ambetter/Celtic offered exchange plans in 40 counties in Missouri in 2018.

Missouri exchange dropped from four insurers to three in 2018

So Missouri’s exchange had three insurers in 2018: Anthem (Healthy Alliance Life Insurance), Cigna, and Ambetter/Celtic (Centene). But that grew to four for 2019, with Medica’s announcement in June 2018 that they planned to join the Missouri exchange in the Kansas City area (Cass, Clay, Jackson, and Platte counties) as of 2019. Medica began offering plans on the Kansas side of the Kansas City area in 2018, and expanded into the Missouri side for 2019.

The Missouri Department of Insurance created a map that shows the coverage areas of the four individual market insurers for 2019 (plans are available both on and off-exchange). In four counties in the Kansas City area, plans are available from three insurers (Cigna, Medica, and Ambetter/Celtic).

Consumers in the St. Louis area could choose from two insurers in 2019, as could consumers in southwestern Missouri. But most rural areas of the state continued to have just one insurer offering plans — in most cases, either Anthem (Healthy Alliance Life) or Celtic/Ambetter.

Anthem’s coverage area shrank in 2018, but expanded in 2019

Until the end of 2017, Anthem offered exchange plans in most of Missouri — everywhere except the 30 western counties that were served by Blue KC. For 2018, however, Anthem’s participation was reduced to 68 counties (a full list is in a press release), and the insurer noted that these were all counties that would otherwise have had no insurers offering coverage.

Among the areas Anthem exited were Boone County (Columbia) and the St. Louis area. In both of those areas, Cigna plans were available for 2019.

Anthem exited these 16 counties: Barry, Boone, Christian, Franklin, Greene, Jasper, Jefferson, Lawrence, Lincoln, Newton, Saint Charles, Saint Francois, Saint Louis, Sainte Genevieve, Warren, and Washington. For 2019, however, Anthem increased their coverage area to 76 counties, returning to Barry, Boone, Christian, Greene, Jasper, Lawrence, Newton, and Saint Francois counties.

Three new insurers joined Missouri’s marketplace for 2020

In addition to the four existing insurers, three new insurers joined Missouri’s exchange for the 2020 plan year:

  • Cox Health Systems began offering EPO plans in seven counties in the Springfield area (Barry, Christian, Greene, Lawrence, Stone, Taney, and Webster, all of which are in Rating Area 8). Cox did not participate in the individual market in Missouri in 2019, but they did offer plans outside the exchange in 2018. For 2020, Cox’s filing noted that their plans would only be available through the exchange, with a projected enrollment of about 8,000 people.
  • Oscar Health began offering coverage on- and off-exchange in the Kansas City area for 2020 (Jackson, Clay, and Platte counties). Oscar’s filing indicated that they anticipated about 2,500 individual market enrollees for 2020. Oscar has not previously offered coverage in Missouri’s individual market.
  • SSM Health Insurance (WellFirst) began offering coverage on- and off-exchange in St. Charles County, St. Louis County, and St. Louis City, which are all in Rating Area 6. SSM is an integrated delivery system with an established presence in the midwest, but they had not previously offered coverage in Missouri’s individual market.

Blue KC returns to western Missouri marketplace for 2021

All seven existing insurers are continuing to offer coverage in Missouri’s exchange in 2021, with varying coverage areas, and Blue KC has returned to the marketplace. Blue KC is offering coverage in the same 30 western Missouri counties where they previously offered coverage.

Lawmakers considered, but did not pass, legislation to create reinsurance program

Reinsurance refers to a system in which insurance companies can pass off certain high-cost claims to a third party (the reinsurance program). Reinsurance kicks in when a claim reaches a certain level, and then the reinsurance program pays a percentage of the claim until it reaches another certain level. The ACA included a federal reinsurance program, but it was temporary and only lasted through 2016. To counter rising premiums and stabilize local insurance markets, states are increasingly pursuing their own reinsurance program. As of 2021, fourteen states are receiving federal “pass-through” funding for reinsurance.

Reinsurance results in lower overall premiums, which means premium subsidies are also lower. Instead of having the federal government keep the savings from the lower premium subsidies, a state can use a 1332 waiver to have the savings pass through to the state. Then the money is used by the state to cover the majority of the cost of operating the reinsurance program.

H.B.2539 / SB1071 was considered by Missouri lawmakers in 2018, but neither bill reached a full vote. The legislation would have reactivated the former Missouri Health Insurance Pool (the state’s pre-ACA high-risk pool), but it would have become the Missouri Reinsurance Pool instead. The fees that were previously assessed on insurers under the MHIP would have started to apply again, to be used to fund the reinsurance program. Between 1991 and 2014, carriers in Missouri paid an average of nearly $6.5 million per year in fees for MHIP.

In addition to state funding, the legislation would have directed the state to apply for a 1332 waiver in order to obtain federal pass-through savings to fund the reinsurance program, starting in 2019. In the states that have already received federal pass-through funding for reinsurance, the federal funding covers the majority of the cost of the program.

But since the legislation didn’t pass, Missouri does not receive any federal pass-through funding for reinsurance.

During the 2018 session, Missouri lawmakers also rejected bills that would have increased the allowable duration of short-term plans, expanded access to association health plans, expanded Medicaid, and added a work requirement to Medicaid.

Transparency and rate review

In May 2016, lawmakers in Missouri unanimously passed SB 865, and Governor Nixon signed it in early July. The new law called for numerous changes in the state’s health care systems, including added transparency for health insurance rates.

Prior to March 2017, Missouri was one of four states without an effective rate review process for ACA-compliant plans (there were five until April 2016, when Alabama implemented an effective rate review process). State regulators did not take an active role in reviewing proposed rates, and the Missouri Department of Insurance did not have access to the rate filings at all. The federal government (specifically, CCIIO – the Center for Consumer Information and Insurance Oversight) conducted the rate review process for Missouri, and rates were published on Healthcare.gov’s rate review page.

SB 865 gives state regulators a bit more leeway but does not actually give them the power to deny rate changes that aren’t justified. Under the new law, regulators are now able to review and publish rate proposals, and determine whether the proposed rates are reasonable. If they aren’t, the regulators will let the health insurers know, but the insurers will still have the option to implement the rates as-proposed. In that case, the state will be able to publicize the fact that the unjustified rates were implemented, but the state will not have the authority to prevent carriers from implementing rates that aren’t justified.

It should be noted that this system is what CCIIO previously provided in Missouri. The federal government can determine whether proposed rates in the state are justified, but they cannot prevent insurers from implementing unjustified rates. Now that SB 865 has taken effect, the state has taken over the process that was previously conducted by CCIIO.

CMS notified Missouri on March 17, 2017, that the state had been deemed to have an effective rate review program. At that point only three states — Oklahoma, Texas, and Wyoming — were still relying on CCIIO for rate review, and that continues to be the case.

Navigator restrictions permanently blocked by federal judge

Missouri is one of about 15 states that has more restrictive training and certification requirements for navigators than what’s required under federal standards. Missouri legislation also prohibits navigators from providing “advice concerning the benefits, terms and features of a particular health plan, or offer advice about which exchange health plan is better or worse for a particular individual or employer.”

Several health care advocacy groups challenged the restriction on providing advice, saying that is the core function of navigators. In January 2014, a federal judge agreed and issued an injunction to halt enforcement of the law. And in April 2015, a federal appeals court concurred, ruling that Missouri could not restrict navigators from helping people enroll in plans through Healthcare.gov.

In March 2016, a federal judge permanently blocked three sections of Missouri’s restrictions on navigators. Navigators in Missouri cannot be barred from providing advice to enrollees (note that this is limited to explaining the differences between plans; plan selection advice can only be provided by a licensed insurance producer). Nor can they be banned from discussing off-exchange plans with consumers. And finally, navigators cannot be required to refer currently-insured consumers to seek advice from a licensed insurance producer. The judge noted that navigators are supposed to be impartial, and forcing them to refer people to insurance agents — who are permitted to recommend one plan over another — would remove some of the impartiality that applies to navigators.

Missouri exchange history

Many Missouri legislators have steadfastly fought against the Affordable Care Act and implementation of the health insurance marketplace.

Legislation to establish an exchange was introduced but failed to pass in both 2011 and 2012. Despite the lack of legislative authorization, some initial workgroups were established. In 2011, then-Gov. Jay Nixon established the Health Insurance Exchange Coordinating Council, which did some initial scoping and planning. Also in 2011, the Senate created the Interim Committee on Health Insurance Exchanges to explore Missouri’s options to establish a state-based exchange.

Members of the Interim Senate committee refused to authorize the use of federal grant money. In April 2012, the Missouri legislature rejected a $50 million grant to upgrade the state’s Medicaid information system as some legislators believed the system would be used as a springboard to building a state-run exchange.

In May 2012, the Missouri legislature approved a ballot measure to prevent the executive branch from authorizing a state-based health insurance exchange without legislative or popular approval — even though Gov. Nixon repeatedly stated his administration would not authorize an exchange by executive order. Voters passed the ballot measure in November 2012, and state defaulted to the federally operated exchange.

In January 2015, Republican Sen. Bob Onder filed a bill that he said was aimed at blocking the Affordable Care Act’s individual mandate. SB 51 would have revoked a health insurance company’s license to sell policies in Missouri if it accepted federal subsidies for policies sold through the federal marketplace. It’s questionable what impact the bill would have had if it had passed. One legal expert told the St. Louis Post-Dispatch, “It’s sort of an exercise in futility.” Ultimately, the bill didn’t advance out of committee.

Missouri health insurance exchange links

HealthCare.gov
800-318-2596

State Exchange Profile: Missouri
The Henry J. Kaiser Family Foundation overview of Missouri’s progress toward creating a state health insurance exchange.

Missouri Department of Insurance
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.
(800) 726-7390 / consumeraffairs@insurance.mo.gov


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.

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