Highlights and updates
- Looking ahead to 2019
- Three insurers offering exchange plans for 2018
- All areas of the state have two insurer options
- BCBSKS offering all new plans for 2018
- Medica: 29% avg rate increase for 2018 included CSR load on silver plans
- Medica does not have an enrollment cap in 2018
- Sunflower/Ambetter/Centene new to Kansas exchange
Kansas exchange overview
Kansas uses the federally run exchange at Healthcare.gov, but with a marketplace plan management design that leaves plan oversight to the state.
98,238 people enrolled in coverage for 2018 through the Kansas exchange during open enrollment for 2018 coverage, which ran from November 1, 2017 to December 15, 2017. For perspective 98,780 people had enrolled the year before, so enrollment was only about half a percent lower for 2018, despite the fact that open enrollment was half as long.
Blue KC exited the exchange at the end of 2017, but Centene joined. Blue Cross Blue Shield of Kansas and Medica both remained in the exchange, so there are a total of three insurers offering coverage, with two insurers offering plans in every county of the state
Looking ahead to 2019
For insurers that wish to offer plans in 2019, form filings were due in Kansas by May 14, 2018. Medica, Sunflower State Health Plan, and Blue Cross Blue Shield of Kansas all filed forms for 2019 coverage in the individual market in Kansas. The filing in SERFF for Blue Cross Blue Shield of Kansas only shows off-exchange plans, but the Kansas Insurance Department confirmed that all three carriers have filed forms for both on- and off-exchange coverage for 2019, so coverage availability is expected to be the same as it is in 2018.
2018 Insurers: Medica and BCBS of Kansas remained in; Centene joined; Blue KC exited
There were three insurers offering plans in the Kansas exchange in 2017: Blue Cross Blue Shield of Kansas Solutions (in all but two counties), Blue Cross Blue Shield of Kansas City (aka Blue KC, available only in Johnson and Wyandotte counties), and Medica.
For 2018, there are still three carriers (and two carrier options in every county), but there were some changes. Plans are available from Blue Cross Blue Shield of Kansas, Medica, and Sunflower/Ambetter/Centene.
May 15, 2017 was the deadline for insurers to file plans with the Kansas Insurance Department if they intended to offer coverage in the state’s individual market (including the exchange) in 2018. However, insurers had two additional months — until July 14 — to file rates to go with those plans.
Blue KC did not file plans by May 15, but didn’t indicate at that point that they would exit the exchange, instead requesting “flexibility” from the state insurance department, amid concerns about market stability. But on May 24, Blue KC announced that they would exit the ACA-compliant individual market at the end of 2017, and would no longer offer ACA-compliant plans on or off the exchange in Kansas or Missouri (this exit did not impact Blue KC employer-sponsored plans, short-term plans, student health plans, Medicare Advantage plans, Medigap plans, or any of their grandmothered or grandfathered individual market plans). Blue KC noted that they had lost more than $100 million in the ACA-compliant market through 2016, a level that they deemed unsustainable.
Blue KC’s exit had a bigger impact in Missouri, where Blue KC plans were offered in 30 counties in 2017. But it had a significant impact in Johnson and Wyandotte counties in Kansas, where Blue KC offered coverage in 2017 (Blue KC was only available in those two counties in Missouri in 2017; the rest of the state was covered by Blue Cross Blue Shield of Kansas Solutions). Between the two states, roughly 67,000 people had to secure new coverage during open enrollment, which began on November 1, 2017, and continued until December 15, 2017 (there was a special enrollment period, however, for people whose plans terminated at the end of 2017; they had until March 1, 2018 to pick a new plan).
At that point, the only other option for 2018 coverage in the Kansas side of the Kansas City metro area was slated to be Medica, which had filed plans for statewide availability in the Kansas exchange in 2018. Medica first joined the Kansas exchange in 2017, and had a 10,000 member enrollment cap that year. They did not initially say whether they would continue to implement an enrollment cap in 2018, although they later confirmed that there would be no enrollment cap for 2018 (an enrollment cap would have been a problem in the Kansas City area if Medica had been the only participating insurer for 2018, as there were 32,000 ACA enrollees just in Johnson and Wyandotte counties alone in 2017).
But in June, 2017, Centene announced that they would enter the exchange in Kansas and Missouri, along with Nevada. Centene already offered Medicaid managed care coverage in Kansas under the name Sunflower State Health Plan, but 2018 is the first year that they’ve offered private plans for sale in the exchange. Sunflower State Health Plan (Ambetter from Sunflower Health) is offering plans in Johnson and Wyandotte counties, filling the gap left by Blue KC’s exit.
Blue Cross Blue Shield of Kansas also filed plans to remain in all of the counties where they offered 2017 coverage (everywhere except Johnson and Wyandotte counties), but the Kansas Insurance Department noted that they are offering all new plans for 2018. Their products are EPOs, rather than the HMO Solutions products that were offered for 2017 (and the word “Solutions” has been dropped from the end of the name, so it’s now just Blue Cross Blue Shield of Kansas)
When health insurance plans terminate at the end of the year, their members are eligible for a special enrollment period. For those with on-exchange coverage, HealthCare.gov maps these enrollees to new plans if they don’t pick their own replacement plan during open enrollment. But even after they’ve been mapped to new plans, the people whose coverage terminated at the end of the year are still eligible for a special enrollment period that extends for 60 days after the plan termination date.
So the special enrollment period continued until March 1, 2018, and it applied to nearly everyone who had coverage in the Kansas exchange in 2017, as well as most people who had ACA-compliant off-exchange coverage.
In Kansas, all of the Blue Cross Blue Shield of Kansas Solutions plans, which were HMOs, were terminated at the end of 2017 to make way for the EPOs from Blue Cross Blue Shield of Kansas. And all ACA-compliant Blue KC plans were also terminated at the end of 2017. The only plans that weren’t terminated were Medica’s, and they only insured 7,574 members in 2017, including on and off-exchange. So out of more than 86,000 total exchange enrollees, the vast majority were enrolled in plans that terminated at the end of 2017, and the off-exchange market was also predominantly BCBS of Kansas Solutions and Blue KC.
All of these individuals had until March 1, 2018 to pick a replacement plan for 2018, regardless of whether they were mapped to a new plan or not.
Rate changes for 2018: BCBS of Kansas and Sunflower are new plans, so no applicable rate increase; Medica’s average increase was 29%.
There are no platinum plans available in the Kansas exchange for 2018, but there are a total of 11 plans available in Johnson and Wyandotte counties, and 12 plans available in the rest of the state. All plans offered in the exchange must also be offered off-exchange, and there are no insurers in Kansas that offer only off-exchange plans.
The following average rate increases were deemed reasonable and have been implemented for 2018:
- Medica: 29 percent, based on assumption that cost-sharing reduction (CSR) funding would not continue (the additional cost to cover CSR has been added to silver plans, and indeed, federal funding for CSR was eliminated in October 2017, so the decision to preemptively add the cost of CSR to silver plan premiums was a good one). Medica had 7,574 members in 2017. Plans are available state-wide in 2018, which includes an expansion into Johnson and Wyandotte counties, where Medica didn’t offer coverage in 2017. A total of seven plans are available, but they are EPOs in Johnson and Wyandotte counties, and PPOs throughout the rest of the state. Medica capped enrollment at 10,000 for 2017, but confirmed that the enrollment cap does not apply for 2018.
- Blue Cross Blue Shield of Kansas: No applicable rate increase because BCBSKS is offering all new plans for 2018. The plans that were offered in 2017 were called Blue Cross Blue Shield of Kansas Solutions, and they were HMOs. For 2018, they were replaced with EPOs from Blue Cross Blue Shield of Kansas. Plans are available in all counties except Johnson and Wyandotte; a total of five plans (all EPO) are being offered.
- Sunflower State Health Plan/Ambetter from Sunflower Health (Centene): No applicable rate increase because Sunflower is new to the individual market in Kansas. Plans are available in Johnson and Wyandotte counties; a total of four plans (all HMO) are being offered.
The Kansas Insurance Department published an overview of changes for the 2018 ACA-compliant market, including the individual and small group markets.
Premium subsidies grew in 2018 to keep pace with average benchmark (second-lowest-cost silver plan) premiums. 86 percent of Kansas exchange enrollees were receiving premium subsidies in 2017, and those individuals were protected from the bulk of the rate increases as long as they took the time to compare the various options available during open enrollment and select the one that represents the best value. People with off-exchange coverage were encouraged to compare on-exchange options as well, as the exchange is the only place where premium subsidies and cost-sharing subsidies are available.
Because the cost of CSR has been added to silver plan premiums in 2018, premium subsidies are larger than they would otherwise have been. As an example, a 50-year-old in Lawrence who earns $30,000 in 2018 can get a bronze plan for as little as 83 cents a month, thanks to a $494/month premium subsidy. She can also get a gold plan for $145/month after her subsidy. The cheapest silver plan available to her would cost $195/month. These pricing oddities (ie, free or nearly free bronze plans, and gold plans that are less expensive than silver plans) are a result of the decision to add the cost of CSR to silver plan premiums, and the larger premium subsidies that created.
2017: 42% average increase for benchmark premiums = much larger subsidies
According to HHS data, the average benchmark plan (second-lowest-cost silver plan) in Kansas were 42 percent more expensive in 2017 than they were in 2016. But 82 percent of Kansas exchange enrollees were receiving premium subsidies in 2016, and those subsidies are tied to the cost of the benchmark plan.
So the sharp increase in benchmark plan prices means that subsidies have also increased sharply, keeping premiums at an affordable level for enrollees who are subsidy-eligible.
HHS has estimated that there were 28,000 people in Kansas who had off-exchange coverage in 2016 but who would be eligible for subsidies if they switched to the exchange.
Carrier changes for 2017
UnitedHealthcare exited the individual health insurance market in Kansas at the end of 2016, both on and off-exchange. For 2016 coverage, UnitedHealthcare had competition from three other carriers in the Kansas exchange, but they all operated under the Blue Cross Blue Shield umbrella: Blue Cross Blue Shield of Kansas, Blue Cross Blue Shield of Kansas Solutions (offered in 103 of the 105 counties in Kansas), and Blue Cross Blue Shield of Kansas City (only available in Johnson and Wyandotte Counties – ie, the Kansas City area).
With United’s exit, Kansas would have been left with only Blue Cross Blue Shield options in the exchange in 2017. But the situation continued to evolve.
The Kansas Insurance Department announced in mid-May that two additional carriers—Medica Insurance Company and Coventry (Aetna)—had filed proposals to sell plans on and off the exchange in Kansas for 2017. Then in early August, Aetna announced that they were putting the brakes on their plans to expand into five additional exchanges—including Kansas—in 2017. As a result, the proposed Coventry plans did not become available in the Kansas exchange for 2017.
In the 2017 rate filing memo submitted by Blue Cross Blue Shield of Kansas, the carrier indicated that they would not offer on-exchange plans in 2017. A June letter from the Kansas Insurance Department confirmed that only two BCBS entities would offer plans in the Kansas exchange in 2017. The following average rate increases were approved for Kansas exchange plans:
- Blue Cross Blue Shield of Kansas Solutions: 47.41 percent
- Blue Cross Blue Shield of Kansas City: 28.1 percent
- Medica: new to the exchange for 2017, enrollment capped at 10,000 members
There has been considerable shifting in the exchange landscape in Kansas over the last few years. Coventry previously participated in the exchange in Kansas, but exited the exchange at the end of 2015. They continued to offer off-exchange plans in Kansas in 2016.
UnitedHealthcare did not participate in 2014 and 2015, but joined the exchange for 2016, and is exiting the entire individual market in the state at the end of 2016.
Kansas now allows network-only plans
Kansas passed legislation (HB2454 – signed into law in April 2016) that allows health insurance carriers to offer EPO plans, and to allow those plans to include a “gatekeeper” requirement similar to HMOs.
EPOs don’t cover any out-of-network care except for emergencies, and they typically don’t require a referral from a primary care doctor (ie, gatekeeper) to see a specialist, as long as the specialist is in the plan’s network. In Kansas, carriers can offer HMOs, but they have to pay an HMO privilege fee, which lawmakers increased in 2015.
Now that HB2454 has been signed into law, carriers can offer EPOs with narrow networks and gatekeeper requirements. The plans could be functionally very similar to HMOs, but wouldn’t be subject to the HMO privilege fee. The bill had support from Aetna, UnitedHealthcare, and Blue Cross Blue Shield of Kansas City, and passed unanimously in both the House and Senate.
Narrower networks are one of the ways that carriers can curtail costs and create plans with lower premiums. They also tend to be popular among healthy applicants – who are more concerned with premiums than with the scope of the plan’s network.
But for 2017, Blue Cross Blue Shield of Kansas City (only available in Wyandotte and Johnson Counties) is the only carrier — on or off-exchange — offering EPO plans . They also offer HMOs. For the other two exchange carriers, Blue Cross Blue Shield of Kansas Solutions is offering only HMO plans, and Medica is offering only PPO plans.
During the 2016 open enrollment period, 101,555 people enrolled in private health plans through the Kansas exchange, including new enrollees and renewals. The 2016 enrollment total is about 5 percent higher than the enrollment total at the end of the 2015 open enrollment period (96,197).
By March 31, 2016, effectuated enrollment in the Kansas exchange stood at 89,566. That’s about 4.7 percent higher than the 85,490 who had effectuated coverage through the exchange at the end of March 2015.
Open enrollment for 2016 – both on and off-exchange – ended at the end of January, although applicants who experience a qualifying event can still enroll in a health plan for 2016. Native Americans or Alaska Natives can sign up for private coverage throughout the year, and enrollment for Medicaid and the Children’s Health Insurance Program (CHIP) is also open all year long.
The penalty for being uninsured is significantly higher in 2016 than it was in 2014 and 2015, so uninsured residents who experience a qualifying event should make sure they enroll in a plan during their special enrollment period. The next general open enrollment period will begin in November 2016, for coverage effective January 2017.
2016 rate changes
Across the full individual and small group market in Kansas (including both on and off-exchange plans), proposed rate changes varied from a decrease of 0.4 percent, to an increase of nearly 38 percent. The Kansas Insurance Department warned that rate increases should be expected for 2016, but the rates that were approved were a little lower on average than the rates that carriers proposed. The average final rate changes across all five existing carriers range from a 9.4 percent increase to a 25.4 percent increase.
But those approved rate changes were finalized long before Coventry announced their exit from the exchange. The rate hikes for Coventry no longer apply, but more than half of the exchange enrollees in Kansas had to select a new plan for 2016.
The majority of exchange enrollees in Kansas receive premium subsidies, which offset a significant portion of the rate increases in 2016. This is contingent on consumers being willing to shop around during open enrollment however, as subsidies can change from one year to another if the price of the second-lowest-cost silver plan changes.
Statewide, the average price for the second-lowest-cost silver plan increased by 16.1 percent in 2016. That’s more than double the national average, and it means average subsidies have increased significantly in Kansas for 2016 – but not by enough to offset some of the higher rate hikes on Kansas plans, highlighting the importance of shopping around during open enrollment.
Subsidies safe for 66,000
The much-anticipated Supreme Court ruling on King v. Burwell was announced in June 2015, with the Court upholding the legality of premium subsidies for millions of Americans in states – like Kansas – where the federal government is running the exchange (Healthcare.gov). As of late June, there were 67,733 people receiving premium subsidies in Kansas; their coverage would have become unaffordable without subsidies.
Even those who pay full price for their health insurance would have seen dramatic rate increases if subsidies had been eliminated. The American Academy of Actuaries estimated that rates in the entire individual market in Healthcare.gov states would have increased by about 35 percent if the King plaintiffs had prevailed. And the Urban Institute put the figure even higher, predicting 55 percent rate increases market-wide if subsidies had been eliminated. And those are just the rate hikes that would have resulted from the elimination of subsidies… they would have been in addition to the normal annual rate increases based on medical cost growth.
Health and Human Services (HHS) reported 96,197 Kansans selected private health insurance through HealthCare.gov during 2015 open enrollment. According to estimates by Kaiser, about 39 percent of Kansans who were eligible to enroll via the marketplace in 2015 actually selected a health plan. The final 2015 open enrollment report shows that 52 percent of Kansas enrollees were new consumers. Twenty-six percent of Kansas enrollees were between the ages of 18 and 34; in all HealthCare.gov states, 28 percent of enrollees fell into the 18-to-34 bracket.
But by the end of March, the total number of people with in-force coverage through the Kansas exchange had dropped to 85,490, and it fell slightly lower by the end of June, to 84,872. Attrition is a normal part the individual health insurance market, as not all enrollees pay their initial premiums, and some insureds cancel their coverage for one reason or another (sometimes simply because they receive an offer of coverage from an employer instead).
Of the Kansas residents whose exchange coverage was in-force on March 31, just under 80 percent qualified for premium subsidies compared to 83.7 percent nationwide.
How much did insurance cost in 2015?
2015 premiums on the Kansas marketplace were up just 4 percent from 2014 rates, according to a comprehensive study completed by The Commonwealth Fund. Nationally, rates were flat. However, the zero percent average increase masked 10+ percent increases in 10 states and 10+ percent decreases in 14 states.
Below average enrollment in 2014
During the first open enrollment period, 57,013 Kansans enrolled in qualified health plans and nearly 14,000 people qualified for either Medicaid or the Children’s Health Insurance Program (CHIP) under existing eligibility criteria according to the Kaiser Family Foundation. In all, about one in five of those Kansans eligible signed up for private insurance — lower than the national average of 28 percent.
Among Kansas residents selecting a QHP, 85 percent qualified for financial assistance. Nineteen percent of Kansans selected a bronze plan (20 percent nationally), 60 percent selected a silver plan (65 percent nationally), 16 percent selected a gold plan (9 percent nationally), 2 percent selected a platinum plan (5 percent nationally) and 4 percent selected a catastrophic plan (2 percent nationally). Thirty-one percent of Kansas enrollees were between the ages of 18 and 34.
Kansas is the only state with a reported increase in the percentage of uninsured individuals between 2013 and 2014. The uninsured rate in Kansas rose from 12.5 percent to 14.4 percent according to a Gallup-Healthways poll. But both the full-year results and a mid-2014 poll that showed an even larger increase have been questioned by both Gallup and Kansas insurance experts. And by the first half of 2015, the Gallup data showed that the uninsured rate had ticked downward to 11.3 percent.
No Medicaid expansion
Kansas has not expanded its Medicaid program, which is called KanCare, despite a December 2013 poll that found 72 percent of registered Kansans voters favored expansion. While other Republican governors proceeded with Medicaid expansion, Gov. Sam Brownback remained opposed — as did the state’s Republican-controlled Legislature, which didn’t act on Medicaid expansion in 2014.
An Urban Institute report shows Kansas missing out on $5.3 billion in federal funding and hospitals losing $2.6 billion in Medicaid reimbursement.
The Kansas Hospital Association continues to advocate for expansion, touting a “Kansas solution” that includes cost-sharing provisions, high-deductible plans, health savings accounts (HSAs) and other provisions that have been proposed or implemented in other conservative states.
Hospital officials have testified during state legislative committee meetings to explain the financial toll of the state’s decision against Medicaid expansion. Rural hospitals in particular are struggling because the Affordable Care Act is partly funded through a reduction in hospital payments from Medicare. In October 2015, Mercy Hospital in Independence, Kansas shut down, becoming the first Kansas hospital to close in nine years; the hospital’s demise has been linked to the state’s rejection of Medicaid expansion.
In states that expanded Medicaid, the Medicare reduction is offset by the increased number of people who are insured (either through private coverage sold on the marketplace or Medicaid). In states that don’t expand Medicaid, the uninsured rate remains higher and hospitals continue to struggle with higher levels of uncompensated (charity) care.
A Medicaid expansion bill, HB 2319, was introduced in the 2015 session and got a hearing before the House Health and Human Services Committee. The acting secretary for the Kansas Department of Health and Environment testified that expansion would cost the state $2.4 billion between 2016 and 2025, and the committee didn’t act on the bill.
Brownback seemingly reversed course on Medicaid expansion in 2015. During a speech to Missouri legislators, Brownback said he would most likely sign off on Medicaid expansion if it were budget neutral. Yet despite renewed calls to expand Medicaid with the news of Mercy Hospital’s closure, Brownback’s position was that the state can’t afford to expand Medicaid.
How Kansas approached marketplace implementation
Kansas opted to use HealthCare.gov rather than implement a state-run marketplace. The decision against a Kansas-run exchange came despite the efforts of Insurance Commissioner Sandy Praeger and some initial support from Brownback. Brownback, while critical of the Affordable Care Act, initially supported Praeger’s exchange planning efforts.
However, Brownback grew less and less supportive over time. In August 2011, Brownback returned a federal grant intended to help the state develop technical infrastructure for running the exchange. The return of the grant effectively quashed a state-run exchange, so Praeger began recommending state-federal partnership as a way for the state to retain some control.
In November 2012, Brownback announced that the state would default to a federally operated exchange, issuing a statement that said in part, “My administration will not partner with the federal government to create a state-federal partnership insurance exchange because we will not benefit from it and implementing it could costs Kansas taxpayers millions of dollars.”
During the 2014 legislative session, Kansas lawmakers debated a bill (SB 362) that would have subjected anyone who wanted to serve as a navigator to requirements above and beyond those at the federal level. Kansas navigators would have been subjected to criminal background checks, been fingerprinted, required to disclose their credit histories, and charged an annual $100 registration fee. The bill would have also prohibited navigators from recommending a specific insurance policy for a consumer. The bill passed the Senate, but failed to clear a House committee.
Kansas health insurance exchange links
State Exchange Profile: Kansas
The Henry J. Kaiser Family Foundation overview of Kansas’ progress toward creating a state health insurance exchange.
Kansas Insurance Department, Consumer Assistance Division
Assists consumers who have purchased insurance on the individual market or who have insurance through an employer who only does business in Kansas.
(800) 432-2484 / Local: (785) 296-7829
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.