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

Average rates decreasing slightly for 2020; Oscar and Cigna are joining the exchange; Non-ACA-compliant plans available off-exchange for 2020

Highlights and updates

Kansas exchange overview

State legislative efforts to preserve or strengthen provisions of the Affordable Care Act

Kansas is among the states that have done the least to preserve the Affordable Care Act’s gains.

Kansas uses the federally run exchange at Healthcare.gov, but with a marketplace plan management design that leaves plan oversight to the state.

89,993 people enrolled in coverage for 2019 through the Kansas exchange during open enrollment for 2019 coverage. That was a drop of about 8 percent from the 98,238 people who enrolled for 2018.

Three insurers offer plans in the Kansas exchange as of 2019: Medica, Blue Cross Blue Shield of Kansas, and Sunflower/Ambetter. All plans offered in the exchange must also be offered off-exchange, and there are currently no insurers in Kansas that offer only off-exchange plans.

The Kansas Insurance Department maintains a website with a variety of information related to health care reform, including an overview of the state’s health insurance market each year.

Kansas still has not expanded Medicaid under the ACA, although lawmakers came close in the 2019 legislative session. So there continues to be a coverage gap in Kansas, leaving roughly 46,000 people without any realistic access to health coverage: Childless adults who earn less than the poverty level are ineligible for premium subsidies (they earn too little) and also ineligible for Medicaid under the state’s existing rules.

Rates steady for 2020; Oscar and Cigna are joining the marketplace for 2020

Kansas has three insurers in the exchange in 2019, but that’s growing to five in 2020. Overall average rates for the existing insurers are virtually unchanged from 2019, although there’s variation from one plan to another in terms of rate changes. According to the federal rate review site, the following average rate changes apply to full-price individual market plans in Kansas for 2020:

  • Medica: 3.19 percent decrease. Plans available statewide
  • Blue Cross Blue Shield of Kansas: 2.96 percent increase (plans available in 103 of the state’s 105 counties, but not in Johnson or Wyandotte counties)
  • Sunflower State Health Plan/Ambetter from Sunflower Health (Centene): 8.73 percent decrease (plans available in 16 counties)
  • Oscar: New to Kansas market (plans available in Johnson and Wyandotte counties, ie the Kansas City area) so no applicable rate change
  • Cigna: New to Kansas market (Kansas City and Wichita areas; a total of eight counties) so no applicable rate change; SERFF filing number CCGH-131933953

Across the three current insurers, the average rate change is an increase of o.3 percent. Two of the three insurers are reducing their average premiums, but BCBSKS has the lion’s share of the market, so their small increase results in a slight overall average increase.

Farm Bureau health plans (not compliant with the ACA) are available for 2020

Kansas passed legislation (H.B.2209, passed with a veto-proof majority and enacted without Governor Kelly’s signature) in 2019 that exempts Farm Bureau health plans from being regulated by the Kansas Insurance Department. Under the new legislation, Farm Bureau can market plans that don’t include all of the ACA’s essential health benefits, and that use medical underwriting to determine eligibility for coverage. Since the plans are not considered health insurance, they are not subject to insurance laws or regulations (the text of HB2209 regarding farmer’s cooperative plans is the same as S.B.32, which was backed by Farm Bureau earlier in 2019).

Kansas Farm Bureau Health Plans became available for enrollment starting October 1, 2019, with coverage effective January 2020. Farm Bureau membership is required in order to enroll in the health plans, but it’s simply a matter of signing up and paying dues (which vary by county)—members do not need to be actively involved in any sort of farming activity. [This differs from neighboring Nebraska, where Farm Bureau plans are only available to people who are actively engaged in agriculture.]

The Kansas Farm Bureau plans are able to impose pre-existing condition exclusions or waiting periods, and can reject applicants altogether if they aren’t considered healthy enough. This is how most individual market health plans operated in most states prior to 2014, but the ACA changed those rules. There are still people who have pre-ACA grandmothered and grandfathered plans that used medical underwriting, but Kansas is now allowing similar plans to be sold once again, via Farm Bureau.

The legislation applies to entities that have been “organized as a farmer’s cooperative” since at least 1983, so it only applies to Farm Bureau and does not allow new farmer’s cooperatives to enter the market.

The legislation was controversial, and while it was supported by Farm Bureau and GOP lawmakers, it was opposed by the state’s ACA-compliant health insurers, who noted that it isn’t fair to allow one organization to play by a different set of rules.

The new Farm Bureau plans in Kansas are similar to the plans that became available in Iowa as of 2019, and to the plans that Tennessee has allowed to be sold for many years. But they are not the same as the Farm Bureau plans in neighboring Nebraska, which are only available to people who are actively engaged in agriculture, do not use medical underwriting, and can only be obtained during an annual open enrollment window (as opposed to the plans in Iowa, Tennessee, and Kansas, which are available year-round to people who are healthy enough to make it through the medical underwriting process).

H.B.2209 also changed the state’s regulations for association health plans (AHPs), making it easier for AHPs to offer coverage to more people. As a result, Land O’Lakes is offering 2020 AHP coverage to farmers in Kansas who are members of one of 18 CO-OPs in the state. Land O’Lakes is no longer offering AHP coverage in Nebraska because the federal rules that allowed them to do so were overturned by a judge in the spring of 2019. But they’re continuing to offer AHP coverage to agriculture CO-OP members in Minnesota, and now in Kansas, because state laws allow it.

As discussed below, enrollment in private plans through the Kansas exchange peaked in 2016 and has declined in each of the three subsequent years. The introduction of the Farm Bureau plans and AHP coverage — with enrollment opportunities that began around the same time as the open enrollment window for ACA-compliant plans — could result in another drop in enrollment for 2020.

The Kansas Farm Bureau estimates that 42,000 people will eventually enroll in the new plans. Some of these people are currently uninsured, and medically underwritten coverage is far better than being without coverage. But the Farm Bureau plans will also appeal to currently insured individuals who are healthy and who either don’t qualify for premium subsidies or qualify for only minimal subsidies (Charles Gaba has a good overview of this with examples from Tennessee, where underwritten Farm Bureau plans have always been offered alongside ACA-compliant plans). To the extent that they siphon healthy members out of the ACA-compliant risk pool, the Farm Bureau could drive premiums higher for ACA-compliant plans.

Kansas exchange enrollment: 2014 through 2019

During the first open enrollment period, for 2014 coverage, 57,013 Kansans enrolled in qualified health plans through HealthCare.gov.

Enrollment grew significantly in year two, as was the case in most states. HHS reported that 96,197 Kansans selected private health insurance through HealthCare.gov during the open enrollment period for 2015 coverage.

During the third open enrollment period, for 2016 coverage, 101,555 people enrolled in private health plans through the Kansas exchange, including new enrollees and renewals. This was an increase of about 5 percent over the 2015 total, and enrollment in the Kansas exchange peaked in 2016, as was the case in the majority of the states that use HealthCare.gov.

For 2017 coverage, enrollment dropped to 98,780 people. This was due to a variety of factors, including steep rate increases in the individual market in Kansas (offset by subsidies for most enrollees, but fully borne by people who had to pay full price for their coverage) and the nascent Trump Administration’s decision to suspend HealthCare.gov’s marketing in the final days of open enrollment.

Enrollment dropped again in 2018, when 98,238 people enrolled in private plans through the Kansas exchange. Rates had again increased significantly, the majority of the state’s enrollees had to switch plans (more details below), the Trump Administration significantly reduced funding for exchange marketing and enrollment assistance, and there was considerable confusion about the status of the ACA after Congress had spent much of 2017 debating various repeal efforts (all were ultimately unsuccessful except the repeal of the individual mandate penalty, which took effect in 2019).

As was the case in many states that use HealthCare.gov, enrollment dropped again for 2019, for the third year in a row. Enrollment in the Kansas exchange by 2019 was about 11 percent lower than it had been in 2016, with 89,993 people enrolled in coverage for 2019. The Trump Administration had again reduced funding for exchange marketing and enrollment assistance, and the elimination of the individual mandate penalty took effect at the start of 2019, potentially deterring some healthy people from enrolling in coverage. In addition, non-ACA-compliant short-term health insurance plans were expanded under Trump Administration regulations in the fall of 2018, allowing some healthy enrollees to use them as a substitute for ACA-compliant coverage in 2019.

All three insurers continue to offer plans for 2019, with single-digit rate increases

Open enrollment for 2019 coverage in Kansas ended on December 15, 2018. Until open enrollment beings again (for 2020 coverage) on November 1, 2019, the ability to select a new plan or make a change to an existing plan is only available to people who experience a qualifying event.

As of May 2018, Kansas had 87,511 people enrolled in on-exchange individual market plans, plus 13,491 enrollees with off-exchange coverage. All of them had an opportunity to select a different plan for 2019, or to renew their existing plan.

Kansas has three insurers that offer plans in the individual market. All three offer coverage both on-exchange and off-exchange. In Leavenworth and Miami counties, plans are available in 2019 from all three insurers. In Johnson and Wyandotte counties, plans are available from Medica and Sunflower/Ambetter. In the rest of the state, plans are available from Medica and Blue Cross Blue Shield of Kansas.

For 2019, the state approved the following average rate increases for the individual market:

  • Medica: 4.3 percent average increase (down from the 10.7 percent average increase that Medica had requested). Medica has 13,469 members in 2018.
  • Blue Cross Blue Shield of Kansas: 8.28 percent average increase. Plans are available in every county except Johnson and Wyandotte.
  • Sunflower State Health Plan/Ambetter from Sunflower Health (Centene): 2.68 percent average increase. Plans are available in the Kansas City area (Johnson, Wyandotte, Leavenworth, and Miami counties; in 2018, Ambetter’s plans were only available in Johnson and Wyandotte counties, so the insurer is expanding their Kansas City coverage area in 2019)

For benchmark plans (the second-lowest-cost silver plan in each area), average premiums increased by 6.8 percent in 2019. The average premium in Kansas in 2019 is $661/month, but that drops to just $149/month after premium subsidies are taken into account (for perspective, the average premium in the Kansas exchange was $624/month in 2018, and $164/month after subsidies were taken into consideration).

There are no PPOs available in the individual market in Kansas. All the plans offered by BCBSKS and Medica are EPOs, and the plans available from Ambetter are HMOs.

As they did for 2018, Kansas insurers are continuing to add the cost of cost-sharing reductions (CSR) to silver plan rates for 2019. This means premium subsidies continue to be larger than they would have been if the federal government hadn’t stopped reimbursing insurers directly for the cost of CSR. Bronze and gold plans continue to be a particularly good value for people who are eligible for premium subsidies but who aren’t eligible for strong CSR benefits (people who are eligible for strong CSR benefits — that generally means an income below 200 percent of the poverty level — are generally better off buying a silver plan, as that’s the only way they can obtain the CSR benefits, which are significant at that income level).

As an example, a 50-year-old in Lawrence who earns $30,000 in 2019 can get one bronze plan for free and another bronze plan for under $11/month, thanks to a $552/month premium subsidy. She can also get a gold plan for $143/month after her subsidy. The cheapest silver plan available to her would cost $185/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.

For perspective, here’s a summary of how average premiums have changed in Kansas over the last several years:

  • 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.
  • 2016: Across the full individual and small group market in Kansas, the average final rate changes ranged from a 9.4 percent increase to a 25.4 percent increase. But Coventry subsequently announced their exit from the exchange, so their rate increase (25.2 percent) no longer applied in the exchange. However, more than half of the exchange enrollees in Kansas had to select a new plan for 2016.
  • 2017: For Blue Cross Blue Shield of Kansas Solutions, average rates increased by 47.4 percent. For Blue Cross Blue Shield of Kansas City, average rates increased by 28.1 percent. Medica was new to the exchange for 2017, so they had no applicable rate change (Medica capped their enrollment at 10,000 for 2017, but lifted the cap for future years).
  • 2018: Rate changes for 2018 were based on the (correct) assumption that cost-sharing reduction (CSR) funding would not continue (the additional cost to cover CSR was added to silver plans). Medica’s average premiums increased by 29 percent. Blue Cross Blue Shield of Kansas technically didn’t have an official rate change for 2018, because they terminated all of their plans (HMOs) and replaced them with new plans (EPOs) at the end of 2017. Sunflower State Health Plan (Ambetter/Centene) also didn’t have an applicable rate change, as they were new to the Kansas market for 2018.

Insurer participation in the Kansas exchange, plus a look at how a new state law has transformed plan offerings

Three insurers offer plans in the Kansas exchange in 2019, but there has been some shifting in the insurer exchange landscape in Kansas over the last few years. Here’s a summary of insurer participation by year:

  • 2014: Aetna/Coventry, and Blue Cross Blue Shield of Kansas Solutions
  • 2015: Aetna/Coventry, and Blue Cross Blue Shield of Kansas Solutions
  • 2016: UnitedHealthcare, and Blue Cross Blue Shield of Kansas Solutions
  • 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.
  • 2018: Blue Cross Blue Shield of Kansas (formerly called Blue Cross Blue Shield of Kansas Solutions), Medica, and Sunflower/Ambetter/Centene.
  • 2019: Blue Cross Blue Shield of Kansas, Medica, and Sunflower/Ambetter/Centene.

And some highlights regarding insurer participation:

Aetna/Coventry initially participated in the exchange in Kansas, but exited the exchange at the end of 2015. They later filed plans to rejoin the Kansas exchange for 2017, but in August 2016, 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.

UnitedHealthcare did not participate in 2014 and 2015, but joined the exchange for 2016. However, they exited the entire individual market in the state at the end of 2016.

Medica joined the exchange in 2017. Their plans became available state-wide in 2018, including an expansion into Johnson and Wyandotte counties, where Medica didn’t offer coverage in 2017 (Medica only offered EPOs in Johnson and Wyandotte counties, and PPOs throughout the rest of the state).

Blue KC exited the individual market (on- and off-exchange) in Kansas and Missouri at the end of 2017, amid concerns about market stability. 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 Kansas 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 for 2018.

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 was the first year they offered private plans for sale in the exchange. Sunflower State Health Plan (Ambetter from Sunflower Health) began 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 would be 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).

Regarding the switch from HMO to EPO plans, Kansas enacted legislation (HB2454) in 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 can be functionally very similar to HMOs, but aren’t 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.

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. Plan terminations obviously include situations in which a carrier exits the market, but they also include scenarios like BCBS of Kansas had at the end of 2017, when all of their HMOs were replaced with EPOs.

So the only Kansas plans that weren’t terminated at the end of 2017 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.

The three insurers that offered plans in 2018 all continued to do so in 2019, so enrollees had much more continuity heading into 2019 than they’d had the year before.

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 then-Insurance Commissioner Sandy Praeger and some early support from then-Governor Sam 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 cost 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

HealthCare.gov
800-318-2596

insureKS.org

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.