During the 2016 open enrollment period, private plan enrollment in Mississippi’s exchange reached 108,672 people. This included renewals and new enrollees, and also accounted for early attrition. In a departure from the previous two years – when attrition wasn’t factored in until after open enrollment had ended – HHS has been subtracting unpaid and cancelled enrollments over the last several weeks. As a result, the effectuated enrollment total shouldn’t be dramatically lower than the enrollment tally as of February 1.
For perspective, there were roughly 61,000 people with in-force coverage as of November 1 (see details below), so Mississippi’s exchange attracted a significant number of new enrollees for 2016; increasing total enrollment by more than 78 percent. When we compare 2016 enrollment with 2015 enrollment (103,600 people), the 2016 enrollment is only higher by about 5,000 people. But when we consider the fact that initial unpaid and cancelled enrollments have already been subtracted, the 2016 enrollment number appears more significant.
Open enrollment for 2016 is now over. You can still enroll in a plan for 2016 if you experience a qualifying event, and Native Americans can enroll year-round. In addition, Medicaid and CHIP enrollment continue year-round. Open enrollment for 2017 is tentatively scheduled to begin November 1, 2016.
Legislation introduced to block Obamacare
On February 8, Republican State Senator Michael D. Watson Jr. introduced SB2543, which would effectively block all Mississippi agencies and employees from having any part in enforcement or implementation of the ACA. The legislation would also prohibit the state from creating a state-based exchange or expanding Medicaid. Neither of those have been done in Mississippi, but legislation blocking them would make it more difficult for a future governor to set a new course for Mississippi.
SB2543 was referred to the Senate’s Medicaid committee as soon as it was introduced. The legislation does not include any language in terms of how Obamacare should be replaced or any sort of alternate structure to make health insurance affordable and accessible to the people of Mississippi; it merely blocks the state from taking any part in the continued implementation of the law.
Three carriers offer plans through the Mississippi exchange: Humana, Ambetter/Magnolia, and UnitedHealthcare. According to the Mississippi Business Journal, average rate changes for 2016 were:
- Magnolia Health/Ambetter: average decrease of 2.9 percent (18,000 enrollees as of November 1)
- Humana: average decrease of 0.2 percent (16,915 enrollees as of November 1)
- UnitedHealthCare: average increase of 6.6 percent (26,000 enrollees as of November 1)
But only Humana’s rate filing (which was approved as-proposed) was displayed on Healthcare.gov’s rate review tool. For 2016, average rate changes for Humana plans in the Mississippi exchange ranged from a 2.5 percent decrease to a 2.4 percent increase. Rate filings for Magnolia/Ambetter and UnitedHealthcare don’t show up on Healthcare.gov’s rate review tool, even after the data was adjusted to show all rates, as opposed to only rate increases of ten percent or more (as was the case from June through October).
The Mississippi Business Journal obtained the above enrollment numbers from the Mississippi Insurance Department. They indicate significant attrition from July through October, as the exchange had 73,223 people with in-force private plan coverage at the end of June, and the total as of November 1 was only about 61,000.
Based on the enrollment as of November 1, the weighted average rate change in the Mississippi exchange was only about 1.9 percent for 2016 – and that came on the heels of an average rate decrease in 2015.
Statewide, the average benchmark (second-lowest-cost Silver) plan premium is 8.2 percent less expensive in 2016 than it was in 2015. Out of the 37 states that used Healthcare.gov in 2015, only four have lower average benchmark premiums in 2016, and Mississippi is one of them. In Jackson, the average benchmark premium for a 30 year old decreased by 9.2 percent – from $305/month to $277/month. Those are unsubsidized premiums; for people who qualify for subsidies, the after-subsidy monthly premium is lower. And as of mid-2015, more than 95 percent of Mississippi’s exchange enrollees were receiving premium subsidies – the highest percentage in the nation (unsurprising, since subsidy eligibility is based on income, and Mississippi has the lowest average household income in the US).
The benchmark plan isn’t necessarily the same plan from one year to the next, so the changes in benchmark premiums don’t really tell us much about how premiums on specific plans are changing. But premium subsidies are tied to benchark premiums, so average subsidies in Mississippi are lower in 2016 than they were in 2015, highlighting the importance of shopping around during open enrollment as opposed to letting plans auto-renew.
Outside the exchange, Blue Cross Blue Shield of Mississippi requested an average rate increase of more than 25 percent, but their final approved rate increase was 16.5 percent. Also off-exchange, Enterprise Live and Freedom Life both ended up with average rate increases of 9.9 percent. UnitedHealthcare is also listed in the rate review tool with a rate increase of 21.1 percent, but only for off-exchange plans that have a total of 513 enrollees.
Blue Cross Blue Shield had the lion’s share of the market in Mississippi prior to 2014 (roughly 80 percent), but they have not participated in the exchange. Their substantial rate increase for 2016 may be a driving factor in the increase in enrollments for the Mississippi exchange, since premium subsidies are only available through the exchange. For a 50 year-old non-smoker in Hinds County (Jackson), the cheapest plan available from BCBS of Mississippi is $436/month. The plan has a $5,000 deductible, $6,500 maximum out-of-pocket, and no subsidies are available since it’s only sold outside the exchange.
That same applicant – with an annual income of $40,000 and no dependents – could get a plan through the exchange for $285/month with a $6,800 deductible. For a plan with a $5,500 deductible, $6,500 maximum out-of-pocket, and copays for office visits and prescriptions (which the BCBS plan does not offer), the price is $330/month through the exchange. And it’s important to note that if the person’s income is lower than $40,000, the premium will be lower as well. As opposed to a plan outside the exchange, which doesn’t include any premium relief, regardless of how little the applicant earns.
It makes sense that some BCBS members who had thus far purchased plans outside the exchange might have switched to on-exchange plans for 2016 as a result of the rate increases on their BCBS plans.
According to an analysis published by The Commonwealth Fund, average premiums in Mississippi were 19 percent lower in 2015 than in 2014. The weighted analysis looked at premium amounts, differences in premiums between urban/suburban/rural areas within states, and insurer participation. But 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.
In 2014, Mississippi’s pre-subsidy average premium was $438/month – the fifth-highest among the 36 states that used Healthcare.gov.
2015 enrollment data
About 103,600 Mississippi residents selected health plans through HealthCare.gov during 2015 open enrollment. While that’s 42,000 more signups than during 2014 open enrollment, it is still just 37 percent of those eligible to enroll according to Kaiser Family Foundation estimates.
And attrition was particularly high in Mississippi in 2015. By the end of March, just 80,011 people had effectuated exchange coverage in place, and that had dropped to 73,223 by the end of June. That’s 71 percent of initial enrollments; nationwide, 85 percent of enrollees had effectuated coverage by the end of June, so Mississippi was well below average in that regard.
The Kaiser Family Foundation estimated that 28 percent of Mississippi’s eligible population had enrolled in coverage through the exchange by the end of March – a little lower than the national average of 36 percent, but higher than twelve other states.
Mississippi’s exchange population tended to be relatively low-income, with 89 percent having incomes under 250 percent of the poverty level. Those enrollees were eligible for cost-sharing subsidies, and 85 percent of them selected silver plans, meaning that they obtained coverage that included the cost-sharing subsidies (cost sharing subsidies are only available if you purchase a silver plan). In all, more than 77 percent of the 73,223 people who had coverage at the end of June were enrolled in plans that included cost-sharing subsidies.
UnitedHealthcare joined the Mississippi marketplace for 2015, bringing the total number of insurers on the individual exchange to three in the state. Humana and Magnolia Health Plan were part of the marketplace in 2014 and returned for 2015.
United’s entry brought welcome competition to Mississippi. For 2014, residents of some counties had access to just a single insurer’s plans through the exchange. In 2011 and 2012 – back when Mississippi was in the process of creating it’s 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 2015, when UnitedHealthcare joined the exchange, every county in Mississippi had at least two participating carriers, and 13 counties had coverage options available from all three carriers.
For 2016, Humana’s plans are not available in all areas of the state. But UnitedHealthcare has expanded to offer coverage state-wide, so every county in the state still has at least two carriers from which to choose, and 32 counties have plans available from all three carriers.
King v. Burwell – subsidies no longer in danger
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; 95 percent of the people who are enrolled in private plans through the Mississippi exchange are 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 be 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).
Small business marketplace
Mississippi began operating its own Small Business Health Options Program (SHOP) exchange — which is called One, Mississippi — in May 2014. One, Mississippi is open to employers with 50 or fewer full-time employees.
How many Mississippians enrolled in 2014?
Mississippi was 33rd in terms of the percentage of eligible individuals who enrolled in a qualified health plan (QHP) through the marketplace in 2014. According to the Kaiser Family Foundation, 61,494 people signed up for health plans, and another 13,779 people qualified for either Medicaid or the Children’s Health Insurance Program (CHIP) under existing eligibility criteria.
Among Mississippi residents enrolling in QHPs, 94 percent qualified for financial assistance, compared to 85 percent nationally. A report released in June by the U.S. Department of Health and Human Services showed the average monthly premium, after tax credits, for Mississippi consumers was just $23. That’s the lowest average in the nation.
Eight percent of Mississippi residents selected a bronze plan (20 percent nationally), 79 percent selected a silver plan (65 percent nationally), 5 percent selected a gold plan (9 percent nationally), 7 percent selected a platinum plan (5 percent nationally) and 1 percent selected a catastrophic plan (2 percent nationally). Thirty-one percent of Mississippi enrollees were between the ages of 18 and 34.
40,000 of the state’s 61,000 exchange enrollees in 2014 selected a plan from Humana (in all but four counties, Humana was the only carrier available in 2014).
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, current 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 OneMississippi, the state-run exchange that Cheney created, opened in October 2012, a year before the ACA-sanctioned exchanges nationwide. OneMississippi 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 OneMississippi 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, OneMississippi shut down. The federal government runs the individual exchange in Mississippi, but OneMississippi opened back up as the state-run SHOP exchange in the spring of 2014, offering health insurance options for small businesses.
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 108,000 of Mississippi’s 359,000 uninsured 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