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

Magnolia/Ambetter offering plans for 2019; rates virtually unchanged from 2018. Enrollment grew nearly 6% in 2019

Highlights and updates

Mississippi exchange overview

Mississippi uses the federally run exchange for individual market plans, so residents who buy their own health insurance enroll through Healthcare.gov. The state initially ran its own SHOP exchange for small businesses, dubbed One Mississippi, but had switched to the federally-run SHOP exchange by 2018 (and the federally-run SHOP exchange had switched to a direct-to-carrier enrollment model by that point).

Blue Cross Blue Shield of Mississippi has a strong presence in the Mississippi individual market, but they do not participate in the exchange. Magnolia/Ambetter is offering offer plans statewide in the Mississippi exchange in 2019, and is the only insurer offering exchange coverage after Humana exited at the end of 2017.

2019 rates and plans

Open enrollment for 2019 plans ended on December 15, 2018, but residents can still enroll in ACA-compliant plans if they have a qualifying event. A total of 88,542 people enrolled in plans for 2019, which was 5.8 percent higher than enrollment had been in 2018. Most states that use HealthCare.gov saw an enrollment decline in 2019, but Mississippi bucked that trend. Among the 39 states that use HealthCare.gov, only six saw their enrollment grow in 2019, and only Oklahoma had a higher percentage increase in enrollment than Mississippi.

Ambetter/Magnolia continues to be the only insurer offering plans in Mississippi’s exchange. Average premiums for Ambetter plans were mostly unchanged for 2019, with an average rate increase of just 0.27 percent.

Almost all of Mississippi’s exchange enrollees — 96 percent — received premium subsidies in 2018 (that’s the highest rate in the nation; the nationwide average was 87 percent; this is unsurprising, since subsidy eligibility is based on income, and Mississippi has the lowest average household income in the US). Premium subsidies are based on the cost of the benchmark plan, and average benchmark premiums in Mississippi are also virtually unchanged in 2019, with an average increase of just 0.2 percent. So average subsidies are very similar to the amounts people got for 2018. The percentage of income that people have to pay for the benchmark plan, after subsidies, is a little higher for 2019 than it was in 2018, but that is at least partially offset by the slight increase in the cost of the average benchmark plan.

Ambetter is continuing to add the cost of cost-sharing reductions (CSR) to premiums for plans at all metal levels (ie, a “broad load”), rather than just to silver plan premiums. This was confirmed in Ambetter’s actuarial memo for 2019.

As discussed below, Mississippi was one of just five states (Colorado, IndianaWest Virginia, and Delaware) where the cost of CSR was added to premiums at all metal levels for 2018, after the Trump Administration cut off federal funding for CSR. For 2019, Delaware and Colorado have switched to having insurers add the cost of CSR only to silver plans, but Mississippi, Indiana, and West Virginia are continuing to have insurers spread the cost of CSR across all plans. Mississippi Commissioner Mike Cheney favors the broad load approach, saying that it’s fairer for everyone.

But when the cost of CSR is added to silver plan premiums, it results in much larger premium subsidies for anyone who gets a subsidy. And people who don’t get a subsidy can either enroll in a bronze or gold plan (without the cost of CSR added to the premiums), or, if off-exchange-only plans are available, those can also be offered without the cost of CSR added in, even at the silver plan level. Adding the cost of CSR to only silver plan premiums is considered the approach that’s most beneficial to the most people.

Interestingly, Ambetter also noted that they did not add to their premiums for 2019 to account for the fact that the Trump Administration has made it easier for healthy people to exit the individual market and enroll instead in longer short-term plans (and for the self-employed, association health plans). Mississippi defaults to the federal rules for short-term plans, so short-term policies in the state are now available with initial terms of up to 364 days.

Blue Cross Blue Shield of Mississippi continues to only offer plans outside the exchange

As has been the case in prior years, Blue Cross Blue Shield of Mississippi is continuing to offer their plans only outside the exchange for 2019. Their average premiums are slightly lower (a decrease of 0.22 percent) for 2019, but premium subsidies are not available to offset the cost of BCBSMS plans, since they’re only sold outside the exchange, and subsidies can only be used for plans purchased in the exchange.

Mississippi exchange enrollment: 2014-2019

For 2014 (the first year that the exchanges were operational), 61,494 people signed up for private plans in the Mississippi exchange. About 40,000 of those enrollees selected a plan from Humana (in all but four counties, Humana was the only carrier available in 2014). Although Mississippi has not expanded Medicaid, another 13,779 people qualified for either Medicaid or the Children’s Health Insurance Program (CHIP) under existing eligibility criteria during that year’s open enrollment period (Medicaid and CHIP enrollment continue year-round, but tend to spike during open enrollment due to the marketing and outreach.

Enrollment grew sharply the following year, when 104,538 people enrolled in private plans through the Mississippi exchange during the open enrollment period for 2015 coverage. But 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.

For 2016 coverage, enrollment grew again, 108,672 people signing up during open enrollment. This included renewals and new enrollees, and also accounted for early attrition through February 1 (this was the first year that CMS accounted for any attrition in their open enrollment reports). But effectuated enrollment stood at 77,747 by March 31, 2016 — that’s an attrition rate of 28 percent, which was more than double the national average rate of attrition during the first quarter.

As was the case in the majority of states that use HealthCare.gov, enrollment in Mississippi’s exchange declined in 2017. During the open enrollment period, just 88,483 people enrolled in private individual market plans through the Mississippi exchange. President Trump took office less than two weeks before the end of open enrollment that year, and immediately eliminated an advertising campaign that had been designed to direct people to HealthCare.gov to enroll in coverage. Across all states that use HealthCare.gov, enrollment dropped by about 5 percent in 2017, but in Mississippi, it dropped by almost 19 percent.

Enrollment declined again in 2018 — as was again the case in the majority of states that use HealthCare.gov — but this time the decrease in Mississippi’s enrollment was similar to the average in other states, which was again about 5 percent. 83,649 people enrolled in coverage through the Mississippi exchange during the open enrollment period for 2018 coverage. The fairly small reduction in enrollment came despite the fact that open enrollment was half as long for 2018, and despite the fact that the Trump Administration slashed funding for enrollment assistance and exchange marketing in the weeks leading up to open enrollment.

88,542 people enrolled in private plans (QHPs) through the Mississippi exchange during the open enrollment period for 2019 coverage. This was an increase of nearly 6 percent, as opposed to an average enrollment decrease of nearly 4 percent across all the states that use HealthCare.gov. So although Mississippi’s exchange enrollment peaked in 2016 and declined in 2017 and 2018 (as was the case in most states that use HealthCare.gov), enrollment trended back upwards in 2019, which was a departure from the norm in HealthCare.gov states (most of which have seen steady declines in enrollment since peaking in 2016).

Insurer participation in Mississippi’s exchange: 2014-2019

In 2011 and 2012 — back when Mississippi was considering creating its own State-run exchange — Blue Cross Blue Shield of Mississippi (which had more than 80 percent of the market share in Mississippi) had told Insurance Commissioner Mike Chaney that they would participate in the exchange. But due to conflicts among the state’s leadership, HHS rejected Mississippi’s exchange application (more details below), and at that point, BCBS of Mississippi pulled out.

That left Humana and Magnolia Health Plan as the only two carriers for 2014. But leading up to the federally-run exchange’s fall 2013 debut, Mississippi had a problem. The two carriers had selected the counties in which they wanted to operate, and 36 of the state’s 82 counties had no participating carriers at all. Humana ultimately decided to go ahead and offer coverage state-wide in 2014, but only four of the state’s counties had plans available from both carriers in 2014.

In 2014 and 2015, plans were available in Mississippi’s exchange from Humana and Magnolia Health Plan (Ambetter/Centene).

For 2016, UnitedHealthcare joined them, bringing the total number of insurers on the individual exchange to three. United was the only carrier in the Mississippi exchange that offered coverage in all 82 counties in the state in 2016. Residents in every county in the state had at least two carriers from which to choose that year, and 32 counties had plans available from all three carriers.

But for 2017, United left the state (as was the case in most states where United had been offering exchange plans), and Mississippi’s exchange was back to just Humana and Magnolia (Mississippi Insurance Commissioner Mike Chaney had reported in August 2016 that a third health insurer had proposed joining the exchange state-wide, but had been rejected by HHS due to “lack of an adequate network and specialists in each county”).

Although Humana exited the exchanges in several states at the end of 2016, they stayed in Mississippi for 2017. There were 32 counties where both insurers offered plans that year, and 50 counties where the only carrier offering plans in the exchange was Magnolia (Magnolia had expanded to offer coverage statewide as of 2017).

Humana’s decision to remain in the exchange was short-lived, however, as they announced in February 2017 that they would no longer offer individual market plans in any state after 2017. But Centene (Magnolia/Ambetter in Mississippi) continued to offer coverage. In April 2017, Centene announced that they were planning to remain in the exchanges in 2018 in the states where they were already participating, which was in contrast to quite a few other insurers’ decisions to exit the exchanges in various states at the end of 2017. According to Centene Chairman and CEO, Michael Neidorff, “Centene’s exchange experience continues to be favorable, and we are achieving margins at the higher end of our targeted range.”

So as of 2018, Magnolia/Ambetter was the only insurer offering plans in Mississippi’s exchange, and that continues to be the case in 2019.

Rate changes in Mississippi’s exchange over the years

2014:

For 2014, individual market health insurance premiums were essentially actuaries’ best guesses, as there was no market experience on which to base the rates (prior to 2014, individual market coverage was medically underwritten, so there was a seismic shift in 2014 in terms of claims experience). In 2014, Mississippi’s pre-subsidy average premium was $438/month — the fifth-highest among the 36 states that used Healthcare.gov.

2015:

In 2015, according to an analysis published by The Commonwealth Fund, average premiums in Mississippi were 19 percent lower than they had been in 2014. The weighted analysis looked at premium amounts, differences in premiums between urban/suburban/rural areas within states, and insurer participation. A similar analysis from PricewaterhouseCoopers found an average rate decrease of 9.3 percent from 2014 to 2015 — still a significant rate decrease, but not as substantial as the Commonwealth Fund’s result.

2016:

Premium changes were generally quite modest in Mississippi for 2016. According to the Mississippi Business Journal, average rate changes for 2016 were:

  • Magnolia Health/Ambetter: average decrease of 2.9 percent (18,000 enrollees as of November 1, 2015)
  • 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)

Once all of the plan selections for 2016 had been finalized, 90 percent of Mississippi exchange enrollees qualified for premium subsidies. Their average pre-subsidy premium was $388 per month (a little lower than the $396/month average across all states that use Healthcare.gov), and their average after-subsidy premium was $91/month (the average after-subsidy premium across all Healthcare.gov states was $106/month that year).

Statewide, the average benchmark (second-lowest-cost Silver) plan premium was 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 had lower average benchmark premiums in 2016, and Mississippi was one of them. 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 benchmark premiums, so average subsidies in Mississippi were smaller in 2016 than they were in 2015.

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 was 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.

2017:

The following rate increases were proposed and approved for the Mississippi exchange in 2017 (rate increases are calculated before premium subsidies are applied):

  • Humana: 43 percent (Humana had about 13,000 exchange enrollees in 2016)
  • Magnolia/Ambetter: 7 percent (Magnolia had about 40,000 exchange enrollees in 2016)

Outside of the exchange, Blue Cross Blue Shield of Mississippi had an average rate increase of 16.12 percent for 2017. At ACA Signups, Charles Gaba calculated an average rate increase of 15.82 percent for the two exchange carriers, which is very similar to the rate hike for BCBSMS off-exchange plans.

2018:

For 2018, Magnolia/Ambetter initially proposed average rate increases of 18 percent for their standard individual market plans, and 21.4 percent for their plans that include adult dental and vision coverage. The rate filing was heavily redacted, but it did note that the proposed rates were based on the assumption that the federal government would continue to fund cost-sharing reductions (CSR), and that larger premium increases would be necessary if CSR funding were to end.

Ultimately, the Trump Administration did eliminate federal funding for CSR in October 2017, but Ambetter/Magnolia had already filed revised rates over the summer with the assumption that CSR funding would end. The revised rate proposal, which was approved by regulators, called for an average increase of 47.3 percent — more than two and a half times as large as the originally proposed increase.

The dramatic increase in the revised rates is because CSR is a larger expense in Mississippi than it is in other states. 86 percent of Mississippi exchange enrollees were receiving cost-sharing reductions at that point — the highest percentage in the nation, and well above the national average of 53 percent. Eligible enrollees have continued to receive CSR benefits, but the federal government is no longer reimbursing insurers for providing that benefit. So insurers in nearly every state added the cost of CSR to their premiums starting in 2018. In most states, the cost of CSR was added only to silver plans, which is beneficial for most enrollees, since premium subsidies are based on the cost of a silver plan, and larger silver plan premiums mean larger subsidies.

But in Mississippi, Ambetter/Magnolia’s revised rate filing noted that the cost of CSR was added to the premiums of all ACA-compliant plans, including those sold outside the exchange. Only a few other states took this “broad load” approach (Colorado, Delaware, Indiana, and West Virginia). Premium subsidies were much larger in Mississippi for 2018 than they were for 2017, since premiums increased by an average of 47.3 percent. But since plans at all metal levels are sharing the burden of the cost of CSR, the free or ultra-low-cost bronze plan premiums (after subsidies) that became available in some areas of the country were not available in Mississippi (and Mississippi has continued to use the “broad load” strategy in 2019).

To clarify, Blue Cross Blue Shield of Mississippi does not add the cost of CSR to their plans, since they don’t incur any costs for CSR because their plans are not available on the exchange. Magnolia’s ACA-compliant plans include the cost of CSR in the premiums regardless of whether they’re sold on or off-exchange.

Mississippi’s Insurance Commissioner, Mike Chaney, noted in August 2017 that he didn’t think that CSR funding would continue, and that ultimately ended up being a prescient call, as CSR funding was eliminated two months later. Chaney’s office had initially directed Magnolia/Ambetter to file rates based on the assumption that cost-sharing reduction funding would continue, but noted that they’d be able to file new rates if CSR funding was not allocated (the revised were ultimately approved, based on the assumption that CSR funding would not continue).

King v. Burwell: Chaney had a plan in case SCOTUS ruling had been different

In June 2015, the Supreme Court ruled that subsidies are legal in every state, regardless of whether the exchange is run by the state or the federal government. That was great news for Mississippi residents, insurers, and healthcare providers; 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.

Enrollment assistance

The University of Mississippi Medical Center got the majority of the Navigator grants that were awarded by the federal government in August 2013 to fund enrollment efforts in Mississippi for 2014. Of $1.1 million that Mississippi received, $832,000 went to UMMC. Oak Hill Baptist Church got the remaining Navigator funding that year, but by 2015, Oak Hill had become the primary Navigator grant recipient in Mississippi, receiving $547,867 to assist with enrollment efforts for 2016 (another $415,224 was awarded to the University of Southern Mississippi in September 2015).

Navigator funding has been drastically reduced under the Trump Administration, however. In 2018, total Navigator grants in Mississippi came to less than $188,000.  My Brother’s Keeper received $100,000 and Oak Hill got about $88,000.

Exchange creation battle in Mississippi

State Commissioner of Insurance Mike Chaney clashed with two governors as to what form a health insurance exchange should take in Mississippi. Chaney, former Gov. Phil Bryant, and former Gov. Haley Barbour are all Republicans and on record as opposing the Affordable Care Act. However, Chaney consistently maintained that the state would be better off running its own exchange.

Chaney pushed hard for a state-run exchange. In 2011, he announced that the Mississippi Comprehensive Health Insurance Risk Pool Association would operate an exchange. The Risk Pool Association developed a plan in which the exchange would be developed in four phases, with work outsourced.

Early exchange planning was carried out by the board of directors of the Risk Pool Association and an advisory board appointed by Chaney. The Risk Pool Association, the advisory board, and the insurance department continued working throughout 2012, and in November, Chaney notified the U.S. Department of Health and Human Services (HHS) that Mississippi intended to implement a state-run exchange. However, Bryant told HHS in December 2012 that Chaney had overstepped his authority.

It was also in 2012 that anti-ACA influences from outside Mississippi (including the Koch Brothers and the Cato Institute) began pressuring Cheney to give up his push for a state-run exchange. But One Mississippi, the state-run exchange that Cheney created, opened in October 2012, a year before the ACA-sanctioned exchanges nationwide. One Mississippi didn’t have any premium subsidies (those wouldn’t be available until the first ACA open enrollment period began in October 2013), but it did have coverage for sale. The task at that point switched to obtaining federal approval to have One Mississippi be the state’s official ACA exchange.

But ultimately, Governor Bryant’s opposition to the exchange was its downfall. In February 2013, HHS rejected Mississippi’s exchange blueprint, telling Chaney that it simply wouldn’t work without the Governor’s support. The exchange would have needed to work with the Mississippi Medicaid program — overseen by a Bryant appointee — and there were too many concerns that Bryant would be able to derail the exchange via funding or hiring decisions. The federal government said at the time that they “didn’t feel that [they] should get involved in a battle between two elected state officials.”

Mississippi was the only state whose exchange blueprint was rejected by the federal government, and in February 2013, One Mississippi shut down. The federal government ran the individual exchange in Mississippi from the start, but One Mississippi opened back up as the state-run SHOP exchange in the spring of 2014, offering health insurance options for small businesses. By 2018, however, Mississippi had opted to return to the federally-run exchange for small businesses. And even the federally-run small business exchange had switched to a direct-to-carrier enrollment model (instead of an enrollment portal on HealthCare.gov) by that point, as small business enrollment in the exchange had been quite low throughout most of the country.

Several factors constrain marketplace enrollment in the Magnolia State. Political opposition to the Affordable Care Act is very strong, many residents are distrustful of government assistance, and outreach efforts are limited. In a state with a 22 percent poverty rate, many people find premiums too expensive — even with subsidies factored in. And the Medicaid coverage gap is significant in Mississippi: Kaiser Family Foundation estimates that 103,000 Mississippi residents are in the coverage gap — ineligible for Medicaid (because the state has refused federal funding to expand Medicaid) and ineligible for subsidies in the exchange because their income is under the poverty level.

Mississippi health insurance exchange links

HealthCare.gov
800-318-2596

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 / healthhelpms@mhap.org


Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.