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

Three insurers in 2018; enrollment dropped less than half a percent. Medica will join in the Kansas City area in 2019

Highlights and updates

Missouri exchange overview

Missouri uses the federally facilitated marketplace, which means residents enroll through Healthcare.gov if they want a plan through the exchange. 2017 marked the first time since ACA-qualified plans became available that Missouri regulators conducted their own review of rates (for plans that will be effective in 2018). Prior to 2017, the federal government handled the rate review process for ACA-compliant plans in Missouri, as they still do for Texas, Wyoming, and Oklahoma.

HHS reported that from 2010 to 2015, a total of 203,000 people in Missouri gained health insurance coverage as a result of the ACA. As of February 2017, effectuated enrollment in Missouri’s exchange stood at 213,186. Missouri has thus far refused to accept federal funding to expand Medicaid, which means that there’s a coverage gap for childless adults with income below the poverty level.

Medica joining in Kansas City area for 2019

Insurers that plan to offer coverage in 2019 had to file rates with the Missouri Department of Insurance by July 25, 2018. But Medica announced in late June that they plan to join the Missouri exchange in the Kansas City area (Cass, Clay, Jackson, and Platte counties). Medica began offering plans on the Kansas side of the Kansas City area in 2018, and will expand into the Missouri side for 2019.

The Missouri Department of Insurance has created a map that shows the coverage areas of the four individual market insurers for 2019 (plans are available both on and off-exchange). In four counties in the Kansas City area, plans will be available from three insurers (Cigna, Medica, and Ambetter/Celtic). Consumers in the St. Louis area will be able to choose from two insurers, as will consumers in southwestern Missouri. But most rural areas of the state will continue to have just one insurer offering plans — in most cases, either Anthem (Healthy Alliance Life) or Celtic/Ambetter.

Average proposed rate increases for 2019 are modest

The Missouri Department of Insurance has posted a summary of the proposed rate changes for 2019. In the individual market, all four insurers plan to offer on-exchange plans, and have filed the following average rate changes:

  • Healthy Alliance Life (Anthem): 3.67 percent increase
  • Cigna: 7.3 percent increase
  • Celtic/Ambetter: 8.6 percent DECREASE
  • Medica: New to the state, so no applicable rate change

At ACA Signups, Charles Gaba has calculated a weighted average proposed rate increase of just 1.88 percent — but he notes that rates would likely be dropping by about 10 percent if the individual mandate penalty wasn’t being eliminated and if short-term and association health plans weren’t being expanded (all of those factors result in fewer healthy people having coverage in the ACA-compliant risk pool, which causes higher premiums).

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

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

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

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

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

But since the legislation didn’t pass, Missouri will not get any federal pass-through funding for reinsurance in 2019.

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

2018 enrollment less than half a percent lower than 2017’s enrollment

243,382 people purchased private plans through the Missouri exchange during open enrollment for 2018 coverage, which ran from November 1, 2017 to December 15, 2017. This was the first time that open enrollment ended before the start of the year, and the enrollment window was only half as long as it had been in previous years.

And yet enrollment was less than half a percent lower than it had been in 2017, when 244,382 people signed up through Missouri’s exchange. Nationwide, across all the states that use HealthCare.gov, enrollment declined by about 5 percent. That was due in part to the shorter enrollment period, but also to the funding cuts that the Trump Administration made to the exchange’s marketing and enrollment assistance budgets, to the price increases for people who aren’t eligible for premium subsidies, and to the general uncertainty that surrounded the ACA and Congressional attempts to repeal it in 2017.

Open enrollment for 2019 coverage will run from November 1, 2018 to December 15, 2018. Between now and then, enrollees need a qualifying event in order to purchase ACA-compliant coverage or switch plans, on or off-exchange.

For 2018, Blue KC and Humana exited ACA-compliant individual market, Ambetter/Celtic joined to fill area left bare by Blue KC exit

Three insurers are offering plans in the Missouri exchange for 2018: Anthem (Healthy Alliance Life Insurance), Cigna, and Ambetter/Celtic (Centene).

The Missouri exchange had four participating insurers for 2017, but two of them — Humana and Blue KC — announced that they would exit the exchange at the end of 2017, and did not offer plans for 2018.

The other two — Anthem (Healthy Alliance Life) and Cigna — continued to offer coverage in the exchange. When Cigna confirmed that they would remain in the seven exchanges where they offered plans in 2017, they noted that their Missouri experience has been somewhat positive, explaining that “If you get the right collaborative relationships up and running with physician groups and hospital groups like we have in Missouri, you can generate a better result, not a stellar result, but a better result.” Cigna’s participation is limited to 10 counties in the St. Louis area and five counties in the Kansas City Area.

Humana announced in February 2017 that they would end their ACA-compliant individual products at the end of 2017, in all 11 states (including Missouri) where they offered coverage in 2017. Humana plans were available in five Missouri counties in 2017: Jasper, Green, Newton, Jackson, and Clay. Humana members needed to select new coverage during open enrollment (November 1, 2017 through December 15, 2017), or during their special enrollment period triggered by loss of other coverage, which extended until March 1, 2018.

Blue KC offered individual market coverage — on and off-exchange — in 30 western Missouri counties in 2017. But they announced in May 2017 that they would exit the ACA-compliant individual market at the end of 2017, in both Missouri and Kansas, and that 67,000 enrollees would need to secure new 2018 coverage during open enrollment. People who have grandmothered and grandfathered individual market plans (ie, purchased prior to October 2013) were not impacted by the exit.

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

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

In June 2017, Centene announced that they would enter the exchange in Kansas and Missouri. Centene already had a Medicaid managed care contract in Missouri, covering Medicaid enrollees under the Home State Health Plan. At that point, it wasn’t clear which counties would be covered by Centene. But on June 30, Missouri Insurance Director Chlora Lindley-Myers announced that Ambetter/Celtic Insurance (a Centene company) would be joining the exchange for 2018, and would offer coverage in all 25 of the counties that would otherwise have been left without an insurer in the wake of Blue KC’s exit. In total, Ambetter/Celtic is offering exchange plans in 40 counties in Missouri in 2018.

There were several other places around the country — in Indiana, Nevada, Washington, Kansas, Tennessee, Wisconsin, and Ohio — that faced the prospect of having no insurers in their exchanges but all of them have ultimately ended up with insurers slated to offer plans.

Anthem reduced coverage area from 84 counties to 68 counties; Cigna and Ambetter covering the counties Anthem left.

On September 1, 2017, Anthem announced that they would be reducing their coverage area on and off-exchange in Missouri’s ACA-compliant individual market for 2018. In 2017, Anthem offered plans in most of the state — everywhere except 30 western counties that were served by Blue KC.

For 2018, Anthem’s participation has been reduced to 68 counties (a full list is in the press release), and the insurer noted that these were all counties that would otherwise have no insurers offering coverage.

Among the areas Anthem exited are Boone County (Columbia) and the St. Louis area. St. Louis residents have Cigna plans available, as they were previously slated to have only Cigna and Anthem. Cigna is also offering plans in Boone County in 2018. Cigna’s rate filing included rating area 5 for 2018, which includes Boone County. Rating area 5 is comprised of 17 counties, but I confirmed with Cigna that their expansion is limited to Boone County, and not the rest of rating area 5.

Anthem exited these 16 counties: Barry, Boone, Christian, Franklin, Greene, Jasper, Jefferson, Lawrence, Lincoln, Newton, Saint Charles, Saint Francois, Saint Louis, Sainte Genevieve, Warren, and Washington.

Four of those counties — Barry, Boone, Christian, and Lawrence — only had access to Anthem plans in the exchange in 2017. But Barry, Christian, and Lawrence are among the 40 counties that Ambetter/Celtic is covering for 2018, and Cigna’s expansion to Boone County means that none of the areas Anthem exited are without insurers in 2018.

Average rate increases for 2018

Proposed rates for 2018 coverage had to be filed in Missouri no later than July 17, 2017, although plan proposals had to be filed by the June 21 deadline that CMS imposed. The Missouri Department of Insurance noted that proposed rate filings would not be public before August 1, 2017, and ultimately the data was publicized on September 1. For all three insurers, the proposed rates were deemed reasonable by regulators.

Missouri’s exchange insurers implemented the following average rate increases:

  • Cigna: 41.97 percent
  • Healthy Alliance Life (Anthem): 36.31 percent
  • Celtic/Ambetter: New to the exchange, no applicable rate increase

All three insurers indicated in their rate filings that they based their 2018 rates on the assumption that federal funding for cost-sharing reductions (CSR, aka cost-sharing subsidies) funding would be eliminated by 2018 (this proved to be a correct assumption, as the Trump Administration cut off CSR funding in October 2017). Insurers still have to provide cost-sharing reductions to eligible enrollees, but the cost of doing so was incorporated into premiums for 2018, since the federal government is no longer covering this cost for insurers.

Across the country, states and insurers took different approaches to the CSR funding issue. The most common choice was to assume that CSR funding would be eliminated, but to add the cost of CSR only to Silver plans, since CSR benefits are only available on Silver plans. Missouri’s insurers opted to go with that option, which is what the Congressional Budget Office noted would be the most effective strategy if CSR funding were to be eliminated, since it allows the increased cost to be almost entirely offset by larger premium subsidies, with unsubsidized enrollees able to purchase plans at other metal levels that don’t have the additional cost for covering CSRs built into their premiums.

88 percent of Missouri exchange enrollees received premium subsidies in 2017, and those subsidies grew in 2018 to keep the net cost of coverage at an affordable level — the percentage of income that subsidy-eligible enrollees have to pay in 2018 is actually slightly lower than it was for 2017. Rate increases are calculated before any subsidies are applied, so people who are eligible for subsidies will be largely protected from the impending rate increases.

But enrollees who aren’t subsidy-eligible (including everyone who enrolls off-exchange) are paying significantly higher premiums in 2018, and may have found that non-Silver plans offer the best value for 2018.

Despite rate increases, people who get subsidies have access to much cheaper plans for 2018

Average rate increases in Missouri were fairly steep for 2018 (see the previous section). But because the cost of cost-sharing reductions (CSR) has been added to Silver plan premiums, and because premium subsidy amounts are based on the cost of a Silver plan, premium subsidies are much larger in 2018 than they were in 2017. The larger premium subsidies are designed to keep the price of the second-lowest-cost Silver plan roughly the same from one year to the next. But since Silver plan rates are increasing more than the rates for plans at other metal levels, the other metal levels tend to be less expensive, after subsidies, than they were in prior years.

Consider a 45-year-old in Kansas City, earning $35,000. In 2017, his premium subsidy amount was $115/month, and the cheapest plan he could get in the exchange would have been $190/month after the subsidy was applied. But for 2018, his premium subsidy is $315/month, and he can get a plan in the exchange for as little as $51/month in after-subsidy premiums.

If his income is $25,000, he can get a bronze plan for free in 2018, whereas his lowest-cost option would have been $54/month in 2017.

These free and low-cost bronze plans are commonplace around the country for 2018, because insurers in most states have taken the approach that Missouri insurers took, adding the cost of CSR to Silver plan premiums, resulting in much larger premium subsidies for 2018.

People who are eligible for CSR benefits will still want to consider purchasing a Silver plan in 2018, as that’s the only way to take advantage of the CSR benefits. But people who don’t get CSR are likely better off with a non-Silver plan. And even some people who are eligible for CSR benefits may find that a low-cost or free bronze plan ends up being a better option than a Silver plan (particularly if their income is on the higher end of the CSR-eligible spectrum — ie, between 200 and 250 percent of the poverty level — making them eligible for only weak CSR benefits).

The Kansas City resident described above, earning $25,000, would be eligible for CSR benefits, but he’d have to pay at least $100/month in premiums for a Silver plan. It would have a $3,000 deductible and $5,700 out-of-pocket maximum, with $25 office visit copays, whereas the free bronze plans available to him would have deductibles of at least $6,650 and out-of-pocket maximums of $7,350. There is no right answer here, and no one-size-fits-all solution, but help is available in every community, online, and over the phone, if you’re struggling to determine which plan will work best for your situation.

Transparency and rate review

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

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

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

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

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

2017 enrollment

244,382 people enrolled in coverage through the Missouri exchange during the 2017 open enrollment period, including new and renewing enrollees. That was nearly 16 percent lower than the 290,201 people who enrolled in the exchange the year before.

Nationwide, there was a decline in enrollment through HealthCare.gov; the average was about 5 percent, though, so Missouri’s enrollment drop was sharper than most states (in states that run their own exchanges, there was a small average increase in enrollment). The drop in enrollment is largely attributed to the uncertain future of the ACA, along with the Trump Administration’s reduction in advertising and outreach for HealthCare.gov in the final week of 2017 open enrollment.

By February 2017, effectuated enrollment in Missouri’s exchange stood at 213,186. Of those enrollees, 88 percent had premium subsidies, and 57 percent had cost-sharing subsidies.

Missouri’s exchange and the GOP effort to repeal the ACA

House Republicans passed the American Health Care Act (AHCA) in early May, with all six of Missouri’s Republican Representatives voting in favor of the legislation. The CBO subsequently estimated that the AHCA would result in 23 million additional uninsured Americans a decade from now.

In June, Senate Republicans unveiled their version of the legislation, titled the Better Care Reconciliation Act (BCRA). The CBO has estimated that the Senate bill would result in 22 million additional uninsured Americans by 2026. According to the Center for American Progress, 479,600 of those people are in Missouri. In addition, available plans under the BCRA would be less robust, with the benchmark plan covering an average of 58 percent of medical costs, as opposed to the ACA’s benchmark plan that covers an average of 70 percent of costs. And the BCRA would also have eliminated cost-sharing reductions for low-income people after 2019, meaning that low-income enrollees would be facing deductibles well in excess of $5,000 starting in 2020, as opposed to the $0-$1000 deductibles that they currently have on Silver plans with built-in cost-sharing reductions.

The Missouri Hospital Association and the Missouri Chamber of Commerce have urged the state’s congressional delegation to avoid any repeal/replace scenarios that curtail coverage, asking them instead to ensure that the path forward includes at least the same level of coverage and number of residents who have health insurance (that’s a challenge for Republican lawmakers, who tend to favor less costly solutions that would result in fewer people covered, and less-robust coverage).

Ultimately, Senate Republicans failed to pass the BCRA, and their other efforts (“skinny” repeal and the Obamacare Repeal Reconciliation Act) also failed in late July. It’s unclear whether the repeal effort will continue in 2017, but the Senate Parliamentarian has ruled that the reconciliation path to repeal can only be used until the end of September; after that, repeal in 2017 would require 60 votes to pass, which is impossible with the current Senate demographics.

2017 rates and carriers

At the end of 2016, Aetna (Coventry) and UnitedHealthcare (All Savers) exited the exchange in Missouri, and their plans are not available for 2017. Aetna is continuing to offer off-exchange plans, but United exited the entire individual market in the state.

Four carriers are offering plans in the exchange in Missouri for 2017, but carrier participation tends to be localized. The majority of Missouri’s counties only have one carrier offering plans in the exchange in 2017, although these tend to be rural counties.

The majority of the state’s population lives in urban areas, most of which still have at least two carriers offering exchange plans (63 percent of Missouri residents live in counties that still have at least two insurers offering plans in the exchange). In the Kansas City area,

In the Kansas City area, Jackson and Clay counties each have three participating insurers in the exchange in 2017 (Humana, Cigna, and BCBSKC). In the Saint Louis area, plans are available from Anthem BCBS and Cigna (ten counties). But in Columbia, Anthem is the only carrier offering plans in the exchange.

The four carriers that offer plans through the Missouri exchange had the following average rate increases for 2017:

  • Blue Cross Blue Shield of Kansas City (Blue KC): 40.7 percent (increase would have been even higher, but hospitals agreed to lower payments in 2017 as part of their contract negotiations)
  • Cigna: 9.1 percent
  • Healthy Alliance Life (Anthem BCBS): 20.13 percent
  • Humana: 34.9 percent

Details about the rate changes for Missouri’s individual market for 2017 are available on Healthcare.gov’s rate review tool.

Blue KC offers coverage in 30 counties in western Missouri, along with two counties in Kansas. In 25 of the 30 Missouri counties where they offer coverage, they are the only carrier participating in the exchange for 2017. In the other five counties, Humana and Cigna are also offering plans.

Blue KC had about 100,000 insureds with individual market coverage in 2016. Roughly 30,000 of them were on pre-ACA plans, while the other 70,000 had ACA-compliant coverage.

When the proposed rates were initially published, Coventry—including both Coventry Health & Life as well as Coventry Health & Life Insurance Company—seemed to have a much higher that expected number of enrollees. I talked with the Missouri Department of Insurance about this, and they said that the size of the individual market has “exploded” in Missouri, and that Coventry had picked up a disproportionate number of the new enrollees, since their rates have been among the lowest in the state.

People who had Coventry plans outside the exchange were able to keep their coverage for 2017. But people with on-exchange Coventry plans needed to select another plan — or the exchange selected one for them — during open enrollment, as Coventry’s plans are no longer available through the exchange as of January 2017.

The DOI also noted that as far as the state’s licensing of health insurance carriers is concerned, they only recognize one Coventry entity—Coventry Health & Life Insurance Company—but that includes an affiliate company, Coventry Health Care of Missouri, which is an HMO (that affiliate entity only shows up on Healthcare.gov’s rate review tool with small group rates). It’s possible that there’s some duplication of membership in the rate filings, although the DOI didn’t have access to the rate filings beyond what’s on Healthcare.gov’s rate review site.

That will change for 2018, however, now that the state takes an active role in the rate review process for ACA-compliant plans.

Navigator restrictions permanently blocked by federal judge

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

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

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

2016 enrollment

290,201 Missouri residents enrolled in private plans through the exchange during the 2016 open enrollment period. 40 percent of the enrollees were new to the exchange for 2016. The rest already had coverage through the exchange in 2015, and either renewed it or switched to a different exchange plan for 2016.

By March 31, effectuated enrollment through the Missouri exchange stood at 252,044. For perspective, enrollments in the Missouri exchange during the 2015 open enrollment reached 253,430 people, but by March 31, 2015, effectuated (in-force) enrollment stood at 219,953. Initial enrollment in 2016 was 14.5 percent higher than the 2015 number, and effectuated enrollment at the end of the first quarter of 2016 remained 14.5 percent higher than it had been a year earlier.

As of January 21, 44 percent of Missouri residents eligible to enroll in plans through the exchange had done so. That was higher than the national average of 41 percent at that point.

Open enrollment for 2016 coverage ended on January 31. The next open enrollment – for coverage effective in 2017 – will begin on November 1, 2016. Between now and then, enrollment will only be possible for people who experience a qualifying event (Native Americans can enroll year-round, as can anyone who’s eligible for Medicaid or CHIP).

The penalty for being uninsured in 2016 will be much higher than it was in 2014 and 2015: $695 per uninsured adult, or 2.5 percent of household income above the tax filing threshold, whichever is higher. The 2.5 percent of income penalty will remain the same going forward, but starting in 2017, the flat rate penalty will be indexed for inflation, starting from the $695 level.

“Gatekeeper” legislation failed

Early in the 2016 legislative session in Missouri, legislation was introduced that would allow more broad use of “gatekeepers” in managed care plans. A gatekeeper requirement means that a health plan can require members to see a primary care physician for a referral in order to see a specialist. Current law in Missouri only allows HMOs to utilize a gatekeeper.

Rep. Don Gosen (R, Ballwin), who was the sponsor of one of the bills, has said that his intention is only that EPOs (exclusive provider organizations) would be able to add gatekeepers. But critics of the bills contend that the language is too broad, and that gatekeeper requirements could ultimately be added even to PPO plans, or to a patient’s ability to use out-of-network benefits. The legislation did not succeed during the 2016 session.

UnitedHealthcare was scrutinized by the Missouri Department of Insurance in 2016 for requiring gatekeeper referrals on non-HMO plans. The issue was settled in July 2016, with UnitedHealthcare paying a $150,000 fine and agreeing to remove the gatekeeper requirements by October 2016.

2016 rates and carriers

89.6 percent of the people with effectuated coverage in private plans through the Missouri exchange as of March 2016 were receiving premium subsidies. At the end of the 2016 open enrollment period, 87 percent of enrollees were receiving subsidies. At that point, the average pre-subsidy premium in Missouri’s exchange was $407 per month, but for people who were receiving subsidies, the average after-subsidy premium was just $94/month. The average after-subsidy premium across all 38 states that use Healthcare.gov is $106/month (the percentage of people receiving subsidies increased by the end of March because those who were receiving subsidies were more likely to effectuate their coverage).

For perspective, the average pre-subsidy premium in the Missouri exchange in 2015 was $370/month, and it dropped to $86/month once subsidies were applied. 88 percent of enrollees were receiving subsidies in 2015.

According to a Kaiser Family Foundation analysis, enrollees in Missouri’s exchange had more options from which to choose in 2016. In 2015, there were plans available from an average of 2.4 insurers in each county in the state. For 2016, that increased to an average of 3.1 insurers per county. The total number of participating insurers is unchanged, but some carriers have expanded their service area. Nationwide, the trend was the opposite, with the average number of participating insurers in each county declining slightly from 2015 to 2016.

Benchmark premiums (second-lowest-cost Silver plan) increased by an average of 10.4 percent in Missouri in 2016. Subsidies are based on the cost of the benchmark plan in each area, so higher benchmark premiums mean that subsidies are also higher. But it’s important for enrollees to shop around during open enrollment, as subsidy increases don’t apply evenly throughout the state, and aren’t enough to offset all of the premium increases for 2016.

According to Healthcare.gov’s rate review tool, final rate changes for 2016 in Missouri’s exchange were as follows:

  • All Savers (UnitedHealthcare): 9.9 percent average increase
  • Blue Cross Blue Shield of Kansas City: average rate increases range from 8 percent to 12 percent
  • Cigna: decrease of 2.01 percent.
  • Coventry: average rate increases range from 20 percent to 30 percent (modified somewhat during the rate review process)
  • Healthy Alliance Life: 9.77 percent (MSP) and 9.98 percent
  • Humana: 14.81 percent (PPOx)

According to Milliman data, the total number of participating carriers – six – is unchanged from 2015 (although it’s an increase from 2014, when there were only four participating insurers).

2015 enrollment

More than 253,000 Missouri residents enrolled in private health insurance through HealthCare.gov during 2015 open enrollment. About 52 percent of enrollees were first-time shoppers on the marketplace. In 2014, about 152,000 Missourians purchased insurance through the exchange.

In July 2015, HHS released county-level enrollment data for all 37 states that used Healthcare.gov in 2015. Missouri’s ecounty breakdown can be seen on this EnrollAmerica report.

Some enrollees didn’t pay their initial premiums, and others cancelled their coverage or it was eliminated due to lack of documentation on immigration status. By the end of June, 212,256 people in Missouri had effectuated private-plan coverage through the exchange. 89 percent of them were receiving premiums subsidies, which averaged $278 per month and reduced average premium payments from $363 to $85 per month.

Subsidies safe in Missouri

The continued availability of subsidies in Missouri was uncertain for the first half of 2015, because the state uses the federally-run exchange. The King v. Burwell lawsuit challenged the legality of subsidies in the federally-run exchange, with plaintiffs claiming that subsidies could only be provided by state-run exchanges. But on June 25, the Supreme Court ruled that subsidies are legal in every state, which means that 189,000 people in Missouri were no longer in danger of losing their premium subsidies, and their premiums did not increase by 327 percent – which would have been the case if subsidies had been eliminated.

Even people who weren’t receiving subsidies would have been priced out of the insurance market if subsidies had been eliminated. If subsidies had been eliminated, The Urban Institute had projected a 55 percent spike in premiums (in addition to regular annual rate increases) for people who were paying full price for their coverage. They also predicted that the overall individual market risk pool size would have dropped by 70 percent if the Supreme Court had struck down the subsidies. Fortunately for the residents, medical providers, and insurers in Missouri, that didn’t happen.

SHOP exchange

Missouri small businesses (those with 50 or fewer employees) can shop for health insurance through HealthCare.gov year-round.

Starting with the 2015 coverage year, Missouri’s small employers were able to offer their employees a choice of several health plans within a single metal level through the SHOP’s “employee choice” option. Missouri was among 14 states using the federal exchange to implement employee choice starting in 2015.

How many people enrolled in 2014?

More than 152,000 Missourians purchased health insurance through the marketplace during 2014 open enrollment. That’s 23.2 percent of the estimated eligible market according to the Kaiser Family Foundation. The national average was 28 percent.

In addition to those purchasing private insurance plans, 45,513 people qualified for either Medicaid or the Children’s Health Insurance Program (CHIP).

Among Missouri residents who purchased health insurance, 85 percent qualified for financial assistance, which matches the national figure. A report released in June by HHS showed the average monthly premium, after tax credits, for Missouri consumers was $59. Fifty-seven percent of enrollees paid $50 or less per month after subsidies.

Twenty-one percent of Missouri residents selected a bronze plan (20 percent nationally), 63 percent selected a Silver plan (65 percent nationally), 13 percent selected a gold plan (9 percent nationally), 0 percent selected a platinum plan (5 percent nationally) and 3 percent selected a catastrophic plan (2 percent nationally). Twenty-nine percent of Missouri enrollees were between the ages of 18 and 34.

Missouri exchange history

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

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

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

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

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

Missouri health insurance exchange links

HealthCare.gov
800-318-2596

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

Missouri Department of Insurance
Assists people insured by private health plans, Medicaid, or other plans in resolving problems pertaining to their health coverage; assists uninsured residents with access to care.
(800) 726-7390 / consumeraffairs@insurance.mo.gov


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

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