Missouri uses the federally-facilitated marketplace, which means residents enroll through Healthcare.gov if they want a plan through the exchange. 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.
2018: Blue KC and Humana exiting ACA-compliant individual market, Ambetter/Celtic joining to fill area left bare by Blue KC exit
Three insurers will offer plans in the Missouri exchange in 2018: Anthem, Cigna, and Ambetter/Celtic (Centene). As of late June, it appears that all counties in the state will have at least one insurer offering coverage through the exchange in 2018.
Proposed rates for 2018 coverage must 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 has said that proposed rate filings will not be public before August 1, 2017.
The Missouri exchange currently has four participating insurers. But two of them — Humana and Blue KC — have announced that they will exit the exchange at the end of 2018.
The other two — Anthem and Cigna — have both said that they’ll continue to offer coverage in the exchange, although the details of their coverage areas are not yet certain. When Cigna confirmed that they’ll remain in their seven current exchanges, 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.”
Humana announced in February that they would end their ACA-compliant individual products at the end of 2017, in all 11 states (including Missouri) where they currently offer coverage. Humana plans are available in five Missouri counties in 2017: Jasper, Green, Newton, Jackson, and Clay. Humana members will need to select new coverage during open enrollment (November 1, 2017 through December 15, 2017).
Blue KC currently offers individual market coverage — on and off-exchange — in 30 western Missouri counties. 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. Blue KC noted in their announcement that they have lost more than $100 million on their ACA-compliant individual market plans through 2016, calling the losses unsustainable. People who have grandmothered and grandfathered individual market plans (ie, purchased prior to October 2013) are not impacted by the exit.
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.
Anthem currently offers plans throughout most of Missouri — everywhere except 30 western counties that are currently served by Blue KC. But Cigna’s participation is limited to 10 counties in the St. Louis area and five counties in the Kansas City Area. 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 of their current counties except for the five Kansas City-area counties where Cigna also offers coverage).
On June 13, Centene announced that they would enter the exchange in Kansas and Missouri. Centene already has 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 be left without an insurer in the wake of Blue KC’s exit. In total, Ambetter/Celtic will offer exchange plans in 40 counties in Missouri in 2018.
There have been several other places around the country that have faced the prospect of having no insurers in their exchanges but have ultimately ended up with insurers offering plans. Pinal County, Arizona initially had no insurers lined up for 2017, but Blue Cross Blue Shield of Arizona ultimately agreed to offer coverage there. For 2018, there were 16 counties in the Knoxville, Tennessee area that didn’t have any insurers slated to offer coverage, but Blue Cross Blue Shield of Tennessee has agreed to re-enter that area of the state. Washington state was also facing the prospect of zero insurers (on or off-exchange) in two counties, but the Insurance Commissioner was able to coax insurers back into those markets as well.
As of June 30, there are three states (Indiana, Nevada, and Ohio) where some counties have no insurers lined up to offer exchange coverage in 2018. But as we’ve seen with Tennessee, Washington, and Missouri, that could certainly change in the coming weeks.
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 forMissouri, 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.
Missouri’s exchange and the AHCA/BCRA
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. But the future of the law is very uncertain. 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 eliminate 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).
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 Heathcare.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.
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).
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.
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
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 / firstname.lastname@example.org