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.
268,445 Missouri residents had enrolled in private plans through the exchange by January 23. That doesn’t count unpaid enrollments that were never effectuated, which is different from how the numbers were reported in 2014 and 2015. In those year, gross total enrollments – including unpaid and cancelled enrollments – were reported weekly during open enrollment, and unpaid/cancelled enrollments weren’t deleted from the report until later in the year.
For perspective, enrollments in the Missouri exchange during the 2015 open enrollment reached 253,430 people, but that included people who never paid their initial premiums, as well as people who cancelled their coverage very soon after enrolling. By March 31, effectuated (in-force) enrollment stood at 219,953.
Enrollment for 2016 – with unpaid enrollments already subtracted – had already surpassed last year’s total with another week left in open enrollment. And they likely won’t decline as sharply in the months following open enrollment, since Healthcare.gov is deleting unpaid and cancelled enrollments in real-time this year.
Open enrollment ends on January 31, for both on and off-exchange plans. After that, enrollment for 2016 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). And 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.
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 is 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.
2016 rates and carriers
According to a Kaiser Family Foundation analysis, enrollees in Missouri’s exchange will have 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 has 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 is 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 Missouri exchange plans are:
- 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 by the federal government 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).
Missouri is one of only five states where the rate review process for ACA-compliant plans is conducted solely by HHS (specifically, by CCIIO – the Center for Consumer Information and Insurance Oversight); state regulators do not take an active role in reviewing and approving (or denying) proposed rates.
At ACAsignups, Charles Gaba projected an average rate increase of 13.9 percent in Missouri several months ago, when proposed rate increases of more than 10 percent had been made public. But the rates had not been finalized by CCIIO at that point, and rate filings were not yet available for carriers that had requested rate hikes of less than 10 percent.
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 enrollment totals for each county can be seen by hovering over the counties on the interactive map.
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.
Overcoming legislative roadblocks
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.
Missouri initially required training and licensing for navigators that went far beyond federal standards. 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 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