Highlights and updates
- Open enrollment for 2019 coverage in Missouri ended on December 15, but residents who have qualifying events can still obtain coverage.
- More than 220,000 people enrolled in plans for 2019, down from a high of more than 290,000 in 2016.
- Short-term health plans are available in Missouri with initial plan terms up to six months.
- Medica joined the exchange in Kansas City for 2019 (and a look at how insurer participation has changed over time in Missouri’s exchange).
- Average rate increases for 2019 were modest (and a look at average rate increases in previous years).
- Lawmakers rejected a bill that would have created a reinsurance program for 2019.
- Starting with 2018 plans, Missouri became an effective rate review state, which means state officials (instead of the federal government) review and approve proposed rates and plans.
Missouri exchange overview
Missouri uses the federally facilitated marketplace, which means residents enroll through HealthCare.gov if they want a plan through the exchange.
Open enrollment for 2019 coverage in Missouri ended on December 15, 2018, but Missourians with qualifying events can still enroll in ACA-compliant plans outside of the open enrollment period.
For 2020 health coverage, insurers in Missouri must submit proposed rates and plans to the Department of Insurance by July 19, 2019.
2019 enrollment, and a comparison with previous years
220,461 people enrolled in private plans through the Missouri exchange during the open enrollment period for 2019 coverage, which ran from November 1, 2018 through December 15, 2018. That was the third year in a row that enrollment declined in Missouri’s exchange, down from a high of more than 290,000 people in 2016. Enrollment in Missouri’s exchange was down 9.4 percent from 2018 to 2019, which was a sharper decline than most states experienced (average enrollment increased slightly in states that run their own exchanges, and decreased by 3.8 percent in states that use HealthCare.gov).
For perspective, here’s a look at prior enrollment numbers in Missouri’s exchange:
- 243,382 people enrolled in plans for 2018. Missouri’s exchange enrollment was less than half a percent lower than it had been in 2017. Nationwide, across all the states that use HealthCare.gov, enrollment declined by about 5 percent in 2018, for the second year in a row.
- 244,382 people enrolled in plans for 2017, which was the first time that year-over-year enrollment declined in Missouri. Nationwide, there was an enrollment drop of about 5 percent in 2017, although Missouri’s enrollment dropped more sharply, by about 16 percent. The enrollment declines in 2017 and 2018 were due to a variety of factors, including uncertainty about GOP efforts to repeal the ACA, the Trump Administration’s decision to sharply reduce funding for exchange marketing and enrollment assistance, and sharp premium increases for people who aren’t eligible for premium subsidies (those rate increases were partially due to the market instability caused by GOP efforts to repeal the ACA).
- 290,201 people enrolled in plans for 2016
- 253,430 people enrolled in plans for 2015
- 152,335 people enrolled in plans for 2014
Four insurers offering plans for 2019, with Medica’s entry in the Kansas City area
Missouri’s exchange had three insurers in 2018: Anthem (Healthy Alliance Life Insurance), Cigna, and Ambetter/Celtic (Centene). But that grew to four for 2019, with Medica’s announcement in June 2018 that they planned to join the Missouri exchange in the Kansas City area (Cass, Clay, Jackson, and Platte counties) as of 2019. Medica began offering plans on the Kansas side of the Kansas City area in 2018, and expanded into the Missouri side for 2019.
The Missouri Department of Insurance 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 are available from three insurers (Cigna, Medica, and Ambetter/Celtic).
Consumers in the St. Louis area can choose from two insurers in 2019, as can consumers in southwestern Missouri. But most rural areas of the state continue to have just one insurer offering plans — in most cases, either Anthem (Healthy Alliance Life) or Celtic/Ambetter.
Missouri exchange dropped from four insurers to three in 2018
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 (Cigna’s participation was 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 for 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 had 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 offered 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 continued 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, 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 offered exchange plans in 40 counties in Missouri in 2018.
Anthem’s coverage area shrank in 2018, but expanded in 2019
Until the end of 2017, Anthem offered exchange plans in most of Missouri — everywhere except the 30 western counties that were served by Blue KC. For 2018, however, Anthem’s participation was reduced to 68 counties (a full list is in a press release), and the insurer noted that these were all counties that would otherwise have had no insurers offering coverage.
Among the areas Anthem exited were Boone County (Columbia) and the St. Louis area. In both of those areas, Cigna plans were available for 2019 (Cigna’s 2018 rate filing included rating area 5, 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.
For 2019, however, Anthem increased their coverage area to 76 counties, returning to Barry, Boone, Christian, Greene, Jasper, Lawrence, Newton, and Saint Francois counties.
Coventry and UnitedHealthcare exited the exchange at the end of 2016
Aetna subsidiary Coventry offered plans in the Missouri exchange until the end of 2016, but abruptly exited the exchange market two weeks before the start of open enrollment for 2017 coverage. I talked with the Missouri Department of Insurance about Coventry’s market share in 2016, and they said that the size of the individual market had “exploded” in Missouri, and that Coventry had picked up a disproportionate number of the new enrollees, since their rates had been among the lowest in the state.
UnitedHealthcare also exited the exchange in Missouri at the end of 2016, and stopped selling any ACA-compliant individual market plans, on- or off-exchange.
People with on-exchange Coventry or UnitedHealthcare plans in 2016 needed to select another plan — or the exchange selected one for them — during open enrollment that fall, as neither insurer’s plans were no longer available through the exchange as of January 2017.
Average rate increases for 2019 were modest
The Missouri Department of Insurance posted a summary of the average rate changes for 2019. In the individual market, all four insurers are offering plans both on- and off-exchange for 2019, with the following average rate changes:
- Healthy Alliance Life (Anthem): 2.15 percent increase (Healthy Alliance Life had proposed a 3.67 percent average increase, but submitted a revised filing in August 2018 with an average rate increase of 2.2 percent)
- 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 calculated a weighted average proposed rate increase of just 1.6 percent — but he noted that rates would likely have dropped by about 10 percent if the individual mandate penalty hadn’t been eliminated and if short-term and association health plans hadn’t been expanded (all of those factors result in fewer healthy people having coverage in the ACA-compliant risk pool, which causes higher premiums).
For perspective, here are the average rate increases for the last few years in Missouri:
Prior to 2018, Missouri deferred to the federal government for rate review of ACA-compliant individual market health insurance. But that changed in 2017 with new state law, and 2018’s rates were reviewed and approved by the state insurance department. Missouri’s exchange insurers implemented the following average rate increases for 2018, which amounted to an overall average increase of about 40 percent:
- 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.
But because the cost of cost-sharing reductions (CSR) was added to Silver plan premiums (this continues to be the case in 2019), and because premium subsidy amounts are based on the cost of a Silver plan, premium subsidies were much larger in 2018 than they were in 2017.
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 was $315/month, and he could get a plan in the exchange for as little as $51/month in after-subsidy premiums.
If his income was $25,000, he could get a bronze plan for free in 2018, whereas his lowest-cost option would have been $54/month in 2017. The larger subsidies continue to be available in 2019, as insurers have continued to add the cost of CSR to silver plan rates.
The four carriers that offered plans through the Missouri exchange had the following average rate increases for 2017, which amounted to an overall average increase of 25.5 percent:
- 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
- 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)
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. As of 2019, Alaska, Oregon, Minnesota, Wisconsin, Maine, Maryland, and New Jersey all receiving federal “pass-through” funding for reinsurance, and several other states 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 was 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 is not receiving 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.
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.
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; plan selection advice can only be provided by a licensed insurance producer). 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.
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, then-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 accepted 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
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.