Health Insurance Marketplace in Missouri
Choosing the Right Health Insurance Plan
There are 5 categories of Marketplace insurance plans: Bronze, Silver, Gold, Platinum, and Catastrophic.
Plans range from bare bones “bronze” plans which cover 60% of pocket medical costs to “platinum” plans which have greater coverage but come with higher premiums. In general higher premiums mean lower out-of-pocket costs and a wider insurer network of doctors and hospitals.The plans are as listed below:
NOTE: All cost sharing is of out of pocket costs. Please see ObamaCare health benefits for services that are covered at no out of pocket charge on all plans. The maximum out-of-pocket costs for any Marketplace plan for 2014 are $6,350 for an individual plan and $12,700 for a family plan.
Bronze Plan: The bronze plan is the lowest cost plan available. It has the lowest premiums and in exchange has the lowest actuarial value. The actuarial value of a bronze plan is 60%. This means that 60% of medical costs are paid for by the insurance company, leaving the other 40% to be paid by you.
Silver Plan: The Silver plan is the second lowest cost plan, it has an actuarial value of 70%. This means that 70% of medical costs are paid for by the insurance company, leaving the other 30% to be paid by you. The Silver plan is the standard choice for most reasonably healthy families who historically use medical services.
Gold Plan: The Gold plan is the second most expensive plan, it has an actuarial value of 80%. This means that 80% of medical costs are paid for by the insurance company, leaving the other 20% to be paid by you.
Platinum Plan: The Platinum plan is the plan with the highest premiums offered on the insurance exchange. The Platinum plan as an actuarial value of 90%. This means that 90% of medical costs are paid for by the insurance company, leaving the other 10% to be paid by you. This plan is suggested to those with high incomes and those in poor health. Although coverage is more expensive up front the 90% coverage of costs will help those who use medical services frequently.
Catastrophic plans – which have very high deductibles and essentially provide protection from worst-case scenarios, like a serious accident or extended illness — are available to people under 30 years old and to people who have hardship exemptions from the fee that most people without health coverage must pay.
Missouri has not chosen to expand its Medicaid program at this time. Read “What if my state isn’t expanding Medicaid?” to learn more. You can find out whether you qualify for Medicaid under Missouri’s current rules 2 ways: Contact your state Medicaid agency right now or fill out an application for coverage in the Health Insurance Marketplace.
Who can help you (the Navigators)
Primaris will lead a coalition of eleven Missouri healthcare and social services organizations that will raise awareness of the coverage options available to Missourians. Primaris, a federal health services contractor for the last 30 years, has operated a free insurance counseling service for Missourians on Medicare, where counselors help clients navigate the local marketplace of Medicare prescription drug and Medicare Advantage plans without bias or cost to the consumer. Primaris will use existing infrastructure to help facilitate the enrollment of consumers in to private health plans.
The Missouri Association of Area Agencies on Aging (ma4) has been the leading voice for older adult services, information, and advocacy in Missouri since 1973. Funding will be used for extensive statewide outreach and education to consumers, including a special session at ma4’s
Show Me Summit on Aging and Health, wellness events, Area Agencies on Aging (AAA) newsletters, ma4 website, public media, social media, and information call centers such as 211.
If you need more detailed analysis, identification of issues, solutions, and implementation of your health insurance plan please let us know with the form below and we’ll get right back to you.
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Accountable Care Organizations in Missouri
ACOs are profit-driven health innovators primarily serving Medicare patients who are financially rewarded by the government and private insurance companies for delivering medical services that lead to better health outcomes for less money.
- The Curators Of The University Of Missouri MO – Health Care Innovation Award
- Rutgers, The State University Of New Jersey (The Center For State Health Policy) MO – Health Care Innovation Award
- Feinstein Institute For Medical Research MO – Health Care Innovation Award
- University Of North Texas Health Science Center MO – Health Care Innovation Award
- Mountain Vista Medical Center Mesa, AZ – BPCI Initiative: Model 2
- State of Missouri MO – Medicaid Emergency Psychiatric Demonstration
Health care facilities where Innovation Models are being tested
- KCMPA-ACO, LLC Kansas City, MO – Advance Payment ACO Model
- Signature Medical Group Saint Louis, MO – BPCI Initiative: Model 2
- SSM DePaul Health Center Bridgeton, MO – BPCI Initiative: Model 2
- SSM St. Mary’s Health Center Richmond Heights, MO – BPCI Initiative: Model 2
- Lester E Cox Medical Centers dba CoxHealth Springfield , MO – BPCI Initiative: Model 2
- St. Charles Orthopaedic Surgery Associates O’Fallon, MO – BPCI Initiative: Model 2
- St. Peter’s Bone and Joint Surgery St. Peter’s , MO – BPCI Initiative: Model 2
- Missouri Baptist Medical Center St. Louis, MO – BCPI Initiative: Model 4
- St. Luke’s Hospital Chesterfield, MO – BCPI Initiative: Model 4
- Des Peres Hospital Saint Louis, MO – BCPI Initiative: Model 4
- Kansas City Quality Improvement Consortium, Inc. Kansas City, MO – Community-based Care Transition Program
- Betty Jean Kerr People’s Health Centers – Central Saint Louis, MO – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Betty Jean Kerr People’s Health Centers – North Site Florissant, MO – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Cross Trails Medical Center – Advance Clinic Advance, MO – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Cross Trails Medical Center – Cape Girardeau Clinic Cape Girardeau, MO – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Family Care Health Centers-FPSE Saint Louis, MO – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Family Health Center of Boone County Columbia, MO – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Fordland Clinic, Inc. Fordland, MO – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Missouri Highlands Health Care – Big Springs Medical Clinic Van Buren, MO – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Missouri Highlands Health Care – Ellington Family Clinic Ellington, MO – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Missouri Highlands Health Care – Iron County Medical Clinic Pilot Knob, MO – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Missouri Highlands Health Care – Viburnum Medical Clinic Viburnum, MO – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Missouri Highlands Health Care – Missouri Highlands Medical Clinic Poplar Bluff, MOA – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Northwest Health Services-Hamilton Medical Clinic Hamilton, MO – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Ozark Tri-County Health Care Consortium DBA ACCESS Family Care Joplin, MO – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Regional Health Care Clinic, dba Katy Trail Community Health- Sedalia Sedalia, MOA – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Rural Alliance for Better Family Health West Plains, MO – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Northwest Health Services-Oregon Clinic Oregon, MOA – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- New Birth Company Overland Park, KS, MO – Strong Start for Mothers and Newborns Initiative
- Signature Medical Group St. Louis, MOA – Strong Start for Mothers and Newborns Initiative
The Insurance Exchange/Marketplace
What has been done, not been done, or left up to the federal government to do.
Establishing the Exchange in Missouri
On November 6, 2012, Missouri voters passed a ballot measure blocking Governor Jay Nixon (D) from establishing an exchange via Executive Order.1 Legislation establishing a state-based health insurance exchange failed in both the 2012 and 2011 legislative sessions. While the Governor initially supported running a state-based exchange, he announced the state would default to a federal exchange in 2014.
Prior to the announcement, the Governor established Missouri’s Health Insurance Exchange Coordinating Council to coordinate the state’s response to federal health reform.2 The Council included executive leadership from multiple state agencies and established four work groups to address exchange components including, Operations; Finance and Coverage; Communications; and Cost-containment and Quality.3 The Council identified a number of consultants to provide background research and insurance market analysis to inform decision-making in the state. In June 2011, the Senate had also created the Senate Interim Committee on Health Insurance Exchanges to explore Missouri’s options to establish a state-based exchange.4
In August 2011, the Missouri Health Insurance Pool Board released a Request for Information for general exchange information technology component solutions and services; however the contract was never awarded.5 Missouri was also participating in the “Enroll UX 2014” project, which is a public-private partnership creating design standards for exchanges that all states can use.6
In August 2010, Governor Nixon allowed a law prohibiting health insurance exchanges established in Missouri from offering insurance policies or riders that provide abortion coverage except in cases of life endangerment of the pregnant woman to become law without his signature (SB 793).7
Essential Health Benefits (EHB): The ACA requires that all non-grandfathered individual and small-group plans sold in a state, including those offered through the Exchange, cover certain defined health benefits. Since Missouri has not put forward a recommendation, the state’s benchmark EHB plan will default to the largest small-group plan in the state, Healthy Alliance (Blue Cross Blue Shield)- Blue Access Choice PPO.
IIn September 2010, the Missouri Department of Insurance received a federal Exchange Planning grant of $1 million. The Missouri Health Insurance Pool, a quasi-governmental, non-profit insurer that expanded to operate the federal high risk-pool in the state, received a $20.8 million federal Level One Establishment grant in August 2011, to build a coordinated information technology infrastructure with a single portal eligibility and enrollment system.8 However, the Senate Interim Committee, which has been critical of the state’s decision to apply for federal grant money without explicit approval from the legislature, has yet to approve spending the funds. In April 2012, the Missouri legislature rejected a $50 million federal grant to upgrade the state’s Medicaid information technology system because lawmakers saw it as a possible framework for building an exchange.9
The federal government will assume full responsibility for running a health insurance exchange in Missouri beginning in 2014.
1. Associated Press. “Nixon: Missouri won’t run health insurance exchange by 2014.” November 8, 2012. Kansas City Star. http://www.kansascity.com/2012/11/08/3907070/nixon-missouri-wont-run-health.html
2. The Health Insurance Exchange Coordinating Council was formerly the Health Care Cabinet
3. Missouri Level One Establishment Grant application:http://www.mhip.org/Documents/Grant/Establishment%20Grant%20Project%20Narrative.pdf
4. Senate Interim Committee on Health Insurance Exchanges.http://www.senate.mo.gov/11info/comm/interim/sihi.htm (Accessed September 16, 2011)
5. Missouri Health Insurance Pool. Request for Information for Health Insurance Exchange Component Solutions and Services. RFI# 2011-001. August 19, 2011.
6. Enroll UX 2014 website. http://www.ux2014.org/
7. Senate Bill 793. Modifies provisions relating to abortion. Delivered to Governor May 25, 2010.http://www.senate.mo.gov/10info/bts_web/bill.aspx?BillID=3187166&SessionType=R
8. HealthCare.gov. “Creating a New Competitive Marketplace: Affordable Insurance Exchange Establishment Grant Awards List.”http://www.healthcare.gov/news/factsheets/exchanges05232011a.html (Accessed August 18, 2011)
9. Nelson, J. “Bill gives Missouri voters say on health exchanges.” May 19, 2012. News-Leader.http://www.news-leader.com/article/20120519/NEWS06/305190025/health-exchanges-missouri-legislature?gcheck=1&nclick_check=
Also of interest
Provided by the Henry J. Kaiser Family Foundation