2019 health insurance rate summary...an insurance broker or agent can help you decide on the right...

2019 Health Insurance Rate Summary

Minnesota Individual and Small Group Markets

October 2, 2018

2019 Health Insurance Rate Summary

Table of Contents Introduction ..................................................................................................................................................1

Minnesota’s Health Coverage Landscape ...............................................................................................................1

Small Group Market ................................................................................................................................................2

Minnesota Small Employer Group Health Plans 2019 Average Rate Changes .......................................................3

Individual Market ....................................................................................................................................................4

Minnesota Individual Health Plans 2019 Average Rate Changes ...........................................................................4

Essential Health Benefits - Comprehensive Coverage for All .................................................................................6

Open Enrollment - Shop, Compare and Choose Early ............................................................................................7

What is a Rating Area? ............................................................................................................................................7

Metal Levels – A Consumer-Friendly Way to Compare Plans .............................................................................. 12

Benchmark Plans .................................................................................................................................................. 12

Health Plan Rate Review ...................................................................................................................................... 19

Health Insurance—Frequently Asked Questions ................................................................................................. 22

Health Care Provider Networks—Frequently Asked Questions .......................................................................... 25

2019 Health Insurance Rate Summary 1

Introduction On behalf of Minnesota consumers, the Minnesota Department of Commerce reviews proposed rates and plans submitted by health plan companies to ensure that the rates and plans comply with state and federal law as well as actuarial standards.

Individual market and small group rates are based on a particular plan of benefits with a particular network of doctors, clinics and hospitals. Rates reflect the combined medical costs of everyone in that company’s market, known as “community rating.”

The Department has completed its review of individual and small group policies that will be available in 2019. Individual plans are available on a calendar year basis, with enrollment from November 1, 2018, through January 13, 2019. There is no open enrollment period in the small group market. Small employers can offer a 12-month plan that begins on the first of any month.

The individual market includes less than three percent of Minnesotans who purchase health plans on their own, through MNsure; a broker, agent or navigator; or directly from a health plan company. The small group market includes about 5.5 percent of Minnesotans, with plans that offer health plan coverage to businesses and organizations with 2 to 50 full-time employees.

Minnesota’s Health Coverage Landscape Minnesota’s uninsured population has declined significantly in recent years, though it rose in 2017. According to the U.S. Census Bureau, 4.4 percent of Minnesotans were uninsured in 2017. The national uninsured rate in 2017 was 8.8 percent.

Minnesota’s Uninsured Rate

Source: Health Insurance Coverage in the United States: 2017, U.S. Census Bureau


Most Minnesotans continue to receive their health insurance coverage through employer-based plans. These include plans where an employer purchases insurance from a health plan company to cover employees. They also include plans that are self-insured – generally, large employers that accept direct financial liability for the costs of claims.

Many other Minnesotans receive their coverage through public programs such as MinnesotaCare, Medicare and Medicaid.

• MinnesotaCare is a premium-based program for Minnesotans who do not qualify for Medicaid and whose incomes do not exceed 200 percent of Federal Poverty Guidelines.

• Medicare is the federal health coverage program for people who are 65 or older, as well as for certain younger people with disabilities and people with End-Stage Renal Disease.

• Medicaid (known in Minnesota as Medical Assistance) is a joint federal-state program that helps with medical costs for people with low incomes.

Where Do Minnesotans Get Their Health Coverage?

*Numbers exceed 100% due to rounding.

Source: Minnesota Department of Commerce Best Estimates, 2018

Small Group Market Small group health plans are designed to provide coverage for businesses and organizations with 2 to 50 full-time employees. These plans are sold directly by health plan companies or through insurance brokers and agents. About 5.5 percent of all Minnesotans receive coverage through small group plans. Based on health plan companies’ financial statements, as of December 31, 2017, about 303,000

Uninsured 4%

Employer, Self Insured 34%

Employer, Fully Insured 18%

Medicare 19%

Medical Assistance/MNCare 17%

Small Group 6%

Individual 3%


Minnesotans were covered by these plans. Ten companies are approved to sell small group health policies in 2019. UnitedHealthcare is new to Minnesota’s small group market in 2019, offering plans statewide.

The final rate increases for 2019 plans offered by companies in Minnesota’s small group market range from a decrease of 2 percent to an increase of 12 percent. As in years past, these rate increases reflect the general rise in costs for medical services and prescription drugs. Rate increases for 2019 also reflect higher medical utilization levels and claims reported by the health plan companies, due to a somewhat less healthy enrollment population than in prior years. Each health plan company’s final average rate change is listed in the table below.

Minnesota Small Employer Group Health Plans 2019 Average Rate Changes

Company Name 2018-2019 Average Change

Blue Cross Blue Shield MN 4.6%

Blue Plus 8.8%

Gundersen Health Plan MN -2.4%

HealthPartners, Inc. 6.7%

HealthPartners Insurance Company 5.0%

Medica Insurance Company 11.9%

PreferredOne Community Health Plan 9.0%

PreferredOne Insurance Company 3.0%

Sanford Health Plan 5.6%

UnitedHealthcare NEW


Individual Market The individual market is available for Minnesotans who do not have access to employer-based coverage and are not eligible for coverage through public programs such as Medicare, Medicaid and MinnesotaCare. As of April 2018, about 155,000 Minnesotans purchased their health coverage on the individual market. Five companies are approved to sell health plans to Minnesotans in 2019 in the individual market.

Consumers will be able to purchase individual market health plans either through MNsure or directly from the health plan companies, or by using brokers, agents or navigators. However, some plans are not available through MNsure, while other plans are not available through brokers and agents.

Every county will have at least one health plan company with several plan options. All but four counties in the state will have at least two companies offering plans in 2019. Every Minnesota county will have at least 14 separate plan options available in the individual market, and all but six counties will have more than 20 plan options available.

Minnesota Individual Health Plans 2019 Average Rate Changes

Company Name 2018-2019 Average Change

Blue Plus -27.70%

Group Health (HealthPartners) -7.40%

Medica Insurance Company -12.40%

PreferredOne Insurance Company not available via MNsure -11.00%

UCare only available via MNsure -9.98%

Many Minnesotans who purchase individual health plans through MNsure will be eligible for federal tax credits that lower the monthly premiums they must pay. Over 65,000 Minnesotans currently collect this subsidy through upfront reductions to premiums. Eligibility for the tax credits is determined when applying to purchase a plan through MNsure. Four companies – Blue Plus, Group Health, Medica Insurance Company and UCare – offer their plans through MNsure.

Consumer protections required in all individual market plans include coverage for preexisting conditions and free preventive care, as well as coverage for prescription drugs and substance abuse and mental health treatment.


Individual Market Rate Trend Factors Key factors cited by health plan companies for 2019 rates include:

• A higher percentage of healthy, less costly enrollees than in the recent past, resulting in lower utilization of medical services and prescription drugs;

• The state reinsurance program (Minnesota Premium Security Plan), which is subsidizing high-cost claims at a higher proportion than what was expected the prior year; and

• Lower federal taxes and assessments than required in the prior year

Reinsurance After the large rate increases experienced in 2016 and 2017 in Minnesota’s individual health insurance market, Minnesota enacted a new state reinsurance program to help reduce and stabilize rates for Minnesotans who buy their own coverage.

The reinsurance program reduces premiums for consumers by partially reimbursing health plan companies for high-cost claims. Specifically, reinsurance reimburses insurers for 80 percent of an individual’s annual claims costs that fall between $50,000 and $250,000.

The reinsurance program reduced premiums for 2018 by about 20 percent on average from what they otherwise would have been without reinsurance, and about 20 percent again on average for 2019.

The Commerce Department secured federal waiver approval in September 2017 for Minnesota’s reinsurance program. The waiver allows the state to use federal funds to cover a significant portion of the annual reinsurance costs and stabilize premium rates for consumers. Federal funding is based on premium tax credit savings that the federal government would have otherwise paid to Minnesotans due to higher rates. The federal funding was approximately $131 million for 2018. Federal funding for 2019 is still unknown. State funds finance the remaining cost of the reinsurance program. The actual cost of reinsurance, as well as the final amount of federal funding, depends on a number of factors, including overall market enrollment and the number of high-cost claims. The reinsurance program ends after the 2019 plan year.

Capacity Limits Three of the five health plan companies on the individual market (Blue Plus, Group Health, PreferredOne) requested and were approved for capacity limits in order to manage their financial risk or network capacity to serve enrollees in 2019. Two companies, Medica and UCare, did not request capacity limits. Medica is available statewide.

A capacity limit is the maximum number of people that a health plan company can accept into its plans for 2019. All current enrollees are guaranteed renewal of their existing coverage, provided that they sign up and pay their premium on time.

If a company reaches its capacity limit, its plans will no longer be offered for sale for six months. However, current enrollees with the health plan company will still be able to renew their existing policies by contacting the health plan company or MNsure. The Commerce Department monitors enrollment activity during the enrollment season. If a plan had reached capacity and stopped accepting new enrollees, Commerce reviews the enrollment and capacity situation after six months to determine whether the health plan company should be re-opened for new sales.


Even with the capacity limits, every Minnesotan who needs coverage will be able to find a health plan in 2019, though not necessarily the specific health plan company or provider network they prefer. To have the best choice, it is important for consumers to shop, compare and select a plan as early as possible once the open enrollment period begins on November 1.

Essential Health Benefits - Comprehensive Coverage for All The Affordable Care Act requires that all health plans offered in the individual and small group markets provide a comprehensive package of items and services, known as “essential health benefits.” No matter what plan you choose, you will have standardized coverage for these essential health benefits – with no dollar limits on the coverage.

The essential health benefits are designed to protect consumers and provide a basic level of coverage in 10 categories of benefits:

1. Ambulatory patient services 2. Emergency services 3. Hospitalization 4. Maternity and newborn care 5. Mental health and substance use disorder services, including behavioral health treatment 6. Prescription drugs 7. Rehabilitative and habilitative services and devices (services and devices to help people with

injuries, disabilities or chronic conditions gain or recover mental and physical skills) 8. Laboratory services 9. Preventive and wellness services and chronic disease management 10. Pediatric dental and vision services (commonly offered through a separate plan).


Open Enrollment - Shop, Compare and Choose Early For 2019, Minnesotans can purchase individual health plans between November 1, 2018 and January 13, 2019. Health plan companies, brokers, agents, navigators and MNsure will have specific plan information, including provider network information, available for consumers in October.

Every county will have at least one health plan company with several plan options. Because of health plan companies’ capacity limits, Minnesotans should shop and make their selection early to have the most options available. Compare plans to find the one that offers the best value for your health needs and budget. For continuity of care, carefully review the provider networks offered by plans to see what doctors, clinics and hospitals are included. If you depend on specific prescription drugs, review the plan’s drug formulary (which is a list of covered medications).

Minnesotans should go to the MNsure website (mnsure.org) to see if they are eligible for federal premium tax credits that automatically reduce monthly premiums. Premium tax credits are available only for policies purchased through MNsure. People with incomes up to 400 percent of the federal poverty level are eligible. In 2019, the top income threshold for tax credits is $48,560 for an individual and $100,400 for a family of four.

What is a Rating Area? Federal regulations have standardized the factors that health plan companies may use when calculating premiums for consumers in the individual and small group markets. Under these regulations, health plan companies may only use family size, age, tobacco use and area of residence (rating area) when setting premium rates.

Each state is divided into rating areas, which are used by health plan companies to set premiums for people who live in the counties in an area. Minnesota has nine rating areas.

Health plan companies are required to calculate their rates based on their projected costs in the specific rating area. These costs may reflect factors such as expected health care provider expenses in the specific rating area. However, they may not reflect the difference in enrollees’ health in the specific rating area.

When health plan companies calculate their premiums, all households within a rating area will have the same geographic adjustment factor applied. This means that households with similar size, age and tobacco use characteristics buying the same plan will pay the same premium. Depending on the rating area you live in, the premium you pay may be higher or lower than the state average.

Health plan companies are not required to offer their plans on a statewide basis. Specific health plan companies and specific plans may be available in some rating areas but not in others. There could also be variation among counties within a rating area. Depending on what county you live in, you may have more or fewer plan options.


Area 1 Area 2 Area 3 Area 4 Dodge Fillmore Freeborn Goodhue Houston Mower Olmsted Steele Wabasha Winona

Carlton Cook Itasca Koochiching Lake Lake of the Woods St. Louis

Blue Earth Faribault Waseca Le Sueur Martin Nicollet Rice Watonwan

Brown Cottonwood Jackson Lincoln Murray Nobles Pipestone Redwood Rock

Area 5 Area 6 Area 7 Area 8 Area 9

Big Stone Chippewa Kandiyohi Lac Qui Parle Lyon McLeod Meeker Renville Sibley Swift Yellow Medicine

Becker Clay Douglas Grant Otter Tail Pope Stevens Traverse Wilkin

Aitkin Beltrami Cass Chisago Crow Wing Hubbard Isanti Kanabec Mille Lacs Morrison Pine Roseau Todd Wadena

Anoka Benton Carver Dakota Hennepin Ramsey Scott Sherburne Stearns Washington Wright

Clearwater Kittson Mahnomen Marshall Norman Pennington Polk Red Lake


Rating Areas


Companies with Individual Market Health Insurance Plans in 2019, by County


Number of Individual Market Health Insurance Plans Available by County, 2019


Metal Levels – A Consumer-Friendly Way to Compare Plans Consumers have the option to choose from many health plans in the individual market. “Metal levels” – bronze, expanded bronze, silver, gold and platinum – reflect the difference in the average percentage of overall costs paid by the health plan company versus the consumer. If you choose a plan at a higher metal level, you will pay a higher monthly premium, but you are more likely to have lower out-of-pocket costs in terms of deductibles, coinsurance and copayments.

Platinum – the plan covers 86-92% of expected costs

Gold – the plan covers 76-82% of expected costs

Silver – the plan covers 66-72% of expected costs

Expanded Bronze – the plan covers 62-65% of expected costs

Bronze – the plan covers 58-62% of expected costs

Catastrophic plans are also available to those under the age of 30. Their price is generally attractive, but their value is similar to that of an expanded bronze plan.

Benchmark Plans The second-lowest priced silver plan available through MNsure for a given county is called the “benchmark plan.” The price of the benchmark plan is used to calculate the federal tax credit that reduces monthly premiums for eligible individuals and families. The tax credit amount is adjusted in relation to the allowable percentage, which is based on the consumer’s income.

Consumers who are eligible for the federal tax credits are not required to purchase the benchmark plan in their area. They will not lose out on credits by choosing a different plan. However, a plan must be purchased through MNsure in order to receive the premium tax credit. When applying to purchase a plan through MNsure, eligibility for the tax credit is determined, as is eligibility for Medicaid and MinnesotaCare, unless a consumer explicitly waives this step in the MNsure process.

Benchmark plans and prices varies by county. The map and table on the next several pages page show the benchmark monthly premium (and change from 2018) in each county for a 40-year-old individual.


2019 Benchmark Plans with Monthly Premium (and Change from 2018) for Age 40 Individual


2019 Benchmark Plans with Monthly Premium (and Change from 2018) for Age 40 Individual

County 2019 Rate Decrease from 2018

Aitkin $331.97 ($82.70)

Anoka $300.01 ($27.21)

Becker $349.95 ($81.55)

Beltrami $355.07 ($59.60)

rBenton $304.00 ($29.62)

Big Stone $382.58 ($97.45)

Blue Earth $404.04 ($67.97)

Brown $410.38 ($88.66)

Carlton $331.97 ($93.73)

Carver $300.41 ($26.81)

Cass $331.97 ($82.05)

Chippewa $382.58 ($97.45)

Chisago $297.39 ($83.76)

Clay $349.95 ($81.55)

Clearwater $366.50 ($93.35)

Cook $331.97 ($93.73)



Cottonwood $431.98 ($84.30)

Crow Wing $355.07 ($59.60)

Dakota $300.41 ($26.81)

Dodge $482.33 ($113.39)

Douglas $349.95 ($81.55)

Faribault $404.04 ($67.97)

Fillmore $482.33 ($113.39)

Freeborn $482.33 ($113.39)

Goodhue $482.33 ($113.39)

Grant $349.95 ($81.55)

Hennepin $300.01 ($27.21)

Houston $482.33 ($113.39)

Hubbard $355.07 ($59.60)

Isanti $297.39 ($83.76)

Itasca $331.97 ($93.73)

Jackson $431.98 ($84.30)

Kanabec $331.97 ($80.80)



Kandiyohi $382.58 ($97.45)

Kittson $358.03 ($55.79)

Koochiching $331.97 ($93.73)

Lac Qui Parle $382.58 ($97.45)

Lake $331.97 ($93.73)

Lake of the Woods $399.28 ($54.32)

Le Sueur $404.04 ($67.97)

Lincoln $431.98 ($84.30)

Lyon $382.58 ($97.45)

Mahnomen $366.50 ($93.35)

Marshall $351.56 ($62.26)

Martin $404.04 ($67.97)

McLeod $382.58 ($97.45)

Meeker $415.27 ($64.76)

Mille Lacs $355.07 ($59.60)

Morrison $355.07 ($59.60)

Mower $482.33 ($113.39)



Murray $431.98 ($84.30)

Nicollet $383.84 ($81.89)

Nobles $431.98 ($84.30)

Norman $366.50 ($93.35)

Olmsted $482.33 ($113.39)

Otter Tail $349.95 ($81.55)

Pennington $351.56 ($62.26)

Pine $331.97 ($82.70)

Pipestone $431.98 ($84.30)

Polk $351.56 ($62.26)

Pope $349.95 ($81.55)

Ramsey $300.01 ($27.21)

Red Lake $351.56 ($62.26)

Redwood $410.38 ($89.16)

Renville $382.58 ($97.45)

Rice $404.04 ($67.97)

Rock $431.98 ($84.30)



Roseau $346.87 ($44.90)

Saint Louis $331.97 ($93.73)

Scott $300.41 ($26.81)

Sherburne $300.01 ($27.21)

Sibley $382.58 ($97.45)

Stearns $304.00 ($29.62)

Steele $482.33 ($113.39)

Stevens $349.95 ($81.55)

Swift $382.58 ($97.45)

Todd $355.07 ($80.27)

Traverse $349.95 ($81.55)

Wabasha $482.33 ($113.39)

Wadena $331.97 ($82.70)

Waseca $404.04 ($67.97)

Washington $300.41 ($26.81)

Watonwan $404.04 ($67.97)

Wilkin $349.95 ($81.55)



Winona $482.33 ($113.39)

Wright $300.41 ($33.21)

Yellow Medicine $382.58 ($97.45)

Health Plan Rate Review

What is an "effective" rate review program? Minnesota has been designated by the federal government as a state with an effective rate review program. This means that all proposed rate increases are scrutinized by actuaries who are working for the public interest to make sure the rates comply with appropriate state and federal laws as well as actuarial standards.

The rate review evaluates the assumptions and information that the health plan companies used to develop rates. Rates must be based on the value of the benefits that consumers receive for their premiums. Rate review also evaluates whether health plan companies will be able to pay the expected medical claims costs and fulfill their financial obligations to the consumers who purchase their policies.

How does an "effective" rate review system operate? Under federal requirements, an effective rate review system must do the following:

• Receive sufficient data and documentation concerning rate increases to conduct an examination of reasonableness of the proposed increases.

• Consider the factors below as they apply to the rates: o Medical cost trend changes by major service categories o Changes in utilization of services (i.e., hospital care, pharmaceuticals, doctors’ office

visits) by major service categories o Cost-sharing changes by major service categories o Changes in benefits o Changes in enrollee risk profile o Impact of over- or under-estimate of medical trend in previous years on the current rate o Reserve needs o Administrative costs related to programs that improve health care quality o Other administrative costs related to programs that improve health care quality


o Other administrative costs o Applicable taxes and licensing or regulatory fees o Medical loss ratio o The impacts of geographic factors and variations o The impact of changes within a single risk pool to all products or plans within the risk

pool; and o The impact of risk adjustment payments and charges.

• Make a determination of reasonableness of the rate increase under a standard set forth in state statute or regulation.

• Post all rate filings on their websites or post a link to the preliminary justifications that appear on the federal RateReview.Healthcare.gov website.

• Provide a mechanism for receiving public comments on proposed rate increases. • Report results of rate review to the Centers for Medicare & Medicaid Services (CMS) for rate

increases subject to review.

Who reviews the rates? Health plan rates are reviewed by actuaries at the Minnesota Department of Commerce. The Commerce Department also reviews the rates submitted by Health Maintenance Organizations (HMOs) under an interagency agreement with the Minnesota Department of Health.

Must health plan companies submit rate filings each year? Yes.

What plans are reviewed? All health plan rates must be approved by the Minnesota Department of Commerce or the Minnesota Department of Health prior to becoming effective, as required in Minnesota Statute section 62A.02.

Self-insured health plans (generally provided by larger employers) are not regulated by the state.

How do health plan companies develop rates? Companies develop rates using estimates of future claim costs, administrative expenses, how much reserves they need to hold, risk adjustment costs (or if negative, credits), and expectations of reinsurance subsidies. Rates cannot be based on recovering financial losses from previous years, though past experience will inform rate-setting in future years.

• Claim costs: The amount a health plan company expects to pay for health care services and goods, such as physician services, hospital fees and prescription drugs, on behalf of all policyholders with similar policies.

• Administrative expenses: The cost of running a health plan. These costs can typically include: o salaries of employees; o costs to maintain computer systems to pay claims; o costs to manage the provider network (for example, signing up doctors, hospitals and

pharmacies);

https://ratereview.healthcare.gov/


o commissions for agents and brokers (called “producers”); o rent; o taxes, fees, and assessments that health plans pay to the State or federal government;

and o other costs to administer the policy (for example, fraud detection and prevention

activities). • Contribution to reserves and profit: Money that a company has left after paying for claims and

administrative expenses. Reserves are needed to pay for claims and administrative expenses in years when the health plan company does not collect enough premiums to cover costs, or when claims for the current year are submitted late.

What do you consider when reviewing a rate request? All health plan rate filings must meet these criteria:

• The anticipated loss ratio must meet Minnesota’s minimum of 71% to 82%, otherwise they would be deemed as excessive;

• The rate justification should demonstrate that they are sufficient enough to cover expected claims and expenses, otherwise they would be deemed to be inadequate;

• Rates must provide a reasonable value to the insured; and • The filing must be complete, correct, and understandable.

In order to demonstrate that the above criteria are met, the filing must include at least the following information:

• Historical information, such as date of issue, any changes in benefits, rates, or profitability; • Historical experience including premiums, claims and enrollment; • Statistical reliability of historical experience; • Assumptions used in projecting the future loss ratio– anticipated changes in claim cost per

person and enrollment. The reasons for a rate increase, such as benefit changes, population changes, tax and fee changes.

How does the Commerce Department decide whether to approve or object to a requested rate change? Approved - If the filing is clear and justifies the filed rates, the filing is approved and the company is notified that the rates may be used.

Objection - If the information in the filing is not clear or does not justify the filed rates or rate increase, the Department of Commerce sends an objection letter to the filing company.

Do rate changes always get approved? No. A decision is made for each filing as to whether the rate is approved or not approved.

What if the health plan company disagrees with the decision? The company can request a hearing, and have a judge decide whether the Department's decision not to approve a filing was reasonable or unreasonable.


What is the public’s role in the rate review process? The Minnesota Commerce Department website provides the public with access to information submitted by health plan companies for their plans with proposed rate increases. Minnesotans also have the opportunity to submit comments to the Commerce Department about the rate proposals. As part of the Commerce Department’s rate review process, Minnesotans may submit public comments on proposed rate increases by e-mail to [email protected].

Who can I contact if I have questions about the rate review process? You can contact the Department of Commerce Consumer Services Center by email at [email protected] or by phone at 651-539-1600 or 800-657-3602 (Greater Minnesota).

Health Insurance—Frequently Asked Questions

What is the difference between “rate” and “premium”? The terms “rate” and “premium” are often used interchangeably. However, the terms represent two different things.

Rate: A rate is the premium schedule that a company issues for its plans.

Premium: The premium is the amount that you pay for a health plan. For example, while the rate may have increased by 0%, your premium may have increased by 3% because you are now one year older, and have moved up one spot on the rate schedule.

How often can premiums go up? Based on current federal law, rates for individual health plans may only change yearly, on January 1. Rates for small employer group coverage can change on a quarterly, semi-annual or annual basis.

What factors affect rates? Individual and small employer group rates are based on a particular plan of benefits with a particular network of doctors and hospitals. Rates are based on the combined medical costs of everyone in that company’s market. This is called “adjusted community rating” – the rates are based on the costs of the entire community. Rates are also affected by competitors’ rates and enrollees, since companies must exchange revenues based on enrollees’ health expectations through the risk adjustment program.

The rising costs of medical care and prescription drugs affect rates. With community rating, your premium may go up, even if you have not received any medical services, because the average cost of medical care and prescription drugs for those participating in the market with you has increased.

For 2018 and 2019, Minnesota’s reinsurance program subsidizes 80 percent of health plan companies’ annual costs that fall between $50,000 and $250,000 for any individual market participant. As a result, health plan companies are able to reduce premiums for all consumers in Minnesota’s individual market. Commerce estimates that reinsurance reduced 2018 premiums by about 20 percent on average, and by about 25 percent on average for 2019.

mailto:[email protected]?subject=Comments%20regarding%20the%20proposed%20rate%20increases

mailto:[email protected]?subject=I%20have%20a%20question%20about%20the%20rate%20review%20process


What factors affect my premiums? In general, how much a health plan company charges depends on the following:

• Your age and the age of any family members in your plan; • Whether or not each person 18 or older uses tobacco; • Where you live (rating area, county); and • The benefits and network of providers in the plan.

Your premium cannot be based on whether you have a health condition.

Why did my health plan premiums go up when I didn’t have any claims (didn’t see a doctor, go to the hospital or get any prescriptions)? Your premium will not go up solely because you have claims, just as it will not go down solely because you do not have claims. Insurance is a pooling of risks, so individuals pay a share of the pooled experience in exchange for not assuming the full risk of their own medical costs.

If you have an individual or small employer group policy, your premium is based on the claims of everyone in your market. If you have coverage under a large employer health plan, your premium is based in part on the claims of everyone in the employer group.

When can I enroll in plans through MNsure? You may enroll during the annual open enrollment period or if you qualify for a special enrollment period. Open enrollment in Minnesota for 2019 coverage for individuals and families begins November 1, 2018, and continues through January 13, 2019.

During open enrollment, you may change plans, change insurance companies or stay with the plan you have, if it’s still available.

What if I want to enroll or change plans outside of the open enrollment period? You may be eligible to enroll in coverage at times other than during the open enrollment period. There are special enrollment periods (SEPs) for individuals or families if they experience certain events such as having a baby, getting married, moving to a new area or losing other health coverage.

If you qualify for a SEP, you usually have up to 60 days following the event to enroll in a plan. If you miss that window, you have to wait until the next open enrollment period.

Can health conditions affect what coverage I can get? No. Health insurance companies no longer can leave coverage out of a plan based on a person’s health condition, a practice that used to be known as a “preexisting condition exclusion,” nor can they charge a higher premium because of a person’s health condition.

What are preventive benefits and how are they covered? Preventive benefits are designed to keep people healthy by providing screening for early detection of certain health conditions or to help prevent illnesses. Plans must cover many preventive services with no out-of-pocket


costs (meaning no deductibles, co-payments and coinsurance) for all new plans beginning. Some of these covered preventive services are:

• Colorectal cancer screenings, including polyp removal for individuals over age 50 • Immunizations and vaccines for adults and children • Counseling to help adults stop smoking • Well-woman check-ups, as well as mammograms and cervical cancer screenings • Well-baby and well-child exams for children

What is a short-term limited duration health plan? These plans are health insurance designed to help bridge a brief, unexpected gap in your health care coverage during a time of transition. They are not required to provide the “essential health benefits” required by the Affordable Care Act.

Under Minnesota law, you can enroll in a short-term plan for up to six months, or 185 days or less. You can have coverage under short-term plans for up to 365 days (12 months) within a 555-day (18 months) period. plan.

Short-term plans do not cover preexisting medical conditions and often lack other coverage, such as prescription drugs. Also, if you are pregnant when you buy the plan, it will not cover any medical expenses associated with your pregnancy.

How can I tell if my doctor or prescription drugs is in the network? The MNsure website has information on provider networks and covered prescription drug lists for insurance companies offering plans through MNsure.

What are out-of-network services, and do I have coverage for them? Services are considered out-of-network if they are from a doctor, hospital or other provider that doesn’t have a contractual relationship with a particular health plan. You should find out whether a provider is in-network before you buy a plan or receive services because you may have to pay significantly more to see an out-of-network provider.

How Can a Broker/Agent or Navigator Help? An insurance broker or agent can help you decide on the right plan at the right price. Brokers and agents can give you advice on a specific plan for you based on your needs. They are paid by the insurance company or companies they represent, and can help you buy a health plan even if you do not choose to enroll through MNsure.

A navigator can only provide you with application and enrollment help if you buy your coverage through MNsure. They can provide impartial information about the health plans available to you, but they cannot recommend a specific health plan. If you need help deciding on the right plan, they may refer you to a broker or agent.


Health Care Provider Networks—Frequently Asked Questions

What is an HMO? An HMO (health maintenance organization) is a plan that provides network access to mainly one large medical group, which is often affiliated with or owned by the HMO.

With HMOs, it is very common that a person must designate a primary care provider who would be responsible for the patient’s primary care services and specialist referrals. Originally, HMOs did not commonly provide access to out-of-network provider services. However, recent HMOs may or may not provide coverage for out-of-network services, so it is important to carefully review the policy.

In the past, HMOs distinguished themselves by offering free or low-cost preventive and primary care to maintain good health, and they also commonly had lower co-payments instead of coinsurance. However, these coverage and design elements no longer distinguish HMOs from non-HMOs.

An HMO network is usually offered by an entity that is specially licensed as an HMO by the Minnesota Department of Health. So the term “HMO” not only refers to the type of network, but also generally refers to a type of license (other licenses include “insurer” and “health service corporation”).

What is a PPO? With a PPO (preferred provider organization), a patient does not need to designate a primary care provider who would be solely responsible for the patient’s primary care services and specialist referrals. However, there is a pre-determined network of providers that must be used in order to access care at a lower cost on an in-network basis.

Use of out-of-network providers is covered by a PPO, but more of the costs are paid by the patient through higher coinsurance, co-payments, deductibles and out-of-pockets maximums.

Many specialist, hospital and outpatient visits could require prior authorization, typically from the health plan company itself.

What is an EPO? An EPO (exclusive provider organization) is a plan in which out-of-network coverage is not provided. A patient who uses an out-of-network provider is responsible for paying all of the costs.

Similar to a PPO, a patient does not need to designate a primary care provider who would be solely responsible for the patient’s primary care services and specialist referrals. However, there is a pre-determined network of providers that must be used in order to access care on a covered, in-network basis.

Many specialist, hospital and outpatient visits could require prior authorization, typically by contacting the health plan company itself.

What is a POS plan? A POS plan (point of service plan) combines characteristics of HMOs and PPOs.

With a POS plan, the patient designates a primary care provider who would be responsible for the patient’s primary care services and specialist referrals. The primary care provider is the patient’s “point


of service.” The primary care provider may make referrals outside of the network, but the coverage would be reduced, similar to a PPO.

What if I have to seek emergency services from an out-of-network provider? Regardless of the type of provider network, all emergency services provided by an out-of-network emergency service provider must be covered as if they were provided by an in-network provider.

Minnesota Statutes 62Q.55, applicable to all insured health plans sold in Minnesota, requires out-of-network be treated like in-network for emergency services. The state’s definition for emergency services was expanded in 2015 to include emergency services delivered outside of the hospital emergency room setting (such as onsite crisis services and ambulance services).

The Affordable Care Act’s definition of emergency services is based on the Emergency Medical Treatment and Labor Act (EMTALA) prudence standard. This standard is used to determine the difference between an emergency and a non-emergency. It is based on the facts and circumstances known and judged by the health care provider at the time of the possible emergency, not at a future point in time that provides hindsight knowledge of whether it was an actual emergency.

While these protections exist for the patient, there have been occasions when an out-of-network emergency or non-emergency service provider lawfully charged a patient for the difference between its “billed charges” and what the health plan company paid as its “allowed charges” (its usual and customary rate for an in-network provider). When a patient is charged for these additional charges, it is known as “balance billing,” which is not allowed in the individual and small group markets if the provider was in-network. (See Minnesota Statutes 62K.11).

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