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Nebraska uses the federally facilitated health insurance marketplace (HealthCare.gov) with a marketplace plan management model. Four insurers offer plans in the exchange for 2023, including one newcomer (Blue Cross Blue Shield of Nebraska) and one exit (Bright Health). The annual open enrollment runs from November 1 to January 15 in Nebraska.
Nebraska uses the federally facilitated exchange, but with a marketplace plan management model, which means that residents enroll in coverage through HealthCare.gov, but the state oversees various aspects of the plans available for sale in the exchange.
Despite work completed by the Nebraska Department of Insurance (DOI), then-Gov. Dave Heineman announced in November 2012 that the state would not operate a health insurance exchange. In rejecting a state-run exchange, Heineman said it would be much more expensive for the state to run its own exchange. He also expressed doubt that even a state-run exchange would give Nebraska much authority over exchange operations.
Before Heineman’s final decision, he had expressed some support for a state-run exchange, and the DOI had studied that option. The DOI gathered input from stakeholders, developed a set of working assumptions around policy and operations, and issued a number of requests for information and requests for proposals to engage subcontractors in developing an exchange.
While the federal government manages most functions for the new marketplace, Nebraska oversees participating health plans. The Nebraska legislature also authorized a work group, called the Nebraska Exchange Stakeholder Commission, to provide input to state and federal officials on how the marketplace should operate.
In early December, 2014, the Nebraska Exchange Stakeholder Commission announced their recommendation that Nebraska continue to have a federally-run exchange, noting that it would be costly and difficult to switch to a state-run exchange at this point, especially given that federal funding was no longer available to establish a state-run exchange.
The open enrollment period for individual/family health coverage runs from November 1 through January 15 in Nebraska.
Outside of open enrollment, a qualifying life event is generally necessary to enroll or make changes to your coverage. But Native Americans can enroll year-round, as can subsidy-eligible applicants with household income up to 150% of the poverty level. And Medicaid/CHIP enrollment is also available year-round.
For 2023 coverage, there are four insurers that offer exchange plans in Nebraska:
All four insurers offer plans statewide.
Bright Health will no longer offer coverage in the individual/family market after the end of 2022, so their plans are not available for 2023.
In 2014, the first year that the ACA-created exchanges were operational, Nebraska’s exchange had three insurers offering plans: Aetna, CoOpportunity (an Iowa-based ACA-created CO-OP), and Blue Cross Blue Shield of Nebraska.
Time (Assurant) joined the exchange for 2015, but CoOpportunity stopped selling plans in December 2014 and was subsequently liquidated; remaining members had to transition to new plans by March 2015. So for 2015, Nebraska’s exchange had plans from Time, Aetna, and Blue Cross Blue Shield of Nebraska.
But Assurant announced in June 2015 that they would exit the individual market nationwide, and their plans were no longer available as of 2016. But two new carriers joined the Nebraska exchange for 2016: UnitedHealthcare of the Midlands, and Medica. So for 2016, there were four insurers offering plans in Nebraska’s exchange: Aetna, Blue Cross Blue Shield of Nebraska, UnitedHealthcare, and Medica.
But UnitedHealthcare announced fairly early in 2016 that they would exit the exchanges in most states — including Nebraska — at the end of 2016. United only joined the Nebraska exchange for 2016 – they weren’t available in the exchange in 2014 and 2015. But their rates were competitive in Nebraska. They offered plans state-wide, and in 65 of the state’s 93 counties, United offered at least one of the two least-expensive silver plans in the exchange.
At that point, it looked like three insurers would participate in Nebraska’s exchange in 2017, and the Nebraska Department of Insurance confirmed by phone in August 2016 that Aetna, Blue Cross Blue Shield of Nebraska, and Medica all planned to offer coverage in the state’s exchange for 2017.
Although Aetna had announced that they would exit nearly all of the 34 exchanges where they participated in 2016, Nebraska officials confirmed that the carrier was still planning to sell coverage in the Nebraska exchange for 2017 (Nebraska was one of four states where Aetna continued to offer plans in the exchange in 2017).
Nebraska Insurance Director Bruce Ramge noted, however, that nothing was final until the carriers signed their agreements with HHS in late September 2016, and said “hopefully we won’t see any other dropouts.” But in late September, Blue Cross Blue Shield of Nebraska announced that they would not offer plans in the exchange in 2017 after all, due to mounting losses. They noted that they had lost $140 million on exchange plans since 2014, and viewed continued participation in the exchange as unsustainable. Blue Cross Blue Shield of Nebraska continued to sell two plans — bronze and catastrophic — outside the exchange for 2017 (in June 2017, BCBSN announced that they would entirely exit the ACA-compliant individual market at the end of 2017. They noted that in order to have continued to offer off-exchange ACA-compliant plans in 2018, they would have had to increase premiums by 50 percent, which would have likely resulted in healthy people dropping coverage while sick people remained on the plans, further increasing overall losses).
So for 2017, Aetna and Medica offered plans in the Nebraska exchange. But Aetna announced in May 2017 that they would not offer on- or off-exchange plans in Nebraska in 2018. In February 2017, Aetna’s CEO, Mark Bertolini, had said that the ACA exchanges were in a “death spiral.” Aetna only offered plans in four state exchanges in 2017, including Nebraska. Bertolini also said that Aetna was the only insurer in the Nebraska exchange in 2017, but Medica also offered plans, and grew their membership significantly in the state in 2017.
Medica offers plans statewide in Nebraska, and has opened an office in Omaha. Their 2017 enrollment in Nebraska increased five-fold over their 2016 enrollment. In 2016, there were 6,276 Medica members in Nebraska. By February 2017, more than 35,500 Nebraska residents had made their initial premium payments for 2017 Medica plans (mostly through the exchange, but that total included off-exchange enrollments as well). Enrollment in the individual market tends to peak early in the year, but Medica’s rate filing later in 2017 indicated that they had 35,269 members.
Medica indicated in February 2017 that they were committed to remaining in Nebraska’s individual market, regardless of the future of the ACA and HealthCare.gov. But there was considerable uncertainty among insurers in the spring of 2017, as the Trump Administration waffled on whether or not they would continue to pay cost-sharing reductions to insurers, and on how strongly the ACA’s individual mandate would be enforced going forward.
Ultimately, Medica did remain in the exchange, statewide. And their membership grew significantly in 2018, as they were the only insurer offering plans in the exchange. In addition, anyone with 2018 off-exchange ACA-compliant individual market coverage in Nebraska also had Medica coverage, as the other insurers had left the market (the bulk of Medica’s membership is on-exchange, however, as the insurer is not actively marketing off-exchange plans).
Medica was once again the only insurer offering plans in the Nebraska exchange in 2019. And as described below, Medica has also partnered with the Nebraska Farm Bureau to offer association health plan coverage to farmers in Nebraska for 2019.
For 2020, however, Bright Health joined Nebraska’s exchange, offering plans statewide. Both insurers have continued to offer plans statewide. And for 2022, two additional insurers have joined them, also offering coverage statewide: Ambetter from Nebraska Total Care and Oscar Health.
For 2023, Blue Cross Blue Shield of Nebraska has joined the exchange, although Bright Health has exited the individual/family market in every state where they had previously offered that coverage.
Blue Cross Blue Shield of Nebraska is new to the state’s exchange for 2023, and Bright Health has left the exchange. But for the other three insurers, the following average rate changes are applicable for 2023, according to ratereview.healthcare.gov (most enrollees receive premium subsidies; these rate changes apply to full-price premiums):
Depending on a person’s income and age, there may be free or very low-cost plans available in Nebraska. There are far more plan options available now than there were a few years ago, although subsidy amounts are smaller than they used to be prior to 2022 (due to the entry of new low-cost health plans in Nebraska’s marketplace for 2022). As an example, consider a 50-year-old in Lincoln who earns $30,000/year. For ease of comparison, we’ll keep him the same age each year (in reality, premiums increase as a person ages, even if the insurer’s overall rates do not increase).
For perspective, average unsubsidized premiums in Nebraska’s exchange are higher than the national average, at $707/month in 2022 (versus a national average of $594 in states that use HealthCare.gov, but down from $866/month in 2019).
In Nebraska, 95% of exchange enrollees were receiving premium subsidies in early 2022 (versus a nationwide average of 89%).
99,011 people enrolled in health plans through Nebraska’s health insurance exchange during the open enrollment period for 2022 coverage, which was by far a record high. The sharp increase in enrollment matched what we saw nationwide in 2022, and was driven largely by the affordability enhancements provided by the American Rescue Plan.
Across all states that use HealthCare.gov, there were average enrollment decreases every year from 2017 through 2020. This is due to a variety of factors, including the elimination of the individual mandate penalty, the Trump administration’s relaxed rules for short-term health plans and association health plans, and the administration’s decision to slash funding for outreach and enrollment assistance (under the Biden administration, this funding has been boosted to record-high levels). But enrollment in Nebraska’s exchange increased in 2018 and again in 2020, bucking the general trend of steady declines that we saw in the majority of states that use HealthCare.gov.
For perspective, here’s a look at individual market QHP (private plans) enrollment numbers in Nebraska over the years:
In 2019, association health plan coverage was available to farmers in Nebraska from Farm Bureau/Medica as well as Land o’ Lakes. This stemmed from new federal rules that the Trump administration issued in 2018 for association health plans, making it easier for self-employed individuals and small groups to join together and obtain health insurance regulated under the ACA’s large group rules. This was still ACA-compliant coverage, but the rules are more lenient for large groups than they are for individual and small group plans (large group plans don’t have to cover the essential health benefits, for example, and aren’t subject to the ACA’s risk adjustment program).
In September 2018, the Nebraska Farm Bureau announced a partnership with Medica to offer an association health plan to Farm Bureau members in the state, at premiums roughly 25% below the premiums for ACA-compliant individual market coverage without any subsidies (people who get subsidies pay far less in premiums, but the Farm Bureau plan was marketed to people who don’t get subsidies). The coverage was robust however, and did appear to include all of the ACA’s essential health benefits. There was an open enrollment period from October 1 to December 12, 2018, during which people who were already Farm Bureau members as of July 2018 were allowed to sign up for coverage under the association health plan, and 700 Nebraska residents enrolled in Farm Bureau coverage for 2019. Enrollment was limited to existing Farm Bureau members in an effort to limit adverse selection; they didn’t want lots of people with significant medical needs to join Farm Bureau solely to get health insurance and then enroll in the plan.
Land O’Lakes also began offering an association health plan for 2019 to farmers in Nebraska who were actively engaged in business with one of 14 participating CO-OPs. The open enrollment period for Land O’Lakes association health plan coverage began October 29, 2018, and was initially slated to end December 21. But it was extended until December 31 due to high demand and a late harvest that made it challenging for farmers to enroll in coverage during the original enrollment period.
In March 2019, a federal judge struck down the Trump Administration’s AHP rules. And in May, the Department of Labor issued new guidance noting that while existing AHPs would be able to finish their current plan year/contract, AHPs would not be able to continue to enroll new members.
As a result of the uncertainty surrounding the federal rules for AHPs, Land O’Lakes stopped offering association health plans in Nebraska for 2020 (but they expanded to Kansas instead, where new state legislation makes the rules more flexible for AHPs). And although Medica continued to partner with Farm Bureau, they offered a short-term plan for 2020, instead of an AHP.
By 2022, however, the Nebraska Farm Bureau did not appear to be offering any type of health coverage other than a telehealth plan, a mobile screening service, and dental/vision coverage.
It should be noted that the association health plan approach that was used for farmers in Nebraska in 2019, and the short-term Medica plan that was offered to Nebraska Farm Bureau members in 2020, are not the same thing that Farm Bureau is offering in several other states, including Iowa and Tennessee.
In those states, Farm Bureau plans are medically underwritten, so they’re only available for purchase by people who are fairly healthy. Coverage is available year-round, anyone can join the Farm Bureau (even if they’re not involved in agriculture) and apply for coverage, but eligibility for coverage is based on the applicant’s medical history.
In Nebraska, however, residents could only enroll in Farm Bureau or Land O’Lakes AHP coverage if they were involved in agriculture, enrollment was limited to an annual open enrollment window, and an enrollee’s health status was not taken into consideration. As of 2020, Land O’Lakes no longer offered coverage in Nebraska, and although Farm Bureau continued to offer health coverage that year, the coverage differed significantly from the Farm Bureau health coverage available in several other states, in that members could only enroll during open enrollment and had to be actively engaged in agriculture, but medical underwriting was not being used to determine eligibility for coverage.
Because the cost of CSR has been added to silver plan premiums starting in 2018, premium subsidies are much larger than they would otherwise have been. Consider a family of four, living in North Platte (parents are 45, and the kids are 15 and 13, and we’ll keep them the same each for each year in order to compare apples to apples and avoid the inevitable premium increases that happen just because we each get older every year).
If they earned $97,000 in 2018, they qualified for a premium subsidy of $2,130 per month. After that subsidy was applied, they could get a bronze plan for as little as $141/month (if they wanted a silver plan in 2018, it would have cost $773/month, and if they wanted a gold plan, it was $1,099/month, after the subsidy was applied).
For 2019, Medica adjusted their pricing to result in even better bargains for people who get premium subsidies (an insurer can do this if they’re the only one offering plans in a particular area, since they know they’ll have the benchmark plan, and will thus know exactly how much all of their plans differ in price from the benchmark plan’s price). If our hypothetical family in North Platte earned $97,000 in 2019, they qualified for a premium subsidy of $2,389/month. They could select from two bronze plans that were entirely free after the subsidy was applied. Or they could get a gold plan for $303/month. There was only one silver plan available, so it was the benchmark and it would have been $778/month after the subsidy (note that this is very similar to the cost of the silver plan in 2018; the benchmark rate stays fairly constant from one year to the next, after subsidies are applied, for people with fairly consistent income).
But in 2017, a family in that same situation would have qualified for a premium subsidy of just $1,322 per month (substantially lower than the 2018 and 2019 subsidy amounts), and the cheapest bronze plan available to them would have been $479/month in after-subsidy premiums (a silver plan would have been at least $748/month — similar to 2018 and 2019 costs, because again, premium subsidies are designed to keep the cost of silver plans fairly consistent from one year to the next — and there were simply no gold plans available in their area (69101 zip code) for 2017).
In December 2017, Senator Ben Sasse (R, Nebraska) tweeted “Have heard from multiple farmers today about panic in their counties about health insurance premium increases for 2018.“
To be clear, premiums for people who don’t qualify for premium subsidies are substantial. If the family in North Platte earned more than $98,400 in 2018, their least-expensive option was a bronze plan that cost $2,282/month in premiums. [Keep in mind that the $98,400 amount was after any contributions to employer-sponsored or self-employment retirement plans, and after any contributions to an HSA. The least-expensive bronze plan was HSA qualified and would have allowed this family to set aside up to $6,900 in an HSA in 2018, lowering their adjusted gross income by that amount.] For 2019, if that family earned more than $100,400 (again, after deductions that will lower their ACA-specific MAGI), their lowest-cost option was $2,314/month.
But there are a few points that need to be made about Sasse’s tweet:
For 2015 and 2016, Healthcare.gov did not have a means of automatically selecting a new plan for enrollees if their health insurer was exiting the exchange altogether. In those instances, enrollees had to either select a new plan themselves during open enrollment, or become uninsured as of January 1.
But in the 2017 Benefit and Payment Parameters, HHS laid out a protocol for automatic re-enrollment that could be used in circumstances where the enrollee’s insurer stops offering coverage in the exchange. According to Inside Health Policy (trial subscription required), Nebraska is one of at least two states that pushed back against HHS on this issue. Nebraska’s Department of Insurance noted that enrolling people in plans from alternate carriers amounts to selling health insurance without a license, and that state officials will not enroll people in the new plans selected by Healthcare.gov.
Nebraska Department of Insurance administrator for health policy, Martin Swanson, said that the state “reserve[s] the right to investigate any future placement of business by unlicensed entities.” (in this case, “unlicensed entities” refers to the federal government).
BCBSN and UnitedHealthcare’s exit from the Nebraska exchange at the end of 2016 was exactly the sort of scenario where this applies. Under the new HHS protocol for re-enrollment, exchange enrollees who had BCBSN or UnitedHealthcare in 2016 — and who did not return to the exchange by December 15, 2016 to select a new plan for 2017 — were auto-enrolled in a new plan, with priority placed on a plan selection at the same metal level and the same product network type (PPO, HMO, POS, EPO). But if those were not available, there’s a hierarchy that would be used to select what amounts to the most similar plan available.
BCBSN and UnitedHealthcare enrollees were advised to seek out their own replacement coverage during open enrollment. For plan selections made between November 1 and December 15, the new plan took effect January 1, with no gap in coverage. For BCBSN and United enrollees who didn’t return to the exchange to pick a new plan, Healthcare.gov’s protocol was to select a plan on their behalf. And despite the state’s push-back on this issue, automatic re-enrollment was the default for Nebraska exchange enrollees whose plans ended and who didn’t return to the exchange to pick their own plans.
The federal government operates the exchange in Nebraska
State Exchange Profile: Nebraska
The Henry J. Kaiser Family Foundation overview of Nebraska’s progress toward creating a state health insurance exchange.
Nebraska Department of Insurance
Assists consumers who have purchased insurance on the individual market or who have insurance through an employer who only does business in Nebraska.
(877) 564-7323 / Toll Free: (800) 833-7352
Nebraska DOI’s overview of the exchange
An in-depth document published in 2012 that detailed how the exchange would work.
Nebraska DOI’s Listening Sessions for 2019 — a detailed analysis of the history and current state of the individual market in Nebraska, plus a look at alternatives like short-term health plans, association health plans, and health care sharing ministries, from a regulatory standpoint.
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.
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