Highlights and updates
- Open enrollment for 2019 coverage in Nebraska ended on December 15, but residents with qualifying events can still enroll.
- Association health plans are now available for Nebraska farmers with open enrollment periods similar to those for ACA-compliant plans.
- Nebraska’s exchange had four insurers in 2016, but was down to just one by 2018. Medica continues to be the only insurer offering plans in the Nebraska exchange in 2019.
- Short-term health plans are available in Nebraska with initial plan terms up to 364 days.
- Average rate increase was just 2.2 percent for 2019, but plans changed from PPOs to EPOs.
- Many enrollees who get premium subsidies saw lower net premium in 2018, and even lower premiums in 2019.
- Enrollment dropped less than 1 percent for 2019, after increasing in 2018 (versus significant nationwide declines each year).
Nebraska exchange overview
Nebraska uses the federally facilitated exchange, but with a marketplace plan management model, which means the state oversees various aspects of the plans available for sale in the exchange.
Enrollment for 2019 coverage began on November 1, 2018 and ended December 15, 2018. In March 2019, Nebraska experienced severe flooding, and the state insurance department reminded residents that federal rules allow for a disaster-related special enrollment period for people who had experienced a qualifying event and had access to a special enrollment period during the time of the disaster, but were unable to enroll during that special enrollment period due to the flooding. The affected counties in Nebraska are indicated on FEMA’s map.
2019 health insurance rates only up about 2 percent, but plans changed from PPOs to EPOs
- Medica Insure: 3.69 percent increase (possibly revised to a 4.24 percent increase)
- Medica with CHI Health: 2.6 percent decrease (possibly revised to a 1.04 percent decrease). These plans continue to only be available in 23 eastern Nebraska counties.
- Elevate by Medica: New for 2019, so no applicable rate increase
Overall, the average rate increase across all of Medica’s plans was 2.2 percent for 2019.
- 2015: The Nebraska Department of Insurance released a sampling of 2015 rates in September 2014. They illustrated 15 different scenarios, with varying household sizes, ages, and geographic locations across the state. For each carrier, they showed the rate change for each scenario, along with an average for all 15 scenarios from each carrier.Across the four carriers that were originally slated to sell plans for 2015 (including CoOportunity), the unweighted average for the 15 sample scenarios was a 10.7 percent increase in premiums. But one carrier — Coventry — had an average rate decrease of 3.4 percent. And while Assurant’s average rate hike across the sample scenarios was 16 percent, their prices in 2014 (off-exchange) were lower than those offered by the exchange plans — they gained market share in 2014 even though they were only available off-exchange (Assurant ended up leaving the market, nationwide, at the end of 2015.
An analysis conducted by the Commonwealth Fund and published in December 2014 found an average rate increase of 10 percent for a 40 year-old non-smoker in the Nebraska exchange, when looking at all plans and metal levels. But for silver plans, the rate increase was an average of just 4 percent, and it’s likely that the rate increase became smaller once CoOportunity’s plans were no longer for sale, since the CO-OP had raised its rates considerably for 2015.
- 2016: In the fall of 2015, the Nebraska Department of Insurance published final approved rates for 2016:
- Blue Cross Blue Shield of Nebraska: 14.8 percent average rate increase
- Coventry: 21.89 percent average rate increase (but actual rates are still lower than BCBS in every sample scenario).
- UnitedHealthcare of the Midlands: New to the exchange, but the approved rates for 2016 were lower than BCBS and Coventry for every sample scenario (note that United only participated in the exchange in 2016; they did not offer plans for 2017).
- Medica: New to the exchange for 2016. Approved rates for 2016 were lower than BCBS and Coventry in some scenarios, and higher in others.
- 2017: For the two carriers offering coverage in the Nebraska exchange, average rate increases for 2017 were as follows:
- Medica: 51.3 percent
- Aetna: 40.5 percent (a sample of approved rate increases for various ages and zip codes)
- 2018: Aetna left the market. Medica increased their average rates by 31 percent. Medica’s rate filing noted that while their plans would be available on and off-exchange for 2018, they were not actively marketing off-exchange plans. Medica offered their “Medica Insure” plan in all 93 counties in Nebraska for 2018. They also offered their “Medica Insure Gold” in 70 counties, and “Medica with CHI Health” in the remaining 23 counties.Medica proposed a 31 percent average rate increase (as of their revised rate filing dated August 15, 2017, which was based on the assumption that cost-sharing reduction (CSR) funding would not continue in 2018). The additional cost to cover CSR was added to silver plans. This turned out to be a prescient decision, as the Trump Administration announced in October 2017 that CSR funding would end immediately.
Medica had previously proposed a 16.9 percent average rate increase, based on the assumption that CSR funding would continue. But with no allocation of funding from Congress, and no assurance from the Trump Administration that funding would actually continue, revised rates were filed in August. Medica initially added a 14.5 percent load to silver plans, bringing the total overall average rate increase to 28.3 percent (as of August 4). But they submitted an additional revised filing on August 15, which also incorporated updated claims experience through the end of July. The result of that additional information, plus the 14.5 percent load on silver plans to cover the cost of CSR, brought Medica’s overall proposed average rate increase to 31 percent.
Participation in Nebraska’s exchange peaked with four insurers in 2016, but had just one by 2018
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 is 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.
2019 enrollment down less than half a percent, after growing more than 4 percent in 2018
87,416 people enrolled in 2019 coverage through the Nebraska exchange during open enrollment, which ended December 15, 2018. That was less than 1 percent lower than the 88,213 people who enrolled in coverage during the previous open enrollment (for 2018 plans). And enrollment in Nebraska’s exchange grew from 2017 to 2018 (going from 84,371 enrollees to 88,213 enrollees). For states that rely on HealthCare.gov, this was rare, as most of those states saw enrollment decrease by an average of 5 percent. Of the 34 states with fully federally-run exchanges, only five had higher enrollment in 2018 than they’d had in 2017.
Across all states that use HealthCare.gov, there was another average enrollment drop of about 5 percent in 2019, due to a variety of factors: The individual mandate penalty no longer applies after the end of 2018. The Trump Administration relaxed the rules for short-term health plans and association health plans, making them a viable alternative (for healthy people) to ACA-compliant coverage. And as was the case the year before, the Trump Administration again slashed funding for outreach and enrollment assistance. But enrollment in Nebraska’s exchange in 2019 is only slightly lower than it was in 2016.
For perspective, here’s a look at individual market QHP (private plans) enrollment numbers in Nebraska over the years:
- 42,975 people enrolled in plans for 2014
- 74,152 people enrolled in plans for 2015.
- 87,835 people enrolled in plans for 2016.
- 84,371 people enrolled in plans for 2017.
Land O’Lakes and Nebraska Farm Bureau are offering association health plans for residents involved in agriculture
In the summer of 2018, the Trump Administration finalized new rules 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 is 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 percent 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 is marketed to people who don’t get subsidies). The coverage is robust however, and does appear to include all of the ACA’s essential health benefits. There was an open enrollment period from October 1 to December 12 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 are 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.
The association health plan approach is not the same thing that Farm Bureau is offering in 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. Under the Trump Administration’s new rules for association health plans, the plans cannot use medical underwriting to determine eligibility or premiums, but the Iowa and Tennessee Farm Bureau plans are not association health plans. In Iowa and Tennessee, the Farm Bureau plans are similar to the pre-ACA individual market: 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, it’s different. Residents can only enroll in Farm Bureau or Land O’Lakes coverage if they’re involved in agriculture, enrollment is limited to an annual open enrollment window, and an enrollee’s health status is not taken into consideration.
[In March 2019, a federal judge struck down the Trump Administration’s AHP rules. The Department of Labor issued a brief response a few days later. The new AHP rules were supposed to take effect for new self-insured AHPs as of April 1, 2019, but had already taken effect in 2018 for fully-insured AHPs. The Nebraska Farm Bureau confirmed by phone in mid-April 2019 that their fully-insured AHP coverage continues to be available for purchase, and nothing has changed for them. Gravie, which administers the Land O’Lakes AHP, also confirmed that nothing has changed about their plan availability as a result of the court ruling; eligible CO-OP members who experience a qualifying event can still enroll in the Land O’Lakes association health plan. ]
If you get premium subsidies, you might have seen a rate reduction in 2018, and even more of a rate decrease for 2019
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 is earning $97,000 in 2019, they qualify for a premium subsidy of $2,389/month. They can select from two bronze plans that are entirely free after the subsidy is applied. Or they can get a gold plan for $303/month. There’s only one silver plan available, so it’s the benchmark, and it would be $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 is after any contributions to employer-sponsored or self-employment retirement plans, and after any contributions to an HSA, since 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 earns more than $100,400 (again, after deductions that will lower their ACA-specific MAGI), their lowest-cost option is $2,314/month.
But there are a few points that need to be made about Sasse’s tweet:
- The median income for farm families in the US was under $78,000 in 2017 (the income comes from their non-farm sources, since median net farm-related income is slightly negative).
- An income of $78,000 will result in premium subsidies for families with three or more members. As noted above, the subsidies became much more substantial starting in 2018. If our family in North Platte was earning $78,000 in 2018, their premium subsidy would have been $2,282 per month, and they could have obtained a bronze plan for free after the subsidy was applied. With a $78,000 income for 2019, they would qualify for a subsidy of $2,545/month and would have access to three free bronze plans and a gold plan that costs just $145/month for the whole family.
- If the family is eligible for employer-sponsored coverage due to one or both spouses having another job in addition to the farm, they can use that coverage instead of buying individual market coverage. But they may be in a situation where it’s only affordable for the employee, and not for the whole family. That’s known as the family glitch. Former Minnesota Senator Al Franken introduced legislation in 2014 to fix the family glitch, but it did not have enough support to pass.
- HHS noted in 2016 that premiums are about 7 percent lower, on average, in states that have expanded Medicaid versus states that have not. Nebraska has not expanded Medicaid, although the state is moving forward with a plan to expand coverage by the fall of 2020, after Nebraska voters approved a Medicaid expansion ballot initiative in the 2018 election. But since Medicaid has not yet been expanded in the state, hospitals face more uncompensated care costs in Nebraska than they would if Medicaid had already been expanded. The multi-year delay in expanding Medicaid in Nebraska also means that the private plans in the exchange are covering people with incomes as low as the poverty level. If the state had expanded Medicaid, the private plans in the exchange would be covering people with incomes of 139 percent of the poverty level and above, since people with income below that level would be eligible for Medicaid instead. Lower incomes correlate with poorer health, so the overall risk pool for private plans in Nebraska would be expected to be healthier (and thus, lower-cost) if Medicaid were expanded. Sasse is a federal lawmaker, so the decision to not expand Medicaid was not his (that rests with governors and state lawmakers). But Sasse has been openly critical of the coverage gains made in other states as a result of Medicaid expansion, perhaps not understanding that it’s a key component of keeping private plan premiums in check?
- As noted above, the average premium increase in Nebraska was slated to be 16.9 percent for 2018, and that would have been the case if federal lawmakers — including Sasse — had allocated CSR funding. But they didn’t, and the result was an average rate increase of 31 percent in Nebraska. Granted, that’s also what has resulted in such oversize premium subsidies in 2018 and 2019, and unsubsidized consumers can avoid the CSR load on premiums by selecting a non-silver plan. But it’s somewhat ironic that the primary factor that drove rate increases for 2018 is something that federal lawmakers could have addressed at any time during early-mid 2017. The rate increases that resulted from the lack of CSR funding were not a surprise — insurers made it very clear in their rate filings that the impact on rates would be substantial if CSR funding were not allocated, but Republican lawmakers preferred to spend much of 2017 focusing on ACA repeal efforts, rather than taking action to stabilize the individual health insurance market.
Nebraska resisted Healthcare.gov re-enrollment, but it proceeded as planned
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.
Nebraska’s Department of Insurance allowed pre-2014 plans to be extended in 2014. Following the Obama Administration’s announcement in March that pre-2014 plans could be extended for up to two more years, the Nebraska Department of Insurance decided in late April to allow pre-2014 health insurance plans to be extended out as far as October 2016.
HHS issued additional extensions in early 2016, 2017, 2018, and 2019 allowing these “grandmothered” plans to continue to renew until as late as October 1, 2020, provided they terminate no later than December 31, 2020 (plans must become ACA-compliant by January 1, 2021, under the terms of the most recent federal guidance). Nebraska agreed to allow carriers in the state to go along with that extension as well; it is up to each carrier to decide whether to accept this option.
Exchange history in Nebraska
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.
Contact the exchange
The federal government operates the exchange in Nebraska
More Nebraska health insurance exchange links
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.