Nebraska

NOTE: This is an updated version of a post from a couple of months ago. Since then, there's been a MASSIVELY important development: The passage of the American Rescue Plan, which includes a dramatic upgrade in ACA subsidies for not only the millions of people already receiving them, but for millions more who didn't previously qualify for financial assistance.

Much has been written by myself and others (especially the Kaiser Family Foundation) about the fact that millions of uninsured Americans are eligible for ZERO PREMIUM Bronze ACA healthcare policies.

I say "Zero Premium" instead of "Free" because there's still deductibles and co-pays involved, although all ACA plans also include a long list of free preventative services from physicals and blood screenings to mammograms and immunizations with no deductible or co-pay involved.

Much has been written by myself and others (especially the Kaiser Family Foundation) about the fact that millions of uninsured Americans are eligible for ZERO PREMIUM Bronze ACA healthcare policies.

I say "Zero Premium" instead of "Free" because there's still deductibles and co-pays involved, although all ACA plans also include a long list of free preventative services from physicals and blood screenings to mammograms and immunizations with no deductible or co-pay involved.

If you have a fairly healthy year, you really could go the entire year without paying a dime in healthcare costs while still taking advantage of many of these free services, and also having the peace of mind that in a worst-case scenario, at least you wouldn't go bankrupt. Not perfect, but a lot better than going bare especially since you wouldn't pay a dime in premiums.

I'm not sure what's going on with Bright Health Care in Nebraska. They entered the state's ACA market in 2020, but for whatever reason they aren't showing up in the HealthCare.Gov Rate Review database. The only carrier listed for the state's individual market is Medica, and the SERFF database for Nebraska doesn't bring up either one.

Even more curious, when I ran a search to make sure that Bright hadn't simply jumped in and then out again the following year, I found this article:

Bright Health Plan announced today its 2021 expansion plan. It will expand access to its Medicare Advantage, individual and family-plan products in select areas, and to add fully-insured small business plans to its available products in certain markets.

When I first ran the preliminary 2020 avg. rate hike numbers for Nebraska in August, the sole carrier offering ACA-compliant policies in the state (Medica) was planning on reducing their average premiums by 5.3%. Yesterday the final, approved rates were posted by CMS, and unsubsidized 2020 premiums will be even lower, by 6.9% on average.

For 2020, Bright Health is joining the Nebraska exchange.

MLR rebate payments for 2018 are being sent out to enrollees even as I type this. The data for 2018 MLR rebates won't be officially posted for another month or so, but I've managed to acquire it early, and after a lot of number-crunching the data, I've recompiled it into an easy-to-read format.

But that's not all! In addition to the actual 2018 MLR rebates, I've gone one step further and have taken an early crack at trying to figure out what 2019 MLR rebates might end up looking like next year (for the Individual Market only). In order to do this, I had to make several very large assumptions:

The floodgates are now officially open for preliminary (not final) 2020 ACA rate filings for both the Individual and Small Group markets. There are several states which only have a single insurance carrier offering policies on the Individual Market, which makes it very easy to calculate the weighted average rate changes...seeing how a single carrier holds 100% of the market.

Among these states are Alaska, Nebraska and Wyoming, where the sole Indy Market carriers are once again Premera BCBS (AK), Medica (NE) and BCBS of Wyoming. Unfortunately, the rate filing forms for all three are partly redacted, making it impossible for me to determine how many total enrollees they have, although I have a pretty good estimate of the on-exchange number as of the end of March for each.

In Alaska, Premera's 2020 rates are virtually unchanged year over year. In Nebraska, Medica expects to reduce rates an average of 5.3%. And in Wyoming, BCBS is only looking to bump up average unsubsidized premiums by 1.6%.

I realize this may seem a bit late in the game seeing how the 2019 ACA Open Enrollment Period has already started, but I do like to be as complete and thorough as possible, and there were still 9 states missing final/approved premium rate change analyses as of yesterday which I wanted to check off my 2019 Rate Hike Project list.

Fortunately, RateReview.HealthCare.Gov has finally updated their database to include the approved rate changes for every state, which made it easy to take care of most of these.

Nebraska has a slightly confusing siutation, which is surprising since Medica is the only carrier offering ACA policies in the state, When I first took a look at the requested premium changes for 2019 back in August, it looked like the average was around 1.0%...that was based on splitting the difference between the 3.69% and -2.60% listings, since the filing form was redacted and I didn't know what the relative market split was between Medica's product lines.

I just realized that while I've written quite a bit about the potential loss of Medicaid coverage for thousands of residents of Michigan, Kentucky and Arkansas over the past few months due to the new work requirement laws in those states, It's been far too long since I've given a shout-out to the four states which are hoping to add Medicaid expansion (or at least continue it, in one case) exactly one week from today.

Bloomberg News has a pretty good overview:

For years, elected leaders in conservative states have resisted expanding Medicaid, the government health program for low-income Americans. Now voters in four of those states will decide the question directly.

Breaking News via the Lincoln Journal Star...

A Lancaster County District judge has dismissed a challenge to the Medicaid expansion petition initiative, allowing the initiative to be placed on the November ballot.

The lawsuit was brought by former state Sen. Mark Christensen and Sen. Lydia Brasch. They alleged the initiative was an unconstitutional delegation of legislative authority, contained more than one subject, which the state Constitution prohibits, and that it failed to identify Nebraska Appleseed as a sworn sponsor.

Last week, Secretary of State John Gale confirmed that enough signatures were gathered by petition circulators to put the question of whether to expand Medicaid to about 90,000 uninsured adult Nebraskans on the Nov. 6 ballot. 

...The campaign has said Medicaid expansion will create and sustain 10,000 new jobs, reduce medical bankruptcies, bring $1.1 billion of Nebraskans’ tax dollars back from Washington, D.C., and produce savings by reducing uncompensated care for those who lack health coverage.

Nebraska is about as simple as it gets--there's only one carrier offering ACA individual market plans. Unfortunately, they've redacted the combined average rate change request between their two plan entries, so all I can do is split the difference and assume around a 1% average increase.

The Urban Institute projected that Nebraska rates would see a whopping 20.4 percentage point increase due to #MandateRepeal and #ShortAssPlans, which are both referenced in Medica's filing. Since they don't get more specific than that, I'm assuming 2/3 of Urban's estimate, or a 13.6% increase.

Unsubsidized Nebraska enrollees are currently paying an average of $854/month, so if accurate, that's a difference of around $116/month or nearly $1,400 for the year. Ouch.

A couple of weeks ago, a joint letter was sent to all four Congressional leaders from AHIP (America's Health Insurance Plans), the BlueCross BlueShield Association, the American Academy of Family Physicians, the AMA, the American Hospital Association and the Federation of American Hospitalsm warning them, in no uncertain terms, of what the consequences of repealing the individual mandate would be:

We join together to urge Congress to maintain the individual mandate. There will be serious consequences if Congress simply repeals the mandate while leaving the insurance reforms in place: millions more will be uninsured or face higher premiums, challenging their ability to access the care they need. Let’s work together on solutions that deliver the access, care, and coverage that the American people deserve.

A week or so ago, the American Academy of Actuaries sent a similar letter to Republican Senate Majority Leader Mitch McConnell stating pretty muc the same thing, but in more vivid detail:

I noted back in August that there will only be one insurance carrier offering policies on the Nebraska individual market next year (Medica), with Blue Cross Blue Shield dropping out.

Medica originally requested a 16.9% average rate hike, but that was based on the assumption that CSR funding would be appropriated. However, Louise Norris reports that the final, approved average increase will actually be more like 31% due specifically to the lack of guaranteed CSR reimbursements.

Medica has 35,269 members on their ACA-compliant individual market plans in 2017. But all of the current Aetna enrollees, as well as off-exchange BCBSNE enrollees, will need to switch to Medica plans at the end of 2017, as Medica will be the only insurer offering plans in Nebraska’s individual market for 2018.

With Blue Cross Blue Shield of Nebraska declining to participate in the Nebraska exchange, that leaves just Medica as the sole individual market carrier. They're asking for a 16.9% average rate hike, 

Interestingly, while Medica's rate filing letter clearly states that the 16.9% request assumes CSR payments will be made and the mandate will be enforced, they also list "unprecedented uncertainty/risk inherent in the marketplace" as one of the key drivers of the increase.

The Kaiser Family Foundation estimates the CSR issue as adding around 15% to NE Silver plans, which translates into roughly a 10% additional increase if spread across all polices, or 26.9% overall.

Between updating the "Who could lose coverage" graphics, prepping for my town hall thing last night and updating the 2018 Rate Hike project, I've gotten way behind on my "Who's saying 'screw rate hikes, I'm just gonna bail completely next year' updates. Let's take care of that now, OK? The first three updates are courtesy of Louise Norris writing for healthinsurance.org; the fourth is vai Kimberly Leonard for the Washington Examiner:

IDAHO: BridgeSpan is out, 4 carriers staying put:

Insurers in Idaho had to submit forms for 2018 plans by May 15, but they have until June 2 to file rates. Mountain Health CO-OP, SelectHealth, PacificSource and Blue Cross of Idaho all filed forms to continue to offer Your Health Idaho plans in 2018.

Ben Sasse is a Republican U.S. Senator from Nebraska. As you might imagine, he's not a fan of the ACA.

About an hour ago, he tweeted the following:

Just heard from small-biz owner--whose plan was cancelled by ObamaCare--that he's been forced into this:
$13k/yr deductible
$15k/yr premium

— Ben Sasse (@BenSasse) April 28, 2017

...which I thought would be the first tweet in a brief thread including some additional details, such as:

As I noted when I crunched the numbers for Texas, it's actually easier to figure out how many people would lose coverage if the ACA is repealed in non-expansion states because you can't rip away healthcare coverage from someone who you never provided it to in the first place.

My standard methodology applies:

A few days ago I noted that up to 50,000 South Dakota residents who previously held out at least had some hope that the state might expand Medicaid under the ACA next year have already had that hope yanked out from under them like a rug:

A proposal to expand a federal health insurance program for needy people could be off the table following the results of Tuesday's election.

The victory of Republican Donald Trump, who has called for a repeal of Obamacare, along with the increasingly conservative Republican make-up of the South Dakota state Legislature could thwart Gov. Dennis Daugaard's efforts to expand Medicaid in the state.

Well, the same dynamic is already playing out in Nebraska as well:

Trump win sinks effort to expand Medicaid in Nebraska

Today (Friday, Sept. 23) happens to be the deadline for insurance carriers to sign agreements with the federal government for participating in the exchange this Open Enrollment period (I'm not sure if today's deadline also applies to the state-based exchanges or not; they might be different). Until today, it looked as though there were going to be 3 carriers offering individual policies on the Nebraska exchange:

The figures compared 2016 and 2017 rates for Blue Cross Blue Shield of Nebraska, Aetna Health Inc. and Medica, the three companies that will offer policies to Nebraskans on the exchange when open enrollment starts Nov. 1.

However, as commenter M E noted, it looks like BCBSNE decided to wait until literally the last minute (last hour, anyway) to change their minds:

Huh. Back in June, when I first ran the requested rate hike numbers for Nebraska, it looked as though there were only two real carriers offering individual plans, either on or off the exchange: Blue Cross Blue Shield and Medica. UnitedHealthcare announced they were leaving NE along with a bunch of other states, and Coventry (aka Aetna) didn't have any filings for 2017, so I assumed they were bailing as well. Finally, the less time spent talking about "Enterprise/Freedom Life" the better. So...it looked like BCBS and Medica were it. Here's what the table looked like:

Hmmm...last year Nebraska had 5 carriers offering individual policies, 2 of which were actually divisions of the same company (UnitedHealthcare). Since United is pulling out of Nebraska, this leaves only three companies...one of which is the mysterious "Freedom Life Insurance Co." which keeps popping up in numerous states as not having a single actual enrollee, and almost always asking for the exact same rate hike: 17.37%. What's up with that?

Anyway, Coventry (actually Aetna) appears to also be gone next year as well...or perhaps they simply haven't submitted their rate filings yet? I suspect the latter because Nebraska's total individual market was over 110,000 people as of 2014, and is likely up to over 130K this year (nearly 88,000 enrolled via the ACA exchange alone this year)...yet adding up the numbers from the official filings only totals around 30,000 people.

With 47 states plus DC under my belt, at this point I'd say I have a pretty good feel for the overall national premium rate increase scene; it still looks like around 12-14% nationally on average, ranging from a low of under a 1% average hike in Maine and Indiana to a high of 40% or so in Alaska and Minnesota.

However, I admit it would be nice, as a point of personal pride, if I could squeeze in the last three states: Nebraska, Pennsylvania and Wisconsin. Fortunately, Louise Norris has brought to my attention the fact that the Nebraska Dept. of Insurance has issued the final approved rate changes for the individual market:

This is an incredibly depressing post for me to write. Last month I received word that CoOportunity Health, one of the 23 co-ops set up as part of the ACA to offer competition with the Big Boys, had run into serious financial trouble and was being yanked off of Healthcare.Gov (they were operating in Iowa and Nebraska, both of which are on the federal exchange).

This surprised me because from everything I had heard, CoOportunity was doing quite well, with upwards of 120,000 QHP enrollees last year. I've written about them several times in the past, and have kind of a special fondness for them because they were one of the first sources I had for solid OFF-exchange QHP enrollment data.

Anyway, as of December 10th, my contact at CoOportunity was unaware of any issues; they reported that everything was going great. On Christmas Eve, I was tipped off about CMS dropping CoOportunity from the exchange completely, but there wasn't a whole lot of detail given as to what had gone wrong beyond vague references to quarterly financial statements, cash flow and annual audits.

Leigh McGivern of coOportunity Health has helpfully provided their final (well, near-final...through 4/14) tallies for both on- and off-exchange enrollments. The exchange-based numbers aren't really relevant to me since those are reported by HHS, but the off-exchange QHPs and ESI's are vital:

IOWA

  • Individual/Family members: 18,358 (10,809 on exchange/7,549 off exchange)
  • Small group members: 7,848
  • Large group members: 274

NEBRASKA

  • Individual/Family members: 30,668 (20,308 on exchange/10,360 off exchange)
  • Small group members: 11,292
  • Large group members: 2,774

TOTAL ON EXCHANGE IOWA AND NEBRASKA (individuals/families): 31,117

TOTAL OFF EXCHANGE IOWA AND NEBRASKA (individuals/families): 17,909

TOTAL BUSINESS (employees and dependents) IOWA AND NEBRASKA: 22,188

TOTAL BOTH STATES ON AND OFF EXCHANGE (individuals/families/businesses): 71,214

This represents increases as follows:

UPDATE: On the down side, I was off by 4% this time around.

On the up side, I UNDERESTIMATED:

Actual Feb. enrollments: 942,833, for a total of 4,242,325 thru 3/01/14.

Sarah Kliff at Vox just announced that the February HHS report is expected to be released today at around 4:00pm. A few items in anticipation of that:

  • As I've noted several times, I'm projecting the report to total around 902,000 exchange-based private QHP enrollments for the month of February (technically 2/02 - 3/01)
  • If accurate, this would bring the cumulative total of exchange-based private QHP enrollments to 4.202 million (from 10/1/13 - 3/01/14)
  • From the data I have, the average daily enrollment rate in February was almost identical to that of January, which had about 1.146 million QHP enrollments. HOWEVER, the January report included five weeks of data (12/28 - 2/01), while the February report will only include four weeks (2/02 - 3/01). Therefore, even at the same daily average, it'll be about 20% lower no matter what.
  • Don't be surprised if Peter Lee of CoveredCA decides to steal some thunder by announcing that California has enrolled 1,000,000 QHPs all by itself either today or tomorrow. However, that would include the past 10 days, while the HHS number will only run thru 3/01.
  • If you want to get REALLY specific, call it 902,800 and 4,202,292.
  • I've been dead-on target 6 times in a row without hyping up my projections beforehand. This time I am hyping myself up beforehand, so I'll probably be way off...but as long as I've UNDERestimated the tally, I'll be perfectly fine with that...
  • The report will be released in about 5 minutes, but my kid gets home from school in about 10, so it'll be a good 20 minutes before I can really post anything. Feel free to follow Sarah Kliff of Vox in the meantime!

Back in January, I found my first solid data on off-exchange enrollments via a Co-Op operating in Iowa and Nebraska called CoOportunity. They helpfully provided their data through January 24, which totalled 10,166 off-exchange enrollments in Iowa and antoher 17,779 in Nebraska.

Last week, they provided an update to these figures. When you add off-exchange individual/family policies to small & large group policies (which are "off-exchange" by definition, since the HC.gov SHOP system isn't operational yet...you get redirected to the individual companies/co-ops), Iowa is up to 12,293 and Nebraska is up to 19,959, as of February 24.

Leigh McGivern, PR & Social Media Manager for CoOportunity Health of Iowa and Nebraska, has done me a huge favor by agreeing to release the Co-Op's on-exchange and off-exchange (direct) enrollment figures through January 24!

Unfortunately, the on-exchange numbers are both less than the 12/28 totals for either states (there are 2 insurance companies operating on Iowa's exchange and 3 on Nebraska's), so I don't know how much those have gone up since December, but the off-exchange numbers are quite impressive and very telling! I'm not breaking out the age data, but here's the key numbers:

Iowa Off-Exchange QHP Enrollments: 5,325 Individual; 4,694 Small Group; 147 Large Group = 10,166

Nebraska Off-Exchange QHP Enrollments: 7,867 Individual; 8,079 Small Group; 1,833 Large Group = 17,779

Between the two, that's nearly 28,000 more people added to the Private QHP tally.

In a December 23rd interview with the Des Moines Register, CoOportunity Health (1 of 2 companies participating in IA's ACA exchange (and 1 of 3 participating in NE) said they had enrolled 2,577 people in private plans in Iowa via the HC.gov exchange as of 12/20. However, they also mentioned a total of 8,583 enrollments state-wide as of 12/20, meaning another 6,006 people were enrolled directly through the company, bypassing the exchange completely.

I contacted Leigh McGivern, the PR representative for CoOportunity Health, who informed me that CoOportunity operates in Nebraska as well, and gave me more recent and detailed numbers for both states: 3,468 exchange-based enrollments (not sure if this is people or households) in Iowa, and another 7,362 exchange-based enrollments in Nebraska.

(Note: The spreadsheet numbers for IA & NE were actually updated with this data a couple of weeks ago, but it took me this long to get around to writing up the explanation)

In a December 23rd interview with the Des Moines Register, CoOportunity Health (1 of 2 companies participating in IA's ACA exchange (and 1 of 3 participating in NE) said they had enrolled 2,577 people in private plans via the HC.gov exchange as of 12/20. However, they also mentioned a total of 8,583 enrollments state-wide as of 12/20, meaning another 6,006 people were enrolled directly through the company, bypassing the exchange completely.

I contacted Leigh McGivern, the PR representative for CoOportunity Health, who informed me that CoOportunity operates in Nebraska as well, and gave me more recent and detailed numbers for both states: 3,468 exchange-based enrollments (not sure if this is people or households) in Iowa, and another 7,362 exchange-based enrollments in Nebraska.