5 areas most at risk of losing insurers on the exchanges

Several U.S. areas are at risk of having one or no health plans operating on the 2018 ACA exchanges, due in part to uncertainty surrounding the future of the ACA's cost-sharing reductions — which compensate payers for subsidizing costs for lower-income individuals — and other ACA provisions like the individual mandate.

Here are the five places most at risk of losing insurers on the exchanges, as reported by The Hill.

1. Iowa. In April, Hartford, Conn.-based Aetna and Des Monies, Iowa-based Wellmark Blue Cross and Blue Shield declared their exit from the state's exchange. The exit means 94 out of 99 counties in Iowa will have one insurer — in most, Minnetonka, Minn.-based Medica — selling individual plans on the HealthCare.gov exchange when open enrollment begins in November. However, Medica spokesperson Larry Bussey told The Hill it is still considering its exchange participation for 2018.

2. Knoxville, Tenn., area. Louisville, Ky.-based Humana decided to leave the 2018 ACA exchanges entirely in February, a move leaving Tennessee's Knoxville area void of on-exchange health insurers. Tennessee Insurance Commissioner Julie Mix McPeak began negotiating with insurers to fill the gap and worked with Chattanooga-based BlueCross BlueShield of Tennessee to incentivize the payer to enter the market.

3. Missouri. Twenty-five counties in Missouri could see no health insurer selling on the state's 2018 exchange following Blue Cross and Blue Shield of Kansas City (Mo.)'s decision to pull operations from the payer's 32-county service area in Missouri and Kansas. BCBSKC, which made the decision last month, projects the move will affect more than 67,000 individuals.

4. Nebraska. Medica is the only insurer selling health plans on Nebraska's exchange next year, The Hill reports. In May, Aetna said it would leave the exchange for 2018.

5. Rural places. Rural areas usually have less competitive insurance markets. In 2017, an average of two insurers participated on the exchanges in rural areas, compared to two and a half insurers in urban settings, The Hill reports.  

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