Medicare Advantage Competition in Nebraska’s Rural Counties

---

 Medicare Advantage (MA) plan availability is uneven across Nebraska. While urban and eastern counties often have many plan options, several rural western counties face very limited competition – in some cases only one insurer (or none) offers MA plans:

• Cherry County – No MA Plans Available: Cherry County has no Medicare Advantage plans at all, meaning beneficiaries there must rely on Original Medicare or Medigap supplements. (In 2024, MA plans were offered in 89 of Nebraska’s 93 counties, leaving a few rural counties like Cherry with no private plan options.)  
• Sheridan County – Only Medica (Cost Plans): In Sheridan County (northwest Nebraska), the only MA options are Medica’s Prime Solution Medicare Cost plans. No standard MA HMO or PPO plans are offered by any other insurer, so Medica is effectively the sole choice. (Cost plans are a type of Medicare plan that can fill gaps when MA is unavailable, but they operate differently from typical MA PPO/HMO plans.)  
• Sioux County – Only Humana: Sioux County (far northwest corner) has only Humana Medicare Advantage offerings. Humana provides a few PPO plan options (such as “Full Access,” “USAA Honor,” and “Choice” PPO), but no other insurer’s plans are available. This leaves Humana as the single MA insurer in Sioux County.  
• Kimball County – Only Aetna: Kimball County (in the southern Panhandle) is served only by Aetna for MA coverage. Aetna offers a handful of plans (including an HMO-POS “Eagle” plan and several PPO/POS plans), but no other company offers plans in Kimball. Thus, Aetna holds a monopoly on MA in this county.  
• Chase County – Only Blue Cross Blue Shield: In Chase County (southwest Nebraska), Blue Cross and Blue Shield of Nebraska (BCBSNE) is the only MA insurer. The BCBSNE Medicare Advantage lineup (e.g. MA Access PPO, MA Connect PPO, MA Core HMO, MA Secure PPO) is available, but no competing carriers offer plans in Chase County. Beneficiaries essentially have BCBSNE as their sole choice for MA coverage.  

Other rural western counties similarly have very few plan choices. For example, Banner, Garden, Deuel, and Grant counties each have only 1–2 insurers active (often just BCBSNE and one other), offering a small number of plans. In 2024, some Nebraska counties had as few as 3 Medicare Advantage plans total (compared to 30–40 plans in the most populous counties). This means many rural seniors effectively have one company’s MA products – or none – available in their county. By contrast, urban areas like Omaha or Lincoln might have dozens of plans from multiple insurers, illustrating a stark urban-rural divide in MA competition.

In the counties above, the types of plans offered are also limited by what the single insurer provides:

• HMO vs PPO: Most plans in rural counties are PPO or PFFS-type plans, since HMOs are harder to maintain with sparse provider networks. For instance, Humana’s plans in Sioux County are PPOs, and Aetna’s plans in Kimball include HMO-POS/PPO options. BCBSNE’s solitary offerings in some counties include an HMO in limited areas (its “Core” HMO where a network exists) and PPO plans elsewhere. Generally, PPOs dominate in these rural markets because they offer slightly more flexibility for out-of-network use if local providers are not in-network.  
• Medicare Cost Plans: As noted, Medica’s Prime Solution plans in certain Panhandle counties (e.g. Sheridan, Dawes) are Medicare Cost plans. Cost plans allow enrollees to see any Medicare provider (with Original Medicare covering services outside the plan’s network), which can be advantageous in provider-scarce areas. However, cost plans are relatively few and are offered by just one insurer (Medica) in those counties – again reflecting minimal competition.  
• MSA Plans: A Medicare Medical Savings Account (MSA) plan – a high-deductible MA plan with a savings account – is theoretically well-suited for rural areas because MSA plans have no provider network restrictions (enrollees can use any doctor or hospital that accepts Medicare). Under an MSA, any provider accepting Medicare is reimbursed, similar to Original Medicare. However, MSA plans are rare. In Nebraska, availability of MA MSA plans has been very limited. (One insurer had offered an MSA plan statewide for only 1 year in 2997. MSA plans have not been available in Nebraska since.  The lack of MSAs means rural seniors don’t currently benefit from this network-free MA model and must choose between the limited network-bound plans or staying on Original Medicare.  

In summary, many western Nebraska counties have only one insurer offering a small handful of MA plans, typically PPO or POS plans that attempt to cover large rural areas. A few insurers (like BCBSNE, Aetna, Humana, Medica, and Wellcare/Centene) have carved up these regions, often resulting in a single-insurer monopoly in a county. Four of Nebraska’s 93 counties had no MA plans at all as of 2024 (forcing beneficiaries there to use Original Medicare), and several others have only one carrier. This limited competition contrasts with the intent of the Medicare Advantage program to use private-plan competition to improve benefits and costs – instead, in rural Nebraska, seniors often face a “take-it-or-leave-it” single-plan scenario.

These competition gaps are closely tied to provider network adequacy issues in rural Nebraska. Medicare Advantage plans must form provider networks that meet CMS’s time-and-distance standards for access to hospitals, primary care, specialists, etc. in each county. In sparsely populated areas, it can be difficult for an insurer to meet network adequacy requirements – there may be only one critical-access hospital and a few clinics in an area, and not all may agree to contract with the MA plan. This leads to several challenges:

• Some Counties Lack In-Network Providers: If a hospital or provider group declines to contract, an MA plan may not be able to serve that county at all (which is one reason certain counties have zero plans). For example, Perkins County’s only hospital (Perkins County Health Services in Grant, NE) dropped all Medicare Advantage contracts in 2024 due to payment and administrative concerns. A local CEO called it a “difficult but necessary decision.” The result is that even though an MA plan might be available on paper in Perkins County, no local hospital is in-network. Seniors would have to travel out of county for in-network hospital care or face high out-of-network costs – effectively making MA impractical in that area.  
• Rural Hospitals and Clinics Exiting MA Networks: This is a statewide trend – a 2025 survey by the Nebraska Hospital Association found about 10% of Nebraska’s hospitals – all rural – have stopped accepting any Medicare Advantage plans. And roughly half of hospitals have dropped at least one MA contract. These provider withdrawals are often due to low reimbursements, slow or denied payments, and heavy paperwork from MA insurers. When a major provider (hospital system or physician group) leaves an MA network, patients lose access and may need to change plans or go out-of-network. State regulators note that in some cases seniors suddenly find that the nearest hospital or clinic is no longer in their plan’s network, which “can leave enrollees without ready access to care” and force them to either pay more out-of-network or delay treatment. The NAIC (National Association of Insurance Commissioners) raised alarm in late 2024 about these network disruptions, warning that delays in care for rural MA enrollees are likely to “result in harm”.  
• Long Travel Distances for Care: Even when an MA plan does serve a rural county, the network may be so limited that enrollees must travel considerable distances to see in-network specialists or hospitals. For instance, an MA plan might have no in-network cardiologist or orthopedic surgeon within 100 miles of a small Panhandle town. CMS’s network adequacy rules do allow longer distance requirements in rural counties, but the practical burden on seniors (long drives, finding transportation) can be significant. Many rural seniors choose Original Medicare for this reason – with Original Medicare they can see any nearby provider that accepts Medicare, whereas an MA HMO might have no local options. A rural hospital CEO described the situation: “There’s nothing worse than telling a patient they can’t come to their hometown facility because their [MA] plan won’t authorize it” for lack of network coverage. Unfortunately, such scenarios are common “daily” occurrences in some Nebraska communities.  
• Provider Perspective – Administrative Burdens: From the providers’ side, contracting with MA plans can be onerous, especially for small rural hospitals. The Nebraska Hospital Association reports widespread issues with MA plans denying or delaying care approvals. Over 89% of Nebraska hospitals say Medicare Advantage has hurt their finances, and 93% report increased administrative costs due to dealing with MA plans. Some hospitals have had to hire extra staff just to manage MA billing and prior authorizations. This has led certain hospitals (e.g. in rural Pender, NE and North Platte, NE) to conclude that dropping MA contracts actually improved their operations and patient satisfaction. The net effect is fewer providers willing to participate, which exacerbates the network adequacy problem in a vicious cycle.
•   

The stark contrast to this situation is Original Medicare. Traditional Medicare has no provider network – any doctor or hospital nationwide that accepts Medicare will treat an Original Medicare patient. Nearly all Nebraska hospitals and physicians accept Medicare assignment, so Original Medicare enrollees in rural areas can use local providers without restriction. Seniors can also add a Medigap supplemental policy to help cover cost-sharing, giving them broad, predictable coverage. This freedom stands in contrast to Medicare Advantage, where private plans “tend to have localized provider networks, as opposed to Original Medicare’s nationwide access” to providers.Notably, Medicare MSA plans (a subset of Medicare Advantage) were designed to mimic some of that Original Medicare flexibility. As mentioned, MSA plans generally do not have networks – “you can go to any Medicare-approved doctor or hospital” under an MSA plan. Providers are paid as if it were Original Medicare, removing the need for the provider to be in a special MA network. This model can eliminate the provider participation barrier for rural healthcare: any clinic or hospital that sees Medicare patients could see an MSA plan patient without a separate contract. Unfortunately, MSA plans have had very low uptake and availability. After a brief period where an MA MSA option was offered in Nebraska (and other states), the last major MSA plan insurer exited by 2024, leaving no MSA plans active locally. Thus, the “Original Medicare MSA” concept exists in theory as a network-free MA alternative, but is not currently benefiting most Nebraska seniors. It does, however, highlight a key point – if seniors in western Nebraska want to use their local providers, Original Medicare (with or without Medigap) is often the only realistic coverage that guarantees access.

The lack of plan competition and network limitations in rural Nebraska has several impacts:

• For Patients: Fewer plan choices often mean less generous benefits and higher out-of-pocket costs. When only one insurer serves a county, that insurer has little incentive to lower premiums or enhance benefits – seniors get a “take it or leave it” offer. If that one plan’s provider network is poor, patients may be forced to travel or pay out-of-network rates. In counties with no MA plans, seniors who prefer to add benefits like dental or vision (commonly offered by MA) simply cannot do so and must stick with Original Medicare. As MA enrollment grows nationwide, there’s concern that rural seniors are being left behind. Many may feel pressured to enroll in a plan with extra perks, only to find their doctor or hospital isn’t covered – leading to delays in care or unexpected bills. Fragmented care can result if patients bounce between providers trying to find someone in-network. In short, limited competition can compromise access and continuity of care for rural Medicare beneficiaries.  
• For Providers: When only one MA insurer operates in a county, that insurer can exert a lot of leverage on local providers (e.g. offering take-it-or-leave-it contract terms). Providers might accept low rates to ensure they can see patients, or they might refuse, knowing patients have no alternative MA plan to switch to. Neither scenario is ideal. Hospitals in one-insurer markets report that they spend extensive time fighting for authorizations and payments from the sole MA company. If they exit the network, they risk losing patients who then travel to in-network facilities elsewhere. This dynamic can undermine the financial stability of rural hospitals – which is already precarious. Indeed, the Nebraska Hospital Association warned that the shift to Medicare Advantage is hurting rural hospitals’ finances (89% of hospitals surveyed reported negative financial impacts). Limited competition among plans doesn’t just affect premiums; it also means providers have fewer avenues to negotiate fair payment or to refer patients within a broad network. Ultimately, some providers choose to opt out of MA entirely (as we’ve seen), which then further reduces the attractiveness of MA plans in that area. It’s a vicious cycle of low competition leading to poor networks, which leads to even less competition as both patients and providers retreat from the MA market.  

In conclusion, western Nebraska’s Medicare Advantage landscape is characterized by minimal competition and notable network gaps. A few counties have no MA plans at all, and many others have only one insurer offering a small selection of plans (often PPO or cost plans). This stands in stark contrast to Original Medicare (or an MSA-type plan) which allows any Medicare provider to participate. The lack of plan competition and the difficulty of establishing adequate provider networks reinforce each other: insurers are wary of entering sparsely populated markets, and providers are hesitant to join networks that may not offer sustainable terms. For Nebraska’s rural seniors, this means fewer choices and potential hardships accessing care. State and federal officials – as evidenced by the NAIC’s 2024 letter – are increasingly concerned about these trends, as limited access and delayed care undermine the core promise of Medicare Advantage in rural America. Many experts advise rural seniors to carefully weigh the trade-offs of MA plans and to ensure their doctors and hospitals are in-network before switching from Original Medicare. In areas with only one or no MA insurer, the Original Medicare model (with its broad provider acceptance) remains the more reliable option for maintaining access to healthcare services