Sept. 23 was the final day for insurers to confirm their health insurance exchange participation in the states relying on the federal Healthcare.gov marketplace. Last-minute decisions by two insurers will affect coverage options in Delaware, Nebraska, Pennsylvania and West Virginia.

BlueCross BlueShield (BCBS) of Nebraska announced it wouldn’t offer coverage on the state’s Affordable Care Act (ACA) exchange in 2017. It had initially requested an average premium increase of 34.9 percent and was approved for a final increase of 42.3 percent, but instead the company will exit the marketplace over a reported $140 million in losses.

“We have a responsibility to all of our 700,000 customers to remain financially secure and stable, and to do so, we just couldn’t continue to sustain these losses,” BCBS of Nebraska said in a statement. “Without changes in the law, we don’t see the Public Marketplace stabilizing, and costs will continue to increase for both insurers and consumers.”

BCBS covered about 20,000 customers through its exchange offerings. Its exit in 2017 leaves two marketplace insurers in Nebraska, Medica and Aetna.

BCBS did leave the door open to a return in 2018. While it's exiting the exchanges, BCBS will continue offering lower-benefit bronze and catastrophic plans in the off-exchange individual market. If the insurer had fully exited the state, it would have been banned from re-entering the exchange for five years. A similar move was made in 2016 by BCBS of New Mexico, which will return to state’s exchange again for 2017.

In three other states, however, exchanges will keep one insurer that had threatened to depart. According to the Pittsburgh Tribune-Review, Highmark will offer exchange coverage in 2017 in Pennsylvania, Delaware and West Virginia, despite losing an estimated $68 million on that section of its business.

Those losses, coupled with Highmark’s lawsuit against HHS for $196 million in unpaid risk corridor funds, made the insurer look like a sure departure. Highmark CEO David Holmberg told the Tribune-Review the company took other steps to reduce costs by intentionally decreasing enrollment in its exchange plans, narrowing its physician networks and cutting reimbursement for doctors under marketplace plans by 4.5 percent.

“We need to get the right rates, the right networks and the right care models in place to make this care model sustainable,” Holmberg said.

Both Highmark and BCBS of Nebraska cited the same area for the federal government to limit insurers’ ACA losses: special enrollment periods. Both companies estimated those customers who sign up for coverage mid-year cost about $1.51 in claims for every $1 they pay in premiums. HHS has announced plans to make those enrollment periods harder to qualify for by requiring proof of eligibility.