Health Plan Weekly

Hype of artificial intelligence reached new heights in 2023, and the health care industry was no exception to that trend. Health insurance firms have been among the first organizations to deploy previous generations of big data tools at scale, and in turn, AI is set to proliferate among health insurers in the near future. How AI adoption will actually impact health insurance operations and finances is an open question.  

Some insiders, like Moody’s Investors Service analysts, expect health insurers to reap dramatic operational and financial benefits by deploying AI. Other experts disagree, including a group of Stanford University researchers who published a Nov. 16 op-ed in JAMA arguing that due to the extreme complexity of medical administration in the U.S., AI using large language models (LLMs) “might exacerbate billing challenges for physicians” and could lead to additional challenges of filed claims by carriers. 

During UnitedHealth Group’s annual Investor Day, analysts focused largely on looming challenges for the firm’s Medicare Advantage business. Yet the company’s executives also revealed some intriguing details about new benefit designs gaining traction in the company’s commercial insurance book of business. 

In reviewing the updated 2024 financial estimates that UnitedHealth released before its Nov. 29 Investor Day, Wells Fargo analyst Stephen Baxter advised investors that “we see higher-than-expected MLR [medical loss ratio] and more modest MA membership growth as items to pick at.”  

Hospitals, buoyed by stabilized finances, have resumed a robust level of transactions. Those deals have drawn more frequent antitrust action by the Biden administration and many state governments, which view hospital mergers and acquisitions as an omen of high health care prices — and augur tough rate negotiations for health insurers.  

An increasing number of those transactions involve so-called “cross market” partnerships, in which hospitals from different markets — and often different states — tie up to avoid antitrust scrutiny from state regulators. State antitrust officials often have more leeway to block hospital transactions, since federal regulators are not allowed to investigate either most intrastate deals or interstate deals with combined revenues of under $111 million.  

The Centers for Medicare and Medicaid Services wants clarification from the federal court that recently ruled against the agency’s interpretation of the law when it comes to commercial insurance plans’ use of copay accumulators before it revises its current policy on such programs.

The Health and Human Services Department filed a motion with the U.S. District Court for the District of Columbia on Nov. 27 seeking an explanation for the court’s late September decision that the policy, which allows plans to use copay accumulators broadly, must be set aside and remanded back to CMS because of the agency’s contradictory reading of the same statutory and regulatory language. 

Nearly 4.6 million people have enrolled in Affordable Care Act marketplace coverage since the start of the 2024 open enrollment period on Nov. 1, a 36% increase compared to the same point during the 2023 OEP, according to CMS. This year’s open enrollment season will last from Nov. 1, 2023, to Jan. 15, 2024, in most states and longer in some state-based marketplaces (SBMs).

More than 4 million people have enrolled through HealthCare.gov in the 32 states that use that platform, and another 501,962 have enrolled across 18 states and the District of Columbia, which use their own marketplaces. Most states are seeing significant membership growth in 2024 compared with the same period last year. Mississippi reported a signup surge of almost 114%.