Health Plan Weekly

About 3.7 million people could gain access to health care if the current 12 nonexpansion states were to fully implement a Medicaid expansion in 2023, according to a recent Urban Institute analysis.

In the upcoming gubernatorial elections in November, Medicaid expansion could be a key issue in several nonexpansion states, including Wisconsin, Kansas and Georgia. All three states had several failed attempts to fully expand Medicaid eligibility.

CMS on Aug. 31 proposed a new regulation aimed at streamlining applications, verifications, enrollment and renewals for Medicaid and Children’s Health Insurance Program (CHIP) coverage. The rule would make a host of changes, such as eliminating the requirement that individuals apply for other benefits as a condition of Medicaid eligibility, requiring that states conduct renewals no more than once every 12 months, and establishing specific guidelines for states to check available data prior to terminating eligibility when a beneficiary cannot be reached due to returned mail. CMS said it estimates that “this proposed rule would remove barriers to enrollment and increase the number of eligible individuals who obtain coverage and are continuously enrolled in Medicaid and CHIP.”  

Despite worrying macroeconomic trends, health insurers have done well this year so far, with all the largest publicly traded health insurance firms posting year-over-year earnings growth in the first half of 2022. Experts tell AIS Health, a division of MMIT, that they don’t expect health insurers to struggle despite ominous signs across the economy.

Those headwinds include inflation; a possible recession, which could decimate employer-based insurance enrollment; medical cost growth; and the resumption of Medicaid eligibility redeterminations, which will force unprecedented amounts of disenrollment. But experts say that insurers with a mix of business lines should be in a strong financial position. The largest risk is likely to insurers that carry a coverage mix disproportionately focused on the commercial market.

Health Care Service Corp. (HCSC) recently agreed to acquire Trustmark Health Benefits, a third-partner administrator (TPA) of health benefits. The pending deal continues HCSC’s expansion from its roots as primarily a traditional commercial insurer to other areas like TPAs and Medicare, and the diversification push is likely to continue, according to health insurance industry analysts who spoke with AIS Health, a division of MMIT.  

For several years, HCSC has been a client of Trustmark Health Benefits, a firm that has more than 600 clients across the U.S. The companies Trustmark works with have self-insured health plans, meaning they are responsible for the cost of providing benefits to their employees. Trustmark generates revenue by helping companies in areas such as administering claims, managing risk, setting up virtual care and engaging with customers. 

In the latest round of rulemaking on the No Surprises Act (NSA), the 2020 law that bans most balance medical billing, providers won concessions from the Biden administration regarding the calculus arbitrators must use to decide billing disputes. One expert tells AIS Health, a division of MMIT, that the new regulation, which takes recent pro-provider court decisions into account, is likely to reduce the amount of cost savings the NSA generates for payers.

The NSA bans the practice of balance, or “surprise” billing. Surprise bills typically involved pricey emergency care, and frequently saddled patients with crippling amounts of medical debt — often tens of thousands of dollars. Patients were charged the cost of care delivered by providers outside their insurance network when the plan and provider couldn’t agree on a fair price for treatment. The law compels health plans and providers to attempt to work out the balance billing disputes between themselves.