Health Plan Weekly

CMS on July 6 released new reporting requirements for states regarding Medicaid and CHIP. The new reporting requirements include updated network adequacy and access standards, a standard format for medical loss ratio reporting, and updates to a web portal for reporting submissions and, eventually, rolled-up data and dashboards compiled from regulatory filings. “The tools we’re releasing today reflect the latest — and certainly not the last — step CMS is taking to increase transparency and ensure that people served through Medicaid and CHIP managed care programs are receiving high-quality, high-value care,” said CMS Administrator Chiquita Brooks-LaSure in a press release. 

The FDA will allow pharmacists to prescribe Pfizer Inc.’s Paxlovid. Patients may be prescribed Paxlovid from a state-licensed pharmacist if they test positive for COVID-19 and provide “electronic or printed health records less than 12 months old, including the most recent reports of laboratory blood work for the state-licensed pharmacist to review for kidney or liver problems,” and “a list of all medications they are taking, including over-the-counter medications so the state-licensed pharmacist can screen for drugs with potentially serious interactions with Paxlovid,” per an FDA press release. The federal government purchased a large amount of Paxlovid doses and has distributed them to pharmacies and clinics across the country — though the drug is not being used as widely as experts predicted. 

After abortion suddenly became illegal in large swaths of the country following the Supreme Court ruling in Dobbs v. Jackson Women’s Health Organization, the health benefits industry is scrambling to figure out whether and how to deliver abortion care to plan members. Chaos and uncertainty are the order of the day, and the upheaval is likely to continue as states consider new restrictions and penalties for administering, funding and being treated with abortions.  

Overnight, health plans are being forced to contend with critical legal and operational issues relating to abortion. Plans with operations across states where abortion is legal and where it has been banned face unprecedented civil — and potentially criminal — liability for delivering benefits. At the same time, plan sponsors and carriers must figure out how to implement travel benefits for employees who reside in states where abortion is banned but are seeking abortion care in states where the procedure is legal (see infographic). And plans may be compelled to share health records relating to abortion benefits and reimbursement with law enforcement agencies prosecuting patients and providers involved in abortions. 

Centene Corp. revealed during its June 17 investor day that it plans to reduce by 65% the amount of office space it leases across the United States as a way to cut costs and appease employees who prefer working from home. Like many large employers, other health insurers have followed suit — or are considering doing so — as they adjust to an office environment that looks much different than was standard before COVID-19. 

Several major insurance companies declined to discuss their office leasing plans when contacted this week by AIS Health, a division of MMIT. But most, if not all, are actively evaluating their real estate footprints, according to Dan Mendelson, the CEO of Morgan Health, JPMorgan Chase Co.’s health care arm. 

Colorado received permission from the Biden administration on June 23 to go ahead with the final element of its so-called “public option,” the Colorado Option. Experts tell AIS Health, a division of MMIT, that the program’s design is likely to deliver more premium savings than Washington state’s public option — and that the savings could make their way to the commercial market, especially if Individual Coverage Health Reimbursement Arrangements (ICHRAs) make further inroads in the Centennial State. 

Experts tell AIS Health that the Colorado Option is innovative and could produce substantial premium savings, in large part because it has aggressive premium reduction goals. Starting in 2023, premiums for Colorado Option plans must be 5% lower than 2021 premiums, ultimately resulting in 15% cuts in premiums in 2025. After that, starting in "2026 and each year thereafter" premiums may increase "above the premium in the previous year by no more than medical inflation, relative to the previous year," per a summary of the law from the state legislature. 

Meeting Medicaid network adequacy requirements for behavioral health providers continues to be a challenge for health insurers, as shown by a recent $4.6 million settlement between Molina Healthcare, Inc., its former behavioral health subsidiary, Pathways of Massachusetts, and the Department of Justice. 

In the case, Molina and Pathways of Massachusetts agreed to pay $4.625 million to resolve False Claims Act allegations that they submitted claims to MassHealth — the state’s Medicaid program — while violating regulations governing how staff are licensed and supervised, the U.S. Attorney’s Office for the District of Massachusetts said on June 21. The settlement in the case, which was first brought by four whistleblowers who were Pathways employees, calls for the former employees to receive $810,000.