Health Plan Weekly

Medicaid eligibility redeterminations are in full swing, but many states have struggled to fulfill automated enrollment requirements mandated by CMS, leading to finger pointing and — at a minimum — hundreds of thousands of members getting kicked off insurance rolls when they should not have been. Experts and one managed care trade group say this unfortunate state of affairs was foreseeable and could have been prevented if state Medicaid agencies had adequate staff and technical resources. 

The problems with automated renewals began this spring, after a yearslong pause in eligibility checks mandated by the federal government in response to the COVID-19 pandemic. With states allowed to resume redeterminations as of April 1, millions of members who enjoyed ongoing Medicaid coverage without income eligibility checks during the COVID public health emergency are expected to be disenrolled because they now make too much money to qualify for the program. But, because of administrative reasons — most often missed paperwork sent by mail — it seems likely that many Medicaid enrollees have lost coverage even though they are still eligible, experts say. 

With open enrollment for Affordable Care Act exchange plans now less than a month away, a clearer picture is beginning to emerge regarding which factors are weighing the heaviest on health insurers’ minds when formulating their 2024 premium rates — as well as how much those rates are set to rise.  

Based on insurers’ 2024 rate requests and their actuarial justifications, it appears that inflation is one of the biggest drivers of proposed rate increases, which states are now in the process of finalizing. However, due to expanded subsidies that have been in place since pandemic relief legislation passed, most exchange customers won’t feel the effects of rising premiums. And researchers who study the ACA exchanges tell AIS Health, a division of MMIT, that generally the individual insurance marketplace remains on solid ground — a far cry from years like 2017 and 2018 that featured significant regulatory uncertainty and major insurer exits. 

A systemwide shift in the direction of value-based contracting has, since the turn of the century, been a cherished goal of many policymakers and health plans. A panel of experts say that a national focus on value-based reimbursement has yielded tangible results, although they say much more must be done to facilitate the value-based care transition — and point out that government may have to play an even bigger role than it already has to make that transformation happen. 

Generally, value-based care is defined as paying providers based on cost and quality metrics, rather than per service or visit, and may believe widespread implementation of value-based payment could bring down overall health care spending. It's no secret that health care costs and spending per capita are much higher in the U.S. than they are in other wealthy countries — and experts predict that commercial insurance costs are set to rise steeply over the next few years. However, according to Melinda Buntin, Ph.D., a professor at Johns Hopkins University’s schools of public health and business, increased scrutiny from policymakers and the health care sector on prices over the past two decades has had some impact. 

Most Affordable Care Act marketplace enrollees choose plans based on price, yet a “surprising” number of enrollees making selections for the 2023 plan year gravitated toward more expensive options due to insurer reputation or breadth of networks, according to a recent Urban Institute study.

Overall, 26.3% of marketplace enrollees chose bronze plans, 57.9% chose silver and 15.8% chose gold in 2023. For the lowest income population, whose incomes were between 100% and 150% of the federal poverty level (FPL), over 81.4% chose silver plans. Silver plans are the only metal tier in which cost-sharing reduction (CSR) plans are available to help enrollees lower their out-of-pocket health care cost responsibilities.