Health Plan Weekly

Three transgender women filed a lawsuit on Sept. 10 against CVS Health Corp.-owned Aetna alleging the insurer denied them coverage of gender-affirming facial reconstruction (GAFR) surgeries and procedures in violation of an Affordable Care Act statute. David Kaufman, a lawyer who is not involved in the case, tells AIS Health the plaintiffs made a “pretty persuasive argument” in the lawsuit, although he points out that court proceedings are “often a tedious, drawn-out process” and it remains to be seen whether a judge will certify the case as a class action. 

The plaintiffs — Binah Gordon, Kay Mayers and an individual identified as S.N. — alleged the surgeries and procedures they sought were medically necessary and that Aetna violated “the prohibition on discrimination on the basis of sex in federally funded health programs and activities under Section 1557” of the ACA. Gordon, a 42-year-old Nebraska resident who works as a language curriculum specialist at a community college, was covered under an Aetna plan in the federal employee health benefits program. Mayers, a 52-year-old Alaska resident who works in information technology, and S.N., a 48-year-old physical therapist from Pennsylvania, were enrolled in Aetna employer-sponsored plans.  

The Biden administration on Sept. 9 finalized a sweeping set of regulations that aims to ensure health plans are covering behavioral health treatment as comprehensively as they cover medical care. The move was met by rapid criticism from a coalition of trade groups representing health insurers and large employers, which argued the new regulations “will not address the inadequate supply of mental health providers.”  

But other groups, such as a mental health advocacy organization tied to the Kennedy family, welcomed the rules as a necessary step forward to ensure compliance with the Mental Health Parity and Addiction Equity Act (MHPAEA). And one health policy expert tells AIS Health, a division of MMIT, that there are reasons to be skeptical of some criticisms lobbed at the new regulations by plan sponsors and insurers.

Health Care Service Corp. (HCSC), which owns Blue Cross Blue Shield plans in Illinois, Montana, New Mexico, Oklahoma and Texas, recently rolled out an “alternative health plan” that combines what essentially is a tiered provider network, price transparency and streamlined medical billing.  

Industry experts who spoke to AIS Health, a division of MMIT, say HCSC’s new benefit design has a variety of intriguing elements that could prove attractive to employers. Indeed, UnitedHealthcare has in recent earnings calls been touting the rising popularity of a similar offering.  

Since Oregon placed a payment cap on hospitals for its state employee health plans, beneficiaries have seen a reduction in out-of-pocket spending and an increase in utilization, according to a recent JAMA Health Forum study. Roslyn Murray, Ph.D., the lead author, tells AIS Health that “there’s an appetite” from other states to implement similar price regulations, although they have faced pushback from providers.