Health Plan Weekly

The share of group health insurance plan enrollees with high health care spending increased from 2013 to 2021, and over 80% of them in 2021 had one or more chronic diseases, according to two studies from the Employee Benefit Research Institute.

By analyzing health care claims of millions of enrollees in a group health plan from the Merative MarketScan Commercial Database, the study found that the share of enrollees incurring spending $100,000 or more per year on health care went up 50%, from 0.6% in 2013 to 0.9% in 2021. The group with the highest spending ($2,000,000 or more) was 2.5 times larger in 2021 compared to 2013.

Friday Health Plans Management Services Company, Inc. — a Colorado-based insurer that offers Affordable Care Act exchange plans in seven states — is in a downward spiral. Concerned by the company’s deteriorating financial situation, state regulators are taking steps such as putting the insurer’s subsidiaries under supervision and placing them into receivership.  

Georgia, for example, recently garnered headlines by announcing that Friday enrollees will need to find a different health plan. And Colorado said on June 1 that it will work with the insurer to wind down its business across the country due to ongoing capital shortfalls. 

In a unanimous 9-0 vote, the Supreme Court on June 1 overturned a lower court’s decision pertaining to the False Claims Act (FCA) and allegations that two large pharmacy chains overcharged the federal government for prescription medications. Experts tell AIS Health, a division of MMIT, that the ruling is significant for health insurers because the FCA disproportionately impacts the health care industry.  

The Department of Justice (DOJ), for instance, said it obtained more than $2.2 billion in settlements and judgments involving fraud and false claims for the 12 months through Sept. 30, 2022. More than $1.7 billion of that total involved the health care industry.

Medicaid resumed eligibility redeterminations in April after a multi-year pause related to the pandemic. This has profound implications for Medicaid managed care organizations, which could lose a large portion of their membership — and it is a major opportunity to boost enrollment for plans operating Affordable Care Act marketplace plans. Those plans could enroll some of the people leaving Medicaid due to redeterminations.

Exchange insurers such as Blue Cross Blue Shield of Louisiana may be able to take advantage of the opportunity. Elevance Health, Inc., the parent company of Anthem, recently announced plans to acquire Blue Cross Blue Shield of Louisiana; Anthem has about 350,000 Medicaid members in Louisiana, according to the AIS Directory of Health Plans (DHP). Blue Cross Blue Shield of Louisiana doesn’t cover any Medicaid members, but has about 70,000 marketplace members, per DHP.