Health Plan Weekly

A federal judge in Texas on March 30 struck down the Affordable Care Act’s requirement that health plans cover, without cost sharing, certain preventive services recommended by the U.S. Preventive Services Task Force (USPTF) — such as preexposure prophylaxis (PrEP) for HIV and screenings for HIV, cancers, suicide risk, and hepatitis C. Policy experts say insurers probably won’t rush to stop covering most affected services, but if the ruling is upheld, they could impose potentially burdensome cost-sharing on PrEP drugs in particular. 

The ACA requires private health plans to cover preventive services recommended by several federal bodies without any cost to members. Those entities are the USPSTF, the Advisory Committee on Immunization Practices (ACIP) and the Health Resources and Services Administration (HRSA). In his ruling, Justice Reed O’Connor found that the policymaking power USPSTF wields would require the task force to be appointed by the president and confirmed by the Senate — but the USPSTF is appointed by federal civil servants, not the president. In O'Connor's view, that means issuing plan requirements based on USPSTF recommendations is unconstitutional.  

Two major health insurers, UnitedHealthcare and Cigna Healthcare, say they’re reworking their prior authorization (PA) policies to improve a process that has triggered a growing chorus of complaints from health care providers and patients. The moves come as CMS is poised to finalize a new regulation that requires insurers to speed up and streamline their PA processes. Industry experts say the policy changes are long overdue and could return PA to serving a useful — rather than overly burdensome — role in the health care system. 

In a March 29 post on its website, UnitedHealth wrote that starting in the third quarter of this year, it will eliminate “nearly 20% of current prior authorizations, as part of a comprehensive effort to simplify the health care experience for consumers and providers.” 

In recent letters sent to seven major publicly traded health insurers, two U.S. senators take aim at the industry’s fierce lobbying campaign against proposed Medicare Advantage rate adjustments — saying insurers are responding to the proposal by threatening to cut benefits for seniors despite spending billions on executive compensation and stock buybacks.  

Corporate finance experts say there are valid criticisms to be made about both rising CEO pay and buybacks, but they argue that larger, systemic issues are driving such behavior across all types of industries. 

The return of Medicaid redeterminations and the resulting changes in the risk pool could mean a more expensive-to-cover mix of members for managed care organizations, according to a recent webinar convened by the American Academy of Actuaries. Experts say that Medicaid managed care organizations will likely lose healthy, employed members, but retain sicker members — and could face artificially inflated costs related to unnecessary disenrollments. 

States can resume Medicaid eligibility redeterminations starting April 1, which means that private Medicaid health plans will see heavy turnover as all of their members are checked for eligibility by state Medicaid agencies. In exchange for a higher Federal Medical Assistance Percentage (FMAP) authorized by Congress as a pandemic relief measure, states agreed to stop income checks for the duration of the COVID-19 pandemic public health emergency (PHE).