Health Plan Weekly

Starting May 11, payers will no longer have to cover any COVID-19 polymerase chain reaction (PCR) testing with no cost sharing for members, or reimburse members who purchase over-the-counter COVID tests. It’s one of many health care policy changes dictated by the planned end of the federal COVID public health emergency (PHE) on that date. Experts tell AIS Health, a division of MMIT, that the transition will likely cause PCR test prices to fall. 

The Families First Coronavirus Response Act and the CARES Act, both passed in 2020, require private health insurers to cover coronavirus tests, with no cost sharing, as well as any services associated with those tests (such as administrative fees), per an expansive reading of both laws implemented by the Biden administration starting in 2021. During 2020, the incumbent Trump administration had required coverage only for “medically necessary” tests ordered by a practitioner. In addition, the Biden administration starting in January 2022 required health plans to reimburse members for up to eight at-home tests per month. 

With nearly all the 2023 open enrollment period data now tallied, it appears that something curious is happening in states that run their own Affordable Care Act exchanges: Enrollment levels are on track to decline compared to 2022. That trend follows years in which state-based marketplaces (SBMs) outperformed states using the HealthCare.gov platform in terms of year-over-year enrollment growth, and it comes as HealthCare.gov states are reporting a significant signup surge compared to 2022. 

Health policy experts tell AIS Health, a division of MMIT, that there are likely multiple factors causing the reversal of fortunes between HealthCare.gov and SBM enrollment. But in an important takeaway for health insurers that operate in the exchanges, they say the trend could indicate that the “addressable market” in certain states is reaching its saturation point. 

Although U.S. employers already contract with a bevy of health and wellbeing vendors, a recent survey found that nearly nine in 10 are planning to make changes to their vendor partnerships in the next two years — chiefly by adding or enhancing current offerings. As companies do so, health insurers have a critical role to play when it comes to integrating various solutions and helping employees find them, an employee benefits expert says. 

Employers’ desire to add and enhance health/wellbeing offerings “doesn’t look like it’s going to stop anytime soon,” says Regina Ihrke, senior director and health, equity and wellbeing leader at WTW. Therefore, large medical benefits carriers “are going to have to continue to be nimble and flexible in who they partner with, and then how they also integrate with other carveout solutions that are out there,” she tells AIS Health, a division of MMIT.