Health Plan Weekly

✦ CMS for the first time on Oct. 12 approved a state’s request to provide gender-affirming care as an essential health benefit (EHB) in the individual and small-group health insurance markets. Colorado’s new EHB-benchmark plan will offer transgender individuals access to a wider range of services than what is currently covered by their health plans, such as eye and lid modifications, face tightening, facial bone remodeling for facial feminization, breast/chest construction and reductions, and laser hair removal. Effective Jan. 1, 2023, Colorado is also adding EHBs in its benchmark plan to include mental wellness exams and expanded coverage for 14 prescription drug classes.

✦ Humana Inc. is expanding its use of Cohere Health’s digital prior authorization platform for musculoskeletal services, the Boston-based digital health company said on Oct. 13. As part of its initial implementation of Cohere Health’s platform, Humana in January 2021 had rolled out the digital solution to 12 states and has since “made significant progress toward achieving its vision to reimagine and modernize processes for prior authorization by reducing approval times, increasing provider satisfaction, and improving delivery of care, all while preserving important benefits such as safety, predictability, and reducing waste,” according to a press release.

Although addressing members’ nonmedical needs — such as transportation, housing and nutrition — has become a popular initiative at many health plans, not all payers have been able to link such actions to improved outcomes and cost savings.

Pittsburgh-based integrated delivery system UPMC, however, recently reported promising results from a pilot program it conducted in its Medicaid managed care plan, in which it partnered with Mom’s Meals to deliver clinically appropriate meals to a select population.

The Biden administration on Sept. 30 issued the latest interim final rule (IFR) to implement the No Surprises Act, and the regulation makes clear that arbitrators will have to use the qualifying payment amount (QPA) — a calculation largely based on median in-network reimbursement rates — as their starting point when settling disputed out-of-network claims. While payer groups praised the rule and provider groups slammed it, some health policy experts say the method outlined for handling payment disputes makes sense — though they caution that it’s unclear how the provider market will ultimately react, or whether costs and premiums will increase due to the No Surprises Act itself.

The IFR stipulates that “when making a payment determination…[arbitrators] must begin with the presumption that the QPA is the appropriate [out-of-network] amount,” according to an HHS fact sheet. “For the independent dispute resolution entity to deviate from the offer closest to the QPA, any information submitted must clearly demonstrate that the value of the item or service is materially different from the QPA.” The IFR also settles other key points such as the scope of federal external review on denied claims and the requirements for calculating good-faith estimates of the cost of care, which providers will soon have to give to patients before a major procedure takes place.