Health Plan Weekly

CVS Health Corp.’s insurance division, Aetna, on Aug. 27 revealed that it became the first major U.S. insurer to update its fertility treatment coverage policy nationally. In what Aetna called a “landmark policy change,” members of eligible plans will now be able to access intrauterine insemination (IUI) as a medical benefit, regardless of their sexual orientation or partner status. 

Yet the insurer did not mention in its press release that it agreed to execute a similar policy change as part of a proposed settlement in a case filed by LGBTQ+ enrollees who claimed Aetna’s fertility treatment coverage policies are discriminatory. In fact, Aetna and other insurers are facing several similar lawsuits, says Alison Tanner, senior litigation counsel at National Women’s Law Center (NWLC).    

Most people enrolled in Affordable Care Act exchange plans had in-network access to fewer than half of clinicians in their area in 2021, according to a KFF study published on Aug. 26. Matthew Rae, the report’s lead author, tells AIS Health the number of physicians in networks varies widely even within states and counties, yet it is still difficult for consumers to compare and choose plans.  

Rae adds that insurers often limit their exchange networks to keep their costs down and competitive in a crowded field, where often dozens of plans vie for enrollees. He points out that insurers seek to price their offerings based on the second-lowest cost plan in the marketplace’s silver category, which is linked to the premium tax credits that most enrollees receive. Plans that are more expensive than the second-lowest cost silver option often only get a small number of enrollees, according to Rae. 

Starting in 2025, The Cigna Group’s Express Scripts will drop Humira (adalimumab) from its largest commercial formularies and instead cover only select biosimilars for the blockbuster autoimmune condition treatment.  

The move will make Express Scripts the second major PBM to prefer biosimilars over Humira after CVS Health Corp. did so in April. And it comes as both Cigna and CVS recently voiced their support for the FDA issuing draft guidance that would make it easier for biosimilars to get an “interchangeable” designation. 

People enrolled in Affordable Care Act marketplace plans had access to 40% of their local physicians in-network, on average, and those who enrolled in more expensive plans generally could access broader networks, according to a KFF analysis.

The analysis studied the percentage of physicians participating in the provider networks of Qualified Health Plans offered in the individual market in the federal and state ACA marketplaces in 2021. It found that only 4% of ACA exchange enrollees were in plans that included more than three-quarters of local doctors in-network, while 23% of enrollees were in a narrow network plan that included fewer than a quarter of the local doctors.

L.A. Care Health Plan and Health Net announced on Aug. 28 they have launched two programs that will collectively invest $90 million over five years to help people experiencing homelessness receive access to care. The health plans will invest $60 million in the L.A. County Field Medicine Program, in which 19 providers will provide coordinated care. They also will invest $30 million in the Skid Row Care Collaborative, which will include harm reduction services, extended hours for urgent care and pharmacies, and onsite specialty medical services in Los Angeles’s Skid Row neighborhood. The programs could assist about 85,000 Los Angeles residents, according to L.A. Care and Health Net, which is a division of Centene Corp. 

A federal district judge on Aug. 26 ruled in favor of TennCare beneficiaries who alleged the state’s Medicaid program caused thousands of residents to lose coverage after the introduction in 2019 of an electronic eligibility determination system, Fierce Healthcare reported on Aug. 28. “After years of litigation, plaintiffs have proven TennCare violated their rights under the Medicaid Act, the Due Process Clause of the Fourteenth Amendment, and the Americans with Disabilities Act,” the judge wrote. Fierce noted the state may appeal the court’s ruling. The Tennessee Justice Center, National Health Law Program and National Center for Law and Economic filed the lawsuit in March 2020.