Health Plan Weekly

The U.S. Dept. of Defense recently awarded $136 billion in contracts for its TRICARE program that provides health care benefits to military service members, retirees and their families. The contract award for the West region went to TriWest Healthcare Alliance of Phoenix, which is partnering with Regence health plans and Health Care Service Corp. to administer the program. Humana Government Business Inc. will continue to serve the East region when the next contracts begin in 2024. Currently, Health Net Federal Services LLC, a subsidiary of Centene Corp., covers the West region with about 2.8 million beneficiaries, and Humana covers the East region with more than 6.8 million enrollees. In 2024, six states in the East region — Arkansas, Illinois, Louisiana, Oklahoma, Texas and Wisconsin, with a total of 1.5 million beneficiaries — will transfer to the West region in order to balance out the number of beneficiaries served by the two regions.

UnitedHealth Group kicked off the managed care sector’s latest round of financial results on Jan. 13 by reporting fourth-quarter and full-year 2022 adjusted earnings per share (EPS) of $5.34 and $22.19, respectively. The company’s adjusted EPS for the prior quarter beat the Wall Street consensus estimate of $5.17, and its medical loss ratio of 82.8% was just a hair higher (worse) than the consensus projection of 82.7%. The firm also reported that its full-year revenues of $324.2 billion grew 13% compared to 2021, “with double-digit growth at both Optum and UnitedHealthcare.” 

Nearly 15.9 million people have signed up for Affordable Care Act exchange coverage since the start of open enrollment on Nov. 1, CMS reported on Jan. 11. “This record-breaking enrollment represents a 13% increase over last year, including over 3 million people new to the Marketplaces,” the agency said in a press release. As in prior enrollment snapshots, the 15.9 million enrollment figure includes signup data from both the federal and state-based marketplaces. In the 33 states using the HealthCare.gov platform, there were 11.9 million plan selections through Jan. 7, 2023, while the 18 state-based exchanges reported 4 million plan selections through Dec. 31, 2022. Americans in most states have until Jan. 15 to sign up for marketplace coverage for 2023, unless they qualify for a special enrollment period. 

This year, a variety of headwinds and tailwinds are likely to buffet the health insurance industry, including inflation, a possible recession, the return of Medicaid eligibility checks, potential policy changes in Medicare Advantage, a split Congress, easing COVID costs and more. But the net effect of all those factors is likely to leave the sector on stable footing, analysts tell AIS Health.

“The tailwinds and headwinds change every year — that’s the case again for ’23. Overall, we think it’s balanced; that’s why we have a stable view,” says James Sung, associate director of insurance at S&P Global Ratings.

A district court judge in Washington state ruled on Dec. 19 that Blue Cross and Blue Shield of Illinois violated the anti-discrimination provision of the Affordable Care Act when it served as a third-party administrator (TPA) of health benefits and refused to cover medically necessary gender-affirming care for a transgender boy.  

The decision “is something that could have a big impact on administrators” of health benefits, David Kaufman, an attorney with Laurus Law Group LLC, tells AIS Health, a division of MMIT. It came one month after the court certified the case as a class-action lawsuit, meaning other individuals who had their gender-affirming care denied could potentially be involved, “so the case probably has a long way to go before it’s settled law,” according to Kaufman. 

For years, all-payer claims databases (APCDs) have been popping up around the country, collecting claims and encounter data in order to help payers, providers, policymakers and others better understand and improve local health care markets. Currently, 18 states have an APCD and at least six are developing one, according to Manatt Health. But in a new report and during a recent virtual summit, the firm argues that the current patchwork of state APCDs isn’t up to the task of providing comprehensive, streamlined data that can help solve the pressing affordability, quality, equity and access issues facing the American health care system.  

Instead, after engaging “more than 40 federal and state policymakers, regulators, researchers, and other health data leaders,” the Manatt report recommends building on the existing state-based APCD structure by creating a Federally Facilitated State Data Partnership model.