Health Plan Weekly

If a new lawsuit filed by two Connecticut union locals against Elevance Health, Inc. is successful, health insurers managing self-funded plans could face a torrent of litigation from unhappy plan sponsors. Plan sponsor trade groups and the attorneys handling the Connecticut lawsuit argue that carriers across the country systematically overcharge administrative services only (ASO) plan sponsors for procedures — and that newly available price transparency data proves it. 

The Connecticut lawsuit alleges that Elevance, the company formerly known as Anthem (which still sells plans under that brand name), charged excessive fees for some procedures or negotiated kickbacks with providers in its network. Attorneys for the union locals — International Union of Bricklayers and Allied Craftworkers Local 1 and Sheet Metal Workers’ Local No. 40 — accuse Elevance of “either unlawfully retaining…improperly discounted amounts for itself, or…imprudently overpaying providers. Either way, [Elevance] is in breach of its fiduciary obligations to the Plans” under the Employee Retirement Income Security Act (ERISA), the suit argues. 

In a move made at a critical juncture in the annual Affordable Care Act open enrollment period, Oscar Health, Inc. recently said it will “temporarily stop accepting new members in the state of Florida.” 

Industry observers tell AIS Health, a division of MMIT, that the decision is clearly linked to fellow startup Bright Health Group, Inc.’s exit from all 15 states in which it was set to sell plans next year. But they’re divided on what the implications are for Oscar’s viability as a business. 

In a Dec. 12 press release, Oscar — which was founded in 2012 and went public in 2021 — said that it “proactively engaged regulators [in Florida], as a result of the changing market dynamics following market exits by certain carriers, regarding options to manage its membership growth.” 

In remarks at a Dec. 13 Brookings Institution event, HHS Secretary Xavier Becerra touted the rollout of the 988 mental health assistance line and the Biden administration’s push for more mental health funding. In addition to promoting the administration’s victories, Becerra also reiterated the urgent need to recruit and retain burnt out practitioners. And he called on Congress to make pandemic-related emergency telehealth flexibilities permanent.   

The relatively low amount of available mental health care providers, particularly for youth and in rural areas, is a stubborn barrier to care that has frustrated health insurers that need to meet network adequacy requirements.  

If the COVID-19 public health emergency (PHE) expires in April 2023, about 18 million Medicaid enrollees could lose their coverage over the following 14 months, an Urban Institute analysis projected. Among them, about 9.5 million people could transition to employer-sponsored insurance, 3.2 million could move to Children’s Health Insurance Program (CHIP) coverage, and 3.8 million could become uninsured. If the PHE were extended for an additional quarter, the number of people losing coverage could rise to nearly 19 million. The PHE is set to last at least through January, as the Biden administration is concerned about the potential of a winter wave of COVID infections.

Here’s how major health insurers’ stock performed in November 2022. UnitedHealth Group had the highest closing stock price among major commercial insurers as of November 30, 2022, at $547.76. Humana Inc. had the highest closing stock price among major Medicare insurers at $549.90.