Health Plan Weekly

About a quarter of the practitioners in Medicaid managed care organization networks provide more than three-quarters of the services used by members, according to an article published by researchers affiliated with Yale and Cornell Universities in the journal Health Affairs this month. Experts say that this concentration of care likely limits access to care for members, and health plans need to do more to make sure their networks aren’t made up of so-called “ghost providers.”

The article, which analyzed claims and enrollment data from Kansas, Louisiana, Michigan and Tennessee during 2015-17, found that care delivery is highly concentrated in both primary care and specialists. However, the authors caution that their study of the states “might not generalize nationally” and only studied four specialties.

Insurer price transparency rules are finally starting to come into effect after years of litigation and administrative delays, but it’s not clear whether insurers will be compliant when deadlines arrive. Health care insiders tell AIS Health, a division of MMIT, that larger carriers have an advantage in implementation and smaller insurers may have a more difficult time keeping up.

Federal enforcement of payer price transparency rules by HHS and the departments of Labor and Treasury will begin on July 1 of this year. That deadline, during which plans will need to “make public machine-readable files disclosing in-network rates and out-of-network allowed amounts and billed charges,” per a government document, is the first of many health plan transparency requirements that will come into effect over the next two years.

With millions of people at risk of losing Medicaid coverage once the COVID-19 public health emergency ends, two states are setting up insurance programs designed to scoop up people who make too much for Medicaid and find Affordable Care Act exchange coverage unaffordable.

If Oregon and Kentucky follow through on their plans to set up Basic Health Programs (BHPs), they’ll join just two other states — New York and Minnesota — that have taken advantage of an often-overlooked provision of the ACA, Section 1331. However, there is some evidence that health insurers are wary of BHPs gaining traction.

CVS Health Corp. posted robust financial results in the first quarter of this year, with revenues increasing by 11.2% to $76.8 billion. Wall Street praised the firm — particularly its Aetna health insurance division — for delivering strong results, and predicted the Caremark PBM would overcome disappointing results for the first quarter.

The integrated health care company’s quarterly adjusted operating income was $4.48 billion, increasing nearly 7% year-over-year from the first quarter of 2021.