Health Plan Weekly

Now that the federal government has banned most surprise medical billing, insurers and providers are beginning to sort out the complexities of implementing the No Surprises Act. Experts are unsure whether the law will slow cost and premium growth, and have concerns that providers will attempt to influence HHS’s in-process rulemaking to drive up prices over the long haul.

The No Surprises Act was passed in December 2020 as part of the Consolidated Appropriations Act, which was otherwise mainly oriented toward pandemic relief. The surprise billing ban, which comes into full effect in 2022, prohibits providers from sending a balance bill to patients. Patients who are treated by an out-of-network provider while incapacitated will pay the same cost sharing that they would have if they had been treated by an in-network provider. Patients treated at an in-network facility by an out-of-network provider will also not be balance billed, unless they authorize care by that provider in written form at least 72 hours in advance. That authorization must be accompanied by the patient’s in-network options and an estimate of the costs that they will incur.

With three coronavirus vaccines authorized for use in the U.S. and production and distribution continually ramping up, it’s now more important than ever for stakeholders across the health care system to get involved in helping Americans get those crucial shots — including those who are the hardest to reach.

To that end, America’s Health Insurance Plans (AHIP) and the Blue Cross Blue Shield Association (BCBSA) recently unveiled a pilot initiative aiming to help vaccinate 2 million seniors who are part of the country’s “most at-risk, vulnerable and underserved communities” such as racial and ethnic minorities. Similarly, a language-services company that frequently works with health insurers is rolling out a Vaccine Equity program aimed at “ensuring that all eligible individuals receive the vaccine, regardless of language or cultural barriers.”

✦ In new guidance, CMS on Feb. 26 expanded the amount and types of COVID-19 testing insurance plans are required to cover without cost sharing. Per a CMS press release: “This guidance makes clear that private group health plans and issuers generally cannot use medical screening criteria to deny coverage for COVID-19 diagnostic tests for individuals with health coverage who are asymptomatic, and who have no known or suspected exposure to COVID-19. Such testing must be covered without cost sharing, prior authorization, or other medical management requirements imposed by the plan or issuer.” Learn more at http://go.cms.gov/3biz0aV.

✦ HealthCare.gov Navigators will have access to $2.3 million in additional marketing funding during the pandemic-related special enrollment period (SEP), which runs through May 15, CMS announced. CMS said 30 organizations across 28 states will be allowed to use the funds. The agency also reported that 206,236 new plans have been selected by consumers during the period between Feb. 15 and Feb. 28, the first two weeks of the SEP. Also, the agency reported that 385,864 consumers have filed requests for coverage in the same period. Find the press release at http://go.cms.gov/3rke6xx and enrollment figures at https://go.cms.gov/2NUJcO9.

Two new analyses from prominent health care research groups argue that huge savings could be realized if private insurers paid providers at roughly the same rate as Medicare does. However, industry experts point out that the political will to do so may not be strong enough — even with a public option supporter in the White House — and such a move could also have very problematic consequences.

First, a research report from RAND Corp. examined three policy options that could reduce hospital prices: regulating prices, improving price transparency and increasing hospital competition. Of those three, researchers found that “price regulation could have the largest impact on hospital prices and spending but would likely face political challenges.” Specifically, hospital spending could be reduced by $61.9 billion to $236.6 billion if reimbursement rates for private plans were capped at 100% to 150% of Medicare rates, creating a 1.7% to 6.5% reduction in national health spending.