Health Plan Weekly

Since the start of the COVID-19 pandemic, the managed care industry has wrestled with how to project utilization of normal care and assess the risk of funding care related to the virus, especially since most carriers have elected to waive cost sharing for COVID-19 treatment. While insurers generally seem to be in good financial shape, experts say that plans face continuing uncertainty — and one actuary suggests that pandemic-related financial risk has met or exceeded the conditions of his modeling’s worst-case scenario.

In the early days of 2021, the U.S. confronted a grim milestone when the tally of Americans who died from COVID-19 reached 400,000. Meanwhile, the Trump administration was criticized for how it handled vaccine rollout and denounced critical public health tactics including mask wearing, while states reopened their economies and public spaces to varying degrees, despite the objections of public health officials.

✦ On Jan. 15, CMS finalized a rule that compels Medicaid, CHIP and Affordable Care Act (ACA) exchange plans to streamline their prior authorization processes. The regulation, which the administration proposed in December (HPW 12/18/20, p. 1), would also require the affected plans to add new capabilities to the Patient Access APIs that they had to build in order to comply with a previously finalized data interoperability rule. Read more at https://go.cms.gov/2LDw8eL.

✦ CMS on Jan. 14 finalized several provisions in the 2022 Notice of Benefit and Payment Parameters (NBPP), cementing controversial new regulations for the ACA exchanges. Payer trade groups criticized the draft rule on various points, particularly an unusually short comment period and a provision that would allow states to abandon a centralized health insurance exchange in favor of relying on brokers, agents and insurers (HPW 1/8/21, p. 5). While that provision was among those finalized, CMS said it “anticipates continuing to review comments and finalizing other proposed policies in a second final rule to be published at a later date.” Read more at http://go.cms.gov/3sku3Vs.

Continuing its spree of approving ambitious waivers before the end of the Trump administration, CMS on Jan. 8 gave Tennessee its blessing to become the first state in the nation to cap its Medicaid funding in exchange for a range of operating flexibilities. Industry insiders tell AIS Health that while the future of Tennessee’s demonstration is uncertain, its approval could still be a point of concern for Medicaid managed care organizations.

“Similar to medical loss ratio (MLR) requirements in the Medicaid managed care final rule, the waiver would give Tennessee more oversight over their Medicaid plans, from flexibility in managed care contracting to rate setting,” explains Abner Mason, founder and CEO of ConsejoSano, a health tech startup specializing in linguistically and culturally aligned Medicaid and Medicare health plan member outreach.

Insurers and other health care organizations are halting or reconsidering donations to federal lawmakers who voted against certifying the results of the presidential election, in moves they say are designed to counter the extremism that led to the Jan. 6 insurrection at the Capitol.

In some cases, these decisions could have a noticeable impact, as many of the organizations announcing changes to their policies gave to members of Congress who voted against certifying election results. But in other cases, the decisions may not have a substantial result since the organization in question hadn’t made many donations in the past or was announcing a review, rather than a change in policy.