Health Plan Weekly

Although health insurers may not approve of all the recently proposed policies for the Affordable Care Act exchanges — in particular, the reintroduction of standardized plans — the Biden administration is sticking to its guns.

That was one of the main takeaways from a discussion during AHIP’s 2022 National Conference on Health Policy and Government Programs, which took place virtually from March 14 through 17. During a March 15 session, Ellen Montz, Ph.D., who is the deputy administrator and director of CMS’s Center for Consumer Information and Insurance Oversight, highlighted three parts of the 2023 Notice of Benefit and Payment Parameters (NBPP) that she said will reinforce CMS’s goal of making the exchanges more consumer friendly.

Biden administration officials during the annual Healthcare Information and Management Systems Society (HIMSS) Conference said CMS intends to revamp its interoperability regulations. CMS Administrator Chiquita Brooks-LaSure said the Interoperability and Patient Access final rule issued in 2020 “did not quite hit the mark” because it didn’t require standardized application programming interfaces (APIs), FierceHealthcare reported. “Our interoperability rule wasn’t interoperable enough, and it led to many open questions about how data should be exchanged,” she added.

New research from the Kaiser Family Foundation (KFF) indicates that 36% of outpatient mental health and substance use disorder visits were delivered via telehealth in the six months ending in August 2021. Those visits spiked because of flexibilities and social distancing requirements implemented during the peak of the COVID-19 pandemic, KFF concluded.

L.A. Care, the Medicaid-focused health plan owned by Los Angeles County, has been fined $55 million by the state of California for allegedly mishandling prior authorizations and coverage appeals. According to state regulators, L.A. Care — the largest nonprofit Medicaid managed care organization (MCO) in the country — mishandled more than 67,000 grievances filed by plan members, which caused sick patients to be denied proper care or wait months for urgent treatment.

Two California agencies, the Dept. of Managed Health Care (DMHC) and Dept. of Health Care Services (DHCS), launched an investigation into L.A. Care’s prior authorization and denial appeals processes after a September 2020 Los Angeles Times article revealed that extremely ill L.A. Care members faced dangerous delays when they tried to see a specialist. The combined $55 million in fines assessed by the agencies far outstrips the previous record fine in California, $10 million, for similar violations, according to the news outlet.

As has been the case in previous quarters, all four of the newly public health insurance startups — Oscar Health, Inc., Bright Health Group, Inc., Clover Health Investments Corp. and Alignment Healthcare, Inc. — reported losses for the final three months of 2021. However, a look at both the fourth quarter and full year reveals that there were considerable differences among those companies in terms of the severity of their losses and the trajectory of their businesses.

“The four public startup health insurers lost $2.5 billion in 2021,” observes Ari Gottlieb, a principal at the consulting firm A2 Strategy Group, who calls that a “staggering amount of money.” Bright Health — which has Medicare Advantage, Affordable Care Act exchange and health care provider assets — was responsible for roughly half of that total loss among the quartet of insurers, losing just under $1.2 billion for the full year.