Health Plan Weekly
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Maine Will Combine Individual, Small-Group Insurance Markets
Maine will merge its small-group and individual exchange health insurance markets starting in plan year 2023. Experts tell AIS Health, a division of MMIT, that the move is a bid to stabilize small-group premiums, which have gone up in recent years.
According to a Feb. 15 press release from the state’s Bureau of Insurance, “the merger, which will pool the risks of the two markets and roll the Small Group coverage into the Maine Guaranteed Access Reinsurance Association (MGARA), is projected to reverse the trend of steady premium increases and declining enrollments in Maine’s Small Group Market, while supporting continued stable pricing in the Individual Market.”
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AHIP Will Prioritize Telemedicine, Health Equity Post-Pandemic
On Feb. 23, health insurer trade group AHIP hosted a virtual State of the Industry presentation, reviewing progress made in 2021 and important issues for the health insurance industry as it looks to a world beyond the COVID-19 pandemic.
Matt Eyles, president and CEO of AHIP, opened the conversation with a look at the organization’s 2021 initiatives and hopes for 2022. Eyles stressed the importance of the No Surprises Act, which aims to protect consumers from surprise medical bills. The legislation went into effect on Jan. 1, but it is currently the subject of a number of lawsuits filed by organizations including the American Hospital Association and American Medical Association (see box, p. 5). “AHIP continues to fight and protect the law,” Eyles said during the presentation.
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Judge Backs Texas Providers in Surprise Billing Suit
Texas providers have notched their first win in the legal battle over the No Surprises Act (NSA), the federal law that bans surprise billing — though the Biden administration can appeal the decision. In a lawsuit brought by the Texas Medical Association (TMA), Judge Jeremy Kernodle of the federal Eastern District of Texas on Wednesday struck down regulations issued by the Biden administration that providers allege favor insurers at their expense in balance-billing scenarios.
The NSA requires payers and providers to work out the balance billing disputes between themselves. If that fails, an HHS-approved independent arbitrator will decide between two payment amounts: one submitted by the provider and one by the insurer. Arbitrators then pick between one of the two proffered amounts using criteria designed by the Biden administration.
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Small-Group Insurance Market Remains Stable Under ACA
About half of small-firm employees worked for an establishment that offered health insurance from 2013 to 2020, and the small-group market has remained relatively stable since the implementation of the Affordable Care Act, according to a recent Urban Institute study. Employee coverage rates at small firms — which have fewer than 50 employees — dropped 2 percentage points, from 57.1% in 2013 to 55.1% in 2020. Meanwhile, employees’ contributions to single and family coverage in the small-group market rose during the study period by 2.3 and 6.0 percentage points, respectively. Though many people anticipated that small firms would transition to self-insurance to avoid ACA’s regulations, small firms were much less likely than larger firms to offer a self-insured plan between 2013 and 2020.
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News Briefs: CMS Unveils Changes to Direct Contracting Model
CMS on Feb. 24 released plans to revamp the Global and Professional Direct Contracting model, which allows participants to share risk and receive capitated payments for serving fee-for-service Medicare beneficiaries. Democrats like Washington Rep. Pramila Jayapal and Massachusetts Sen. Elizabeth Warren have criticized the model for transforming “the care of a traditional Medicare beneficiary to care typically seen in a private Medicare Advantage (MA) plan despite the fact that the patient chose not to enroll in an MA plan,” in Jayapal’s words. However, in good news for insurers like Clover Health, which are counting heavily on direct contracting revenue, CMS appears to still allow health insurers to apply for the renamed ACO Realizing Equity, Access, and Community Health (REACH) Model. As part of the overhaul, CMS promised greater “participant vetting, monitoring and transparency,” more promotion of provider leadership and governance, and a larger focus on health equity, among other changes.
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