Health Plan Weekly

This time last year, protests were erupting across the U.S. calling for racial justice and the COVID-19 pandemic was disproportionately impacting communities of color — events that prompted many health insurance providers to release statements affirming their commitment to addressing racial disparities and place diversity and inclusion officers in the C-suite. Now, industry experts agree that concrete action must follow intentions and discussed some of the puzzle pieces to addressing health inequity during the AHIP 2021 Institute & Expo Online, which was held June 22-24.

“Longstanding institutional and social prejudices have kept people of color from adequate health care, frankly, for generations. Unfortunately, this is a complex issue, which is why it hasn’t been solved yet. No individual or even any single company can solve it alone; it’s going to take public sector and private sector partnerships working together to address social determinants of health,” said Gateway Health President and CEO Cain Hayes during the keynote session, Health Equity in America: An Urgent Call to Action. “Health plans, providers, employers, government agencies and others really have a unique opportunity to help address the impact of race, ethnicity and gender on people’s health outcomes.”

From lingering COVID-19 impacts to potential enrollment increases from expanded subsidies and slimmed-down Medicaid rolls, health plans have had a slew of factors to consider when filing their 2022 rate request for Affordable Care Act exchange plans. Based on what information can be gleaned from a look at the earliest of these filings, many insurers seem to be projecting a return to pre-pandemic normalcy in 2022.

“I felt like for many carriers, they were looking at 2022 almost as if COVID hadn’t occurred,” says Sabrina Corlette, a research professor at the Georgetown University Health Policy Institute’s Center on Health Insurance Reforms. “I was surprised at how little discussion there was, generally, of long-term COVID impact.”

The Biden administration on July 1 released an interim final rule (IFR) that launches implementation of the No Surprises Act, the December 2020 legislation that banned balance billing by health care providers in most cases. Experts say the rule is good for consumers but that the mechanism used to calculate billing rates could lock in high prices — though they aren’t yet sure whether the arbitration mechanism that will be used to adjudicate disputed claims will ultimately benefit providers or payers in the long term.

The IFR, which is subject to a 60-day public comment period, “is expected to go into effect as written,” according to a Health Affairs blog post by authors including Katie Keith, a health care attorney and research professor at Georgetown University’s Center on Health Insurance Reforms. According to the post, “topics in this IFR include patient cost-sharing protections, notice and consent standards for waivers, rules for calculating the qualifying payment amount (QPA), disclosure requirements, and complaints processes, among other standards.” The authors also expect additional rules to be published in the months ahead of the No Surprises Act’s Jan. 1, 2022, implementation date.

✦ The Biden administration on July 1 released a regulation that takes the first step toward implementing the No Surprises Act, which bans surprise medical billing. The rule, which was the subject of fierce lobbying from various industry stakeholders, lays out most of the patient protections from surprise out-of-network bills that will take effect on Jan. 1, 2022, “including obligations for payers, providers and regulators,” Loren Adler, an associate director of the USC-Brookings Schaeffer Initiative for Health Policy, wrote on Twitter. The regulation also details how to calculate the “qualifying payment amount” that “plays a substantial role in determining” the minimum out-of-network payment from plan to provider, he noted. In addition, the rule took aim at policies unveiled by major insurers that retroactively deny certain emergency room claims if a visit is deemed non-emergent, saying “these practices are inconsistent with the emergency services requirements of the No Surprises Act and the ACA.”

✦ Daniel Tsai, who previously served as assistant secretary for MassHealth and Medicaid director in Massachusetts, is the new deputy administrator and director of CMS’s Center for Medicaid and CHIP Services. Tsai played a key role in Massachusetts’ Section 1115 waiver program, which “implemented one of the most at-scale shifts to value-based care in the nation,” CMS said in a June 28 news release. “Through the waiver, MassHealth also launched a unique program committing significant investments for nutritional and housing supports to address the social determinants of health for high cost, at-risk individuals,” the agency said.