Health Plan Weekly

For the 1.3 million Americans living with blood cancers, their already daunting condition is not made any easier by the fact that private health plans — particularly those on the Affordable Care Act exchanges — often exclude National Cancer Institute (NCI)-designated treatment facilities from their provider networks, according to a new analysis.

The report, produced by Manatt Health and The Leukemia & Lymphoma Society, focused on four states’ policy and regulatory frameworks governing marketplace plans, with researchers conducting interviews with state regulators, insurers and cancer care providers to learn about “policy challenges that may hamper patients’ ability to navigate and obtain proper treatment for their cancer.”

Across the U.S., about 2 million individuals with private insurance are admitted to the hospital each year for childbirth. It’s the No. 1 cause of hospitalization in the nation, and it’s also the cause of significant out-of-pocket health care costs, with an average bill of about $3,000, according to a paper published in June in the Official Journal of the American Academy of Pediatrics.

For one in six childbirths, the out-of-pocket cost exceeds $5,000, the University of Michigan-based researchers noted. The average bill for newborns who are admitted to the neonatal intensive care unit is also $5,000, with one in 11 bills exceeding $10,000 for NICU care. Only 5% of patients had their hospital stay for childbirth covered in full by insurance.

The Biden administration on June 28 made good on its previous pledge to roll back certain Trump-era regulations regarding the Affordable Care Act exchanges when it issued a proposed rule that CMS deemed a “continuation” of the already finalized two-part Notice of Benefit and Payment Parameters for 2022. But the most consequential part of the proposal, experts say, wasn’t a policy reversal so much as a new idea that federal health officials want to try on for size: offering a monthly special enrollment period (SEP) for a select group of individuals.

“To provide more opportunities for certain low-income consumers to access premium-free or very low-cost coverage made available by the American Rescue Plan Act of 2021, we are proposing to provide Exchanges the option to implement a monthly SEP” for people with a household income no greater than 150% of the federal poverty level (FPL), CMS said in a fact sheet outlining the proposed rule’s provisions.

✦ Hospitalized COVID-19 patients covered by private insurance paid an average of $534 out-of-pocket on medical costs, while Medicare Advantage members paid a mean $680 within 90 days of discharge, according to a study by University of Michigan and Boston University researchers that is pending peer review. The researchers also found that one in 14 privately insured patients and one in 10 Medicare Advantage beneficiaries paid more than $2,000.

✦ Medicare Advantage now covers more than four in 10 Medicare beneficiaries, meaning MA enrollment has doubled over the past 10 years, according to the Kaiser Family Foundation (KFF). KFF found that the scale of MA enrollment varied significantly by state, with 50% or more beneficiaries enrolled in MA plans in Minnesota, Florida and Puerto Rico, but less than 20% in Vermont, Maryland, Alaska and Wyoming. Nationally, 29% of Medicare beneficiaries live in a county where more than half of all Medicare beneficiaries are enrolled in Medicare Advantage plans.

Cigna Corp. — which made headlines earlier this year when it indicated patients could receive a monetary award if they switch from a high-priced psoriasis drug to a cheaper biologic — now appears to be making that strategy an official program, starting with a different drug.

In a recent press release, the insurer revealed that starting in July, two approved biosimilars for Janssen’s immunosuppressive drug Remicade (infliximab) — Avsola and Inflectra — will move to preferred status on its formularies. “With these updates, Cigna is taking concrete steps to help patients and plans realize the promise of alternative, clinically effective treatment options,” the company said.