Health Plan Weekly

For an individual health insurance market that is already hitting its stride, the new pandemic relief legislation’s expansion of Affordable Care Act (ACA) subsidies is yet another positive catalyst that should make the exchanges more attractive to insurers and customers alike, experts tell AIS Health. And it could have wide-ranging implications for the business and policy dynamics underpinning the ACA marketplaces, affecting everything from the risk pool to insurer competition to state-based reinsurance programs.

Under the American Rescue Plan, which President Joe Biden signed into law on March 11, individuals who already qualified for premium tax credits under the ACA will see more generous financial aid, including expanded access to zero-premium plans for lower-income people. In addition, people whose incomes were too high to qualify for subsidies — those who earn more than 400% of the federal poverty level (FPL) — will be eligible for reduced premiums for the first time thanks to a provision that caps marketplace premiums at 8.5% of all enrollees’ income.

✦ Ohio Attorney General Dave Yost (R) revealed in a March 11 press release that the state is suing Centene Corp. “for an elaborate scheme to maximize company profits at the expense of the Ohio Department of Medicaid (ODM).” The lawsuit alleges that Centene’s subsidiary Buckeye Health Plan used “a web of subcontractors for the provision of pharmacy benefits in order to misrepresent pharmacy costs, resulting in millions of dollars of overpayments by ODM.” In a statement, Centene responded that the state’s “claims are unfounded, and Envolve will aggressively defend the integrity of the pharmacy services provided to the State of Ohio.” As part of a larger effort to overhaul its Medicaid managed care program, Ohio in January announced that in 2022 it will replace a host of PBMs contracted by Medicaid managed care organization — including Centene’s Envolve Pharmacy Solutions — with just one PBM, Gainwell Technologies. Read more at https://bit.ly/3exKtpa.

✦ Cigna Corp. will now offer Medicare Advantage (MA) members in 11 states who have chronic kidney disease (CKD) and end-stage renal disease (ESRD) in-home kidney care management from Monogram Health, a renal care startup. The new states include “most of Florida,” along with Texas, Pennsylvania, Illinois, North Carolina, South Carolina, New Jersey, Delaware, Maryland, Missouri, Kansas and Colorado, plus the District of Columbia. The benefit was previously available to individual MA customers in Arkansas, Arizona, Alabama/North Florida, Mississippi, Tennessee and Georgia. According to the press release, “Monogram’s care management staff of nurse case managers and social workers regularly visit CKD and ESRD patients in their homes [and]…develop personalized care plans aimed at keeping customers with kidney disease healthy and out of the hospital. Care management strategies include medication therapy management, co-morbidity management and collaboration with nephrologists and primary care physicians on evidence-based renal care pathways…[and] addressing patients’ social determinants of health.” Visit http://prn.to/30A1E11.

A private online health insurance marketplace for individual market, small group and Medicare Advantage policies, eHealth, has formed a high-powered advisory panel with a bipartisan group of former governors, federal lawmakers and other officials, including former Louisiana Gov. Bobby Jindal (R) and former Surgeon General Jerome Adams, M.D. Former Kentucky Gov. Steve Beshear (D) will chair the committee.

The goal of the new eHealth Public Policy Advisory Committee is to help promote the use of technology and public-private partnerships to solve health care problems in a non-partisan way, says committee member John Desser, eHealth senior vice president for public policy and government affairs and a former HHS deputy assistant secretary for health policy. “We hope to become a resource to policymakers who are open-minded about taking a less ideological approach,” he tells AIS Health.

Although health insurers typically try to emphasize the strength of their financial performance when issuing quarterly and annual earnings reports, the COVID-19 pandemic’s largely positive effect on managed care margins in 2020 has led some companies to downplay their earnings and instead emphasize how much money they’ve given back to members, health care providers and community organizations.

The trend has become a common thread in publicly traded insurers’ earnings reports and conference calls, but it was particularly visible in two recent press releases from Blue Cross Blue Shield insurers, which don’t have shareholders to appease.

Now that the federal government has banned most surprise medical billing, insurers and providers are beginning to sort out the complexities of implementing the No Surprises Act. Experts are unsure whether the law will slow cost and premium growth, and have concerns that providers will attempt to influence HHS’s in-process rulemaking to drive up prices over the long haul.

The No Surprises Act was passed in December 2020 as part of the Consolidated Appropriations Act, which was otherwise mainly oriented toward pandemic relief. The surprise billing ban, which comes into full effect in 2022, prohibits providers from sending a balance bill to patients. Patients who are treated by an out-of-network provider while incapacitated will pay the same cost sharing that they would have if they had been treated by an in-network provider. Patients treated at an in-network facility by an out-of-network provider will also not be balance billed, unless they authorize care by that provider in written form at least 72 hours in advance. That authorization must be accompanied by the patient’s in-network options and an estimate of the costs that they will incur.