Health Plan Weekly

With surprise billing banned by Congress in the No Surprises Act passed in December 2020, HHS has rolled out regulations that will shape the adjudication process for disputed out-of-network claims. Payers and plan sponsors are largely on board with the rules that the agency has released, but insurers have raised concerns about the pace of implementation and the long-term effect the rules will have on health care prices.

America’s Health Insurance Plans (AHIP) on Sept. 7 submitted comments on a July interim final rule (IFR) that, among other matters, outlines the way quasi-benchmark reimbursement rates, known as the qualifying payment amount (QPA), will be calculated. The insurance trade group was largely positive about the IFR, but raised concerns about the scope and timeline of payment database implementation. AHIP called on HHS to extend the implementation deadline and create a “good faith safe harbor” for plans struggling to navigate the early years of the new system’s implementation.

✦ The U.S. Chamber of Commerce withdrew its lawsuit challenging the “transparency in coverage” rule that required insurers and employers to reveal unprecedented amounts of data about negotiated rates for health care services. The Chamber and the Pharmaceutical Care Management Association (PCMA) had filed twin lawsuits challenging the Trump-era rule’s provisions requiring the disclosure of negotiated rates with in-network providers, historical allowed amounts to out-of-network providers, and historical net prices for prescription drugs furnished by in-network providers, via “standardized, regularly updated machine-readable files” by Jan. 1, 2022. The Chamber’s decision to dismiss its lawsuit comes after the Biden administration issued guidance on Aug. 20 that postponed the drug-price disclosures indefinitely and delayed the requirement to reveal the other data in machine-readable files by six months. PCMA, in a statement sent to AIS Health following the issuance of the new guidance, stated that the trade group “is reviewing the status of our litigation on the Transparency in Coverage rule.”

✦ Blue Cross and Blue Shield of North Carolina will offer members a type 2 diabetes prevention program called Eat Smart, Move More, Prevent Diabetes. The year-long program was developed and will be delivered by NC State University, and the Blues insurer said it is “reaching out to eligible members who have been diagnosed with prediabetes or who are at high risk of developing type 2 diabetes and inviting them to participate.” The insurer said a similar program in place since 2005 produced $972 in average annual savings per member.

The Biden administration has awarded $80 million in grants to 60 organizations to hire more than 1,500 health exchange Navigators, according to HHS. One expert predicts the move will help boost overall enrollment in exchange plans and Medicaid — and help match enrollees to the right kind of coverage.

In an Aug. 27 press release, HHS said the increased Navigator funding is intended to improve health insurance coverage for underserved and disadvantaged groups. During the Trump administration, funding for Navigators was cut dramatically, dropping from $63 million in 2016 to $10 million in 2018 and 2019.

Cigna Corp. will increase its Affordable Care Act exchange offerings in 2022 by 93 new counties across 10 states that it already served and adding three new states — Georgia, Pennsylvania and Mississippi — the insurer said on Aug. 26. The carrier has been expanding its footprint over the past few years, currently ranking 11th in national ACA enrollment with 324,230 members. Its major state markets are Virginia (114,093 members), Missouri (77,000 members) and Tennessee (65,300 members).

Two sizeable regional Blue Cross Blue Shield plans, CareFirst of Maryland, Inc. and Highmark Inc., are teaming up to offer a “new collaboration and health insurance offering” for labor unions. While it’s certainly not the first insurance product to be targeted at organized labor groups, Union Blue does seem to have the ingredients for success in that space, one industry expert says.

In an Aug. 31 press release, CareFirst and Highmark said their new offering will be “a best-in-class healthcare administration experience that meets the unique needs of the men, women and families of labor.” The Northeastern Blues plans said Union Blue will feature “a high-touch experience, committed service and data analytics that enable CareFirst and Highmark to generate deep insights about labor members’ needs, proactively manage their care, and help improve health outcomes.”