Health Plan Weekly

With unpredictable risk caused by the intensifying COVID-19 pandemic, estimating claims and enrollment will be more difficult than ever for health insurance companies in 2021, and the task has particularly high stakes for smaller payers.

Member enrollment has shifted a great deal during the pandemic-driven economic crisis, with many Americans losing their jobs and employer-backed health insurance. A substantial portion of those people have enrolled in Medicaid or Affordable Care Act (ACA) exchanges, but analysts and actuaries are still working to determine how many people landed in what part of the health insurance industry and how many people lost coverage altogether.

Building on previously finalized regulations aimed at advancing data interoperability in health care, CMS on Dec. 10 proposed a new rule that would require certain health plans to make their prior authorization processes more efficient and share even more data with providers and patients.

Although the proposal is arriving in the waning days of the Trump administration, it will likely survive the transfer of executive power, one health policy expert tells AIS Health. As for the affected health plans, complying with the new directives probably won’t take a herculean effort considering they’re already doing so much to modernize their data systems to align with the new interoperability mandates, another expert says. However, preparing to comply with all the new requirements is going to be challenging.

✦ The U.S. Supreme Court on Dec. 10 ruled unanimously against the Pharmaceutical Care Management Association (PCMA) in a case challenging an Arkansas law regulating PBMs. In Rutledge v. PCMA, the justices rejected the trade group’s argument that the Arkansas law is preempted by the Employee Retirement Income Security Act of 1974. By permitting the Arkansas law to stand, the ruling paves the way for legislation regulating PBMs in other states. Read the opinion at https://bit.ly/375ArY5.

✦ Humana Inc. on Dec. 10 said it plans to launch a new value-based payment model called Primary Care First (PCF). The model was first established by the CMS Center for Medicare and Medicaid Innovation and applied to fee-for-service Medicare, and Humana will be the only private insurer to offer its own version of PCF in all 48 contiguous states and the District of Columbia. Humana’s PCF model, which will launch on July 1, 2021, will apply to “members of certain Humana Medicare Advantage plans.” For participating practices, the model will offer “a prospective capitated payment, which takes into account achievement of quality and outcomes-based measures,” according to Humana. Read more at https://bwnews.pr/341nH2I.

Most insurers waived member cost sharing for COVID-19 treatment through the end of 2020, and some payers, mainly nonprofits, have begun to extend those waivers into 2021. An industry insider expects more for-profit carriers will soon feel obliged to do the same.

According to America’s Health Insurance Plans, these non-profit and Blue Cross Blue Shield plans have waived member cost sharing for in-network COVID-19 treatment for some or all members: