Health Plan Weekly

Insurers that participate in the individual, small-group and large-group markets are projected to issue a record high $2.7 billion in medical loss ratio (MLR) rebates to their customers this year — nearly doubling the $1.4 billion in rebates issued last year, according to a recent Kaiser Family Foundation analysis. Almost 75% of the rebates in 2020 will come from individual market insurers. Looking ahead, the analysis notes that even if individual market insurers experience losses in 2020 due to costs related to the COVID-19 pandemic, they could still owe rebates in 2021 because MLR rebates are calculated using the last three years of insurers’ financial data. Individual market rebates were so high in 2020 primarily because insurers had strong financial performances in 2018 and 2019.

As COVID-19 spreads nationwide, insurers have dramatically cut back on in-person care management of their highest-risk chronically ill members while ramping up their capacity for remote monitoring via telehealth. This move — however necessary — likely will lead to repercussions in future months, some analysts warn.

“Face-to-face programs have stopped, as have programs run in nursing homes and other residential facilities,” Dan Mendelson, founder of Avalere Health, tells AIS Health. “Examples are in-person annual wellness visits and home visits attendant to managing complex chronic illnesses. This is appropriate right now given the crisis, but will come at a cost, in that this kind of care management adds value.”

An April 15 study published in Health Affairs found surprise billing occurred in 8% of procedures at ambulatory surgery centers (ASCs), and the average balance of each bill increased by 81% between 2014 and 2017. According to the study, bills for anesthesia administered either by physicians or certified registered nurse anesthetists (CRNAs) comprised 69% of the studied surprise bills.

Experts tell AIS Health that a very small number of anesthesiology practitioners drive most of the surprise billing and price distortion in ASCs, and only legislation can solve the problem.

Bids for the 2021 Medicare Advantage and Part D plan year are due June 1, and new research on the 2020 Annual Election Period (AEP) suggests that seniors are flocking to MA plans primarily because of enhanced supplemental benefits such as over-the-counter (OTC) allowances and dental coverage, as well as $0 premium options, with notable growth in $0 PPO selections. But while lessons from the prior AEP can inform benefit design and marketing approaches for the next enrollment cycle, plans this fall will be challenged by the double whammy of a presidential election and a predicted second outbreak of COVID-19, industry experts observed during a recent webinar hosted by Gorman Health Group (GHG), a Convey Health Solutions company.

Health insurers are encouraging their own on-staff clinicians to volunteer on the front lines of the fight against COVID-19, offering to continue salaries and benefits for those who sign up to help fight the pandemic that has now claimed more than 46,000 American lives.

At the same time, plans are shifting clinical staff members away from cancelled in-person care management and quality improvement activities and toward telephonic care management activities designed to ensure certain members get the help they need, says Michael Lutz, a senior consultant with Avalere Health.