Health Plan Weekly

With nearly all states having completed the Medicaid “unwinding process” that shed millions of people from the rolls, a new analysis finds that total Medicaid and Children’s Health Insurance Program (CHIP) enrollment is actually higher than it was before the COVID-19 pandemic. One expert tells AIS Health that private insurers helped conduct crucial outreach to ensure people losing coverage could get insured elsewhere — although Medicaid managed care organizations (MCOs) still are grappling with the financial consequences of the unwinding.  

More than 25 million people lost their Medicaid or Children’s Health Insurance Program (CHIP) coverage and over 56 million had their coverage renewed during the Medicaid eligibility redetermination process, according to a KFF analysis of data released by states and CMS. Though millions have been disenrolled, nearly 10 million more people are currently enrolled in Medicaid/CHIP than at the start of the pandemic. 

Starting in April 2023, states were permitted to resume disenrolling people from Medicaid who no longer qualify after a multiyear pause of routine eligibility checks during the COVID-19 public health emergency. Compared to pre-pandemic levels, total Medicaid/CHIP enrollment is now higher in all but four states: Colorado, Montana, Arkansas and Tennessee. Missouri and North Carolina saw Medicaid/CHIP enrollment growth of more than 50%, as of May 2024. 

In the latest twist in Arizona’s controversial quest to implement new statewide long-term care contracts with Centene Corp. and UnitedHealth Group, a Republican state senator said he is looking into the potential mismanagement of state taxpayer dollars by Gov. Katie Hobbs (D). That includes the questionable procurement of Medicaid contracts serving approximately 26,000 elderly and disabled members conducted by the Arizona Health Care Cost Containment System (AHCCCS).

The HHS Office of Inspector General (OIG) is asking Humana Inc. and a division of CVS Health Corp.’s Aetna to refund the federal government a combined $11 million for estimated overpayments, according to two reports posted on Sept. 25. OIG is seeking $6.8 million from Humana and $4.2 million from Aetna’s HealthAssurance based on extrapolated audit findings. For the Humana audit, the agency examined a random sample of 240 enrollee-years for which Humana submitted high-risk diagnosis codes in 2017 and 2018. It found that for 202 enrollee-years, the claims submitted by Humana to CMS “were not supported by the medical records and resulted in $497,225 in overpayments.” HHS OIG performed a similar analysis for HealthAssurance and found the medical records did not support the diagnosis codes for 222 of the 269 sampled enrollee-years and resulted in $657,744 in overpayments. Humana and Aetna both disagreed with the findings, according to the report.  

Just days after The Cigna Group’s Express Scripts sued the Federal Trade Commission over an interim report that criticized PBMs, the FTC revealed that it is suing Express Scripts, UnitedHealth Group’s Optum Rx, and CVS Health Corp.’s Caremark for “artificially inflating” insulin prices.

The FTC said its administrative complaint also names the “Big Three” PBMs’ affiliated group purchasing organizations that serve as prescription drug rebate aggregators: CVS’s Zinc Health Services, Cigna’s Ascent Health Services, and UnitedHealth’s Emisar Pharma Services.

The FTC alleges that the three PBMs, which together processing 80% of all prescription drug claims, “created a perverse drug rebate system that prioritizes high rebates from drug manufacturers, leading to artificially inflated insulin list prices.”