Health Plan Weekly

Legal odds are growing long for the Affordable Care Act’s preventive services coverage mandate after a June 21 appeals court decision, which didn’t resolve a lawsuit that could undermine the legal authority of federal preventive services experts to recommend those services be covered free of charge by health plans. The next stage of the Braidwood v. Becerra suit will be decided by either the conservative Supreme Court or a federal judge who has issued a series of rulings undermining the ACA. 

The U.S. Court of Appeals for the Fifth Circuit found that the federal government can still require health plans to provide some preventive services to plan members free of charge under the Affordable Care Act — for now. The ruling still leaves open the possibility that, in the end, Braidwood could upend the preventive services coverage regime set up by the ACA. In the next step of Braidwood, the Biden administration must decide whether to petition the Supreme Court for an appeal, or let the case be decided by Texas District Court Judge Reed O'Connor, who has repeatedly ruled against provisions of the ACA. 

More and more plan sponsors are interested in introducing risk-based reimbursement in their contracts with health insurers. That interest has grown into a range of plan designs: On the extreme end, plan sponsors like CalPERS are introducing upside and downside risk to entire third-party administrator contracts. A more incremental approach sees health insurers offering upside risk to plan sponsors based on the health insurer’s ability to control costs for a specific condition. 

UnitedHealthcare on June 26 launched such an offering, called the Level2 Assured Value Program. It’s a new payment model for an existing Type 2 diabetes management benefit design called Level2. 

With two recent papers, a right-leaning think tank has managed to draw the ire of a wide array of health benefits stakeholders — including the top insurer trade group, a major health insurer, employers, unions, agents and brokers.  

Both papers come at a time when health care industry stakeholders are increasingly trying to read the tea leaves to determine what policies President Joe Biden or former President Donald Trump would embrace if reelected. 

In a paper published in May, the Paragon Health Institute argues that not only should federal policymakers end the enhanced Affordable Care Act subsidies that have been in place since 2021, but they should also cap the current open-ended tax exclusion for employer-sponsored health insurance.  

Politicians from both parties have been pushing for site-neutral payment reforms, a concept that says payers should reimburse the same amount for outpatient services regardless of whether the service is performed in a hospital, ambulatory surgical center or physician’s office. But getting such a policy passed by Congress has proven elusive. And as Larry Levitt, KFF’s executive vice president for health policy, said during a June 17 KFF webinar: “It’s anybody’s guess what Congress might do in this divisive and chaotic political environment.” 

Advocates for site neutrality came close to notching an incremental win last December when the House of Representatives passed the Lower Costs, More Transparency2 Act, which included a provision for Medicare site-neutral payments applying to drugs administered in an outpatient setting. However, the legislation has since stalled.