Health Plan Weekly

A bipartisan group of senators has introduced price transparency legislation crafted by the Committee on Health, Education, Labor and Pensions (HELP) that would require plans and providers to publish all of their negotiated rates, codify the Transparency in Coverage (TiC) rule, make data-sharing rules more specific and stringent, and increase fines for noncompliance with data sharing requirements. However, the legislation does not include any site neutrality requirements, although one D.C. insider says that policy is still under discussion in the Senate. 

The Senate bill, S-3548, comes on the heels of the House of Representatives passing the Lower Costs, More Transparency Act in December. The House bill would also codify the TiC rule, make data-sharing requirements stricter and increase fines for noncompliance to as much as $10 million. However, unlike the Senate bill, the House bill would include a tentative step toward site neutrality by barring providers from charging facility fees to Medicare for provider-administered drugs given to patients in outpatient departments. The new Senate bill also does not include any PBM reforms — the Senate Finance Committee has taken the lead on that issue. 

Although 2024 seems far removed from the height of the COVID-19 pandemic, the ripple effects associated with that disruptive global crisis are still influencing how this year will turn out for the U.S. health insurance sector, two top credit ratings firms predict.  

“We’re calling it the pandemic hangover,” says Brad Ellis, senior director in Fitch Ratings' North American insurance rating group.  

“I think this year might be the last year we’re seeing what we call pandemic-related effects on the industry,” adds James Sung, director of insurance ratings at S&P Global. 

Three startup “insurtechs” — Oscar Health Inc., Clover Health Investments Corp. and Alignment Healthcare Inc. — presented at the J.P. Morgan Health Care Conference in San Francisco last week, where they reiterated earlier projections that they expect to close 2024 in the black. Oscar and Clover expect to turn a profit in 2024, while Alignment says it will break even. 

Oscar reiterated its promise to be profitable in 2024, and it teased entry into the Individual Coverage Health Reimbursement Arrangement (ICHRA) market. ICHRAs, which allow participating employers to reimburse employees for Affordable Care Act marketplace coverage at a fixed rate in lieu of purchasing a traditional group health plan, have also been identified as a target market by Centene Corp. in recent weeks. 

The share of employer-sponsored health insurance (ESI) enrollees who are in self-funded plans — meaning the employer, rather than an insurer, collects premiums and bears responsibility for paying claims — increased to 60% in 2021 from 55% in 2015, according to a recent Health Affairs study.

Based on 2015 and 2021 Clarivate Interstudy enrollment data, researchers found that in 80.5% of U.S. counties in 2021, the majority of ESI enrollees were in self-funded health plans. Over the years, 78.2% of counties saw growth in the share of ESI enrollees in a self-funded plan. Generally, that growth was concentrated in states with a lower percentage of self-funded plan enrollees in 2015.

The Biden administration on Jan. 17 finalized its interoperability and prior authorization (PA) requirements for government-funded payers, including insurers offering Medicare Advantage and managed Medicaid plans as well as plans on federally facilitated exchanges. CMS said in a press release that “these policies will improve [PA] processes and reduce burden on patients, providers, and payers” and estimated they would lead to $15 billion of savings over a 10-year period. The rules include a requirement that MA and Medicaid plans starting in 2026 will have to send PA decisions within 72 hours for urgent requests and seven days for non-urgent requests. Payers will also have to disclose a reason for denying a PA request and publicly report PA metrics.  

The Cigna Group has named Brian Evanko president and CEO of Cigna Healthcare, its health insurance arm. Evanko will continue to serve as The Cigna Group’s chief financial officer, a role he has held since January 2021. He previously led Cigna Healthcare’s U.S. government business. Cigna also promoted Bryan Holgerson to president of Cigna Healthcare’s U.S. commercial business, replacing Mike Triplett, who will retire by the end of the year. In addition, The Cigna Group hired Ann Dennison as deputy CFO. Dennison was previously the CFO at Nasdaq. Further, Evernorth President and CEO Eric Palmer expanded his role to lead The Cigna Group’s enterprise strategy and corporate development teams.