Health Plan Weekly
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News Briefs: Court Upholds ACA Preventive Services Coverage Mandate, for Now
The U.S. Court of Appeals for the Fifth Circuit on June 21 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. Prior to Braidwood v. Becerra, federal regulators relied on recommendations for preventive services from medical experts in several federal agencies, especially the U.S. Preventive Services Task Force (USPSTF), the Advisory Committee on Immunization Practices (ACIP) and the Health Resources and Services Administration (HRSA). Based on those recommendations, non-grandfathered health plans governed by the ACA would have to cover certain preventive services free of charge, including vaccinations and contraceptives. In their ruling in Braidwood, the Fifth Circuit's judges agreed with Texas District Court Judge Reed O'Connor's earlier finding that USPTF did not have the constitutional authority to recommend preventive services coverage mandates to federal regulators. In further litigation in O'Connor's court, the other agencies could come under the same scrutiny. According to Richard Hughes IV, partner at Epstein Becker Green, the Fifth Circuit "agree[s] that there's a constitutional problem with the [USPTF]." In addition, he says, "they just raise more questions with respect to whether the other bodies' roles are constitutional." For the time being, Hughes says, other than the plaintiffs, "all other private payers and employers subject to the ACA requirements must continue to provide zero [cost] out-of-pocket coverage for recommended preventive services, including PrEP for HIV." But going forward, Hughes says, "the requirement to cover vaccines and contraceptives could be in jeopardy."
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As Insurers Are Sued Over AI Use, Regulators Aim to ‘Get Ahead’ of the Issue
Three major health insurers have denied allegations brought against them in lawsuits pertaining to the use of artificial intelligence in coverage decisions. While The Cigna Group, Humana Inc. and UnitedHealth Group may succeed in getting the cases dismissed, those companies and other payers could continue to face scrutiny over their use of AI, according to Ileana M. Hernandez, a partner at Manatt, Phelps & Phillips, LLP.
“The staggering volume of claims and complexity of claims that insurance plans need to review on a daily basis make insurance reviews an attractive target for using AI,” said Hernandez, who spoke on June 12 during a Manatt webinar. “However, the use of algorithms for review of coverage issues has resulted in questions, concerns, investigations and now lawsuits.”
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‘We Don’t Need to Do M&A,’ Cigna Chief Financial Officer Says
Months after rumors of a brewing deal with Humana Inc. generated a spate of headlines, The Cigna Group’s chief financial officer is signaling clearly that the company isn’t eager to jump into the mergers and acquisitions game until the conditions are just right.
“We continue to view inorganic activity through the lens of, it needs to be strategically attractive for the company,” CFO Brian Evanko said during a question-and-answer session with analyst Nathan Rich during the Goldman Sachs Global Healthcare Conference on June 11.
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Elevance Execs Dish on ACA Exchange, Commercial Segment Strategies
Although improving Medicare Advantage margins has been the hottest topic recently in managed care, executives at Elevance Health, Inc. at a recent investor conference made some noteworthy comments about the firm’s commercial and Affordable Care Act exchange businesses — both of which insurers are talking more glowingly about amid government-business headwinds.
Regarding the company’s ACA exchange business, “we certainly aren’t looking for membership over margin,” Morgan Kendrick, president for the insurers commercial and specialty health benefits segment, said during a June 12 question-and-answer session at the Goldman Sachs Global Healthcare Conference.
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AHIP 2024: UnitedHealth, Elevance Execs Get Real About Provider-Directory Woes
There are persistent challenges around the collection and transmission of that data between providers and payers. The same is true of the quality of the data itself. It's a key challenge for the health insurance industry as payers try to measure provider quality and transition to value-based contracting.
"I'll just say the accuracy of our directory is bad. It just is," said Mike Kane, senior vice president for provider data operations at UnitedHealthcare. Kane was speaking on a June 12 panel organized by the Council for Affordable Quality Healthcare (CAQH) at the 2024 AHIP Conference in Las Vegas. "About half of every single provider [data profile] that our members call, there's at least one data element in our directory that's wrong."
"It's a horrible, horrible experience," Kane said.
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