Health Plan Weekly

On Sept. 29, a U.S. District Court ruled in favor of patient advocates who challenged a regulation that allowed most individual and group market health plans to use copay accumulator programs. So far, it isn’t clear how CMS will respond to the ruling, likely leaving health plans and PBMs waiting eagerly for guidance from the agency. But one thing is certain: Health insurers aren’t happy about the decision. 

Insurers created copay accumulator programs in response to the drug manufacturer practice of offering copay assistance programs — including coupons and copay cards — to defray high out-of-pocket costs patients might face for branded drugs. When copay accumulator programs are applied, health plan enrollees are not allowed to count any direct-to-consumer discounts toward their deductibles or out-of-pocket maximums.  

Medicaid eligibility redeterminations are in full swing, but many states have struggled to fulfill automated enrollment requirements mandated by CMS, leading to finger pointing and — at a minimum — hundreds of thousands of members getting kicked off insurance rolls when they should not have been. Experts and one managed care trade group say this unfortunate state of affairs was foreseeable and could have been prevented if state Medicaid agencies had adequate staff and technical resources. 

The problems with automated renewals began this spring, after a yearslong pause in eligibility checks mandated by the federal government in response to the COVID-19 pandemic. With states allowed to resume redeterminations as of April 1, millions of members who enjoyed ongoing Medicaid coverage without income eligibility checks during the COVID public health emergency are expected to be disenrolled because they now make too much money to qualify for the program. But, because of administrative reasons — most often missed paperwork sent by mail — it seems likely that many Medicaid enrollees have lost coverage even though they are still eligible, experts say. 

With open enrollment for Affordable Care Act exchange plans now less than a month away, a clearer picture is beginning to emerge regarding which factors are weighing the heaviest on health insurers’ minds when formulating their 2024 premium rates — as well as how much those rates are set to rise.  

Based on insurers’ 2024 rate requests and their actuarial justifications, it appears that inflation is one of the biggest drivers of proposed rate increases, which states are now in the process of finalizing. However, due to expanded subsidies that have been in place since pandemic relief legislation passed, most exchange customers won’t feel the effects of rising premiums. And researchers who study the ACA exchanges tell AIS Health, a division of MMIT, that generally the individual insurance marketplace remains on solid ground — a far cry from years like 2017 and 2018 that featured significant regulatory uncertainty and major insurer exits.