Health Plan Weekly

Since 2021, just three consumer operated and oriented plans (CO-OPs) have remained operational out of the original 23 nonprofit insurers created by the Affordable Care Act. Now, one of the three survivors — Common Ground Healthcare Cooperative (CGHC) — is poised to shed its CO-OP identity and combine forces with CareSource, a Medicaid-focused insurer based in Ohio.  

In a Feb. 27 press release, CGHC said it was “financially healthy and on track to repay” all loans that it’s received from the federal government.  

“Even so, it’s challenging as a nonprofit startup to support necessary investments in operations and diversification while keeping premiums affordable for our members,” CEO Cathy Mahaffey said.  

Comprehensive information about appeals of coverage denials by Medicaid managed care organizations is not available, and state and federal officials are far from setting a common, national data standard, according to a March report from the Government Accountability Office (GAO). The report reiterates some of the same conclusions made by another federal watchdog, the HHS Office of Inspector General (OIG), in a July 2023 report about Medicaid MCOs’ prior authorization denials, and experts say they do not expect data reporting to improve in the short term. 

Medicaid MCOs are facing increasing regulatory pressure over prior authorization and other utilization management (UM) practices, particularly at the state level. Federal lawmakers have yet to approach Medicaid UM reforms with the same bipartisan zeal that they have brought to revamping Medicare Advantage practices. But the new GAO report, which was prepared at the request of Sen. Ron Wyden (D-Ore.) and Rep. Frank Pallone (D-N.J.) is an indication that powerful Democratic members of Congress are taking interest in reforming UM in managed Medicaid. 

During a keynote session at the AHIP Medicare, Medicaid, Duals & Commercial Markets Forum, health plan leaders offered sobering assessments about the state of health equity in the U.S. Still, they offered concrete steps their organizations have taken with community partners to address systemic inequalities. 

“I would give us a grade of ‘C’ [on health equity]. Probably, before the murder of George Floyd, I would have given us a ‘D,’” said Karen Dale, market president and chief diversity, equity and inclusion officer at AmeriHealth Caritas. Floyd was killed by a white police officer during an arrest made outside a Minneapolis convenience store in May 2020, sparking nationwide protests over police brutality and racial inequality.  

The American Academy of Actuaries has urged the Biden administration to follow through on its proposal to rescind a controversial 2018 rule that granted more regulatory leeway to association health plans (AHPs). Rescinding the 2018 AHP regulations will protect consumers and strengthen the actuarial health of the Affordable Care Act exchanges, according to Academy Senior Health Fellow Cori Uccello and a February public comment letter from the organization.   

The comments by the professional association are in response to a December 2023 regulatory proposal that followed through on long-expected plans to rescind the 2018 rulemaking. Those regulations, put forward by the Trump administration, significantly loosened the requirements that apply to AHPs and their close cousins, multiple employer welfare arrangements (MEWAs). The 2018 rule was never implemented, however, because it was largely blocked by a summary judgment issued as a result of litigation by 11 states and the District of Columbia. 

The typical cost for a patient-provider email messaging claim was $39 in 2021, including both the portion paid by health plans and by patients. Although insurers covered the full cost for 82% of these claims, the patients who need to pay out of pocket typically spent $25 on a typical email message, according to Peterson-KFF Health System Tracker.

Use of electronic health communications has exploded since the COVID pandemic as more patients are seeking medical care remotely. CMS introduced several new billing codes in 2020 to help health care providers bill patients and insurers for a range of digital health services including electronic visits or asynchronous patient portal messages that require medical decision-making and at least five minutes of clinician time over a seven-day period.