Health Plan Weekly

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. 

Although executing mergers and acquisitions (M&A) is an important part of health insurers’ growth toolkit, industry insiders tell AIS Health, a division of MMIT, that companies could face challenges completing deals in 2024 due to factors such as high interest rates and government intervention.  

The Federal Trade Commission (FTC) and Department of Justice (DOJ) last month finalized updated merger guidelines for the first time since 2020. The FTC and DOJ noted the guidelines “are not themselves legally binding, but provide transparency into the Agencies’ decision-making process.” 

Law firm Morgan Lewis wrote in a Dec. 21 brief that the FTC and DOJ are “dramatically expanding the number and type of transactions that the agencies will consider presumptively unlawful,” although the authors noted that the agencies have both “lost several merger cases in the last few years.” 

Managed care experts predict that 2024 will see further and deeper adoption of artificial intelligence (AI) across the health care sector despite emerging legal risk. Meanwhile, regulation of AI in health care is already underway, but mostly at the state level, with action in Congress stalled and the Biden administration taking an incremental approach. 

Health insurers for years have put big data at the center of significant capital investments and operational changes, as major insurers have portrayed themselves as technology players with vast proprietary data sets. For many insurers, automation and algorithms are already intrinsic to claims processing, prior authorization, revenue cycle management and actuarial work. AI could make those insurance processes faster and cheaper.  

Health insurer trade groups have several bones to pick with the proposed 2025 Notice of Benefit and Payment Parameters (NBPP), the annual regulation that sets the rules of the road for the Affordable Care Act exchanges. In the case of certain proposals, AHIP and the Blue Cross Blue Shield Association (BCBSA) are even arguing that CMS is exceeding its legal authority. 

Those proposed rule changes concern the process that states use to define their essential health benefits (EHB) benchmark plans, according to comments on the 2025 NBPP filed on or before a Jan. 8 deadline. The ACA lists 10 general categories of EHB that all individual market plans must cover — such as emergency services and prescription drugs — allowing states to determine the specific services that are included in those broad categories. To do that, state officials select a benchmark plan among a list of HHS-approved options, and insurers then use that benchmark to design their benefits.