North Carolina began its long-awaited Medicaid expansion Dec. 1. About 600,000 people are newly eligible for coverage, according to the state’s Medicaid department. Just 10 states have yet to expand Medicaid, and CMS Administrator Chiquita Brooks-LaSure urged them to take action in a statement. “It’s crucial that the ten remaining states expand their Medicaid programs so that the millions of people in the coverage gap today can receive the essential health care they need,” she said. The state currently serves 2,318,187 Medicaid beneficiaries, with 78% enrolled in managed care plans.
Clover Health Investments Corp. announced on Dec. 1 that it will exit the ACO Realizing Equity, Access, and Community Health (REACH) Model at the end of the 2023 performance year. The startup insurer noted that “the decision will have no impact on its ACO REACH beneficiaries, and Clover will continue to fulfill all of its obligations under the ACO REACH Program for the 2023 performance year.” Clover missed its pre-discount benchmark by $2.69 million for 2022, an improvement from a nearly $16.9 million loss in 2021. For 2023, Clover offered plans in 15 states, but CEO Andrew Toy said in a press release that “we have not seen a clear line to profitability in this business and it has also become quite clear that, over the same period of time, we have made far greater and swifter strides on our path to profitability in our Medicare Advantage insurance business.” Clover currently enrolls 80,631 MA members in six states.
CVS Health Corp.-owned Aetna has reversed course on a previously announced telehealth coverage change, Politico reported last week. The insurer had planned on ending virtual coverage for intensive outpatient and partial hospitalization program care on Dec. 1, but an Aetna spokesperson told Politico that Aetna would no longer go through with that decision. Groups such as the American Society of Addiction Medicine and the Consortium Representing Eating Disorders Care previously raised concerns about the proposed change. Aetna is currently the third-largest health insurer in the U.S., serving 23,660,554 members, with about 72% enrolled in employer-sponsored coverage.
AbbVie in recent weeks sued Novartis’ Sandoz and four other generic drugmakers over copies of its immunology drug Rinvoq (upadacitinib). Though Rinvoq’s U.S. patents won’t begin to expire until 2033, the suit aims to stop any generic versions from being marketed ahead of those expirations. The JAK inhibitor was first approved in 2019 for the treatment of moderate to severe rheumatoid arthritis, an indication for which it currently holds covered or better status for 97% of all insured lives. 35% of covered lives have preferred access to Rinvoq, largely with utilization management restrictions applied. Norstella’s Evaluate Pharma projects the drug will generate $3.8 billion in global sales by the end of 2023.
Nearly 4.6 million have enrolled in Affordable Care Act exchange plans for 2024 since open enrollment began on Nov. 1, including 919,900 people who did not have exchange plans this year. The data captures sign-ups through Nov. 18 for people in the 32 states that use HealthCare.gov for enrollment and through Nov. 11 for people in the 17 states and Washington, D.C., that have state-based marketplaces. CMS Administrator Chiquita Brooks-LaSure said in a press release that “we have seen an increase in plan selections and a significant increase in the number of new enrollees year over year.” The three largest exchange insurers in the U.S. are Centene Corp. (3,258,194 members), Florida Blue (1,226,000 members) and Aetna (940,720 members), as of the latest update to AIS’s Directory of Health Plans.
Republicans in the Georgia House of Representatives are mulling the possibility of expanding Medicaid in the state, according to a Nov. 17 report in the Atlanta Journal-Constitution. Legislators held hearings earlier this month, listening to testimony about how Arkansas’ Medicaid expansion program cut its uninsured rate, as well as North Carolina’s upcoming expansion. About 2.91 million people currently receive Medicaid benefits in Georgia, and expansion could make an additional 450,000 people newly eligible for coverage.
Milwaukee-based integrated health system Froedtert Health on Nov. 1 finalized a plan to purchase Ascension Wisconsin’s interest in Network Health and fully acquire the commercial and Medicare Advantage insurer. Each organization previously held a 50% ownership interest in the insurer, which serves 23 Wisconsin counties and enrolls 116,756 members, according to AIS’s Directory of Health Plans. About 36% of its members are enrolled in commercial risk-based products, while 62% are enrolled in MA. Earning its third consecutive overall 5-star rating for 2024, Network Health was recently listed as one of 31 MA Prescription Drug contracts to earn 5 stars from CMS.
The Cigna Group’s Express Scripts PBM announced on Nov. 14 that it’s launching a new “cost-plus” prescription drug pricing model for its clients. With the Express Scripts ClearNetwork, “clients pay a straight-forward estimated acquisition cost for individual medications, in addition to a small markup for pharmacy dispensing and service costs.” Express Scripts plans on launching the model in early 2024 and applying it toward generic, branded and specialty drugs. Express Scripts currently serves 22.3 million commercial pharmacy lives and 950,000 Medicare pharmacy lives.
Doug Langa, Novo Nordisk’s vice president for North America, told analysts on an earnings call on Nov. 2 that about 80% of people with health insurance are paying less than $25 per month for Wegovy (semaglutide), a popular weight loss medication, Reuters reports. Langa added that “most major PBMs and health plans are covering” Wegovy, which the FDA initially approved for Type 2 diabetes but expanded the indication to weight management two years ago. Novo Nordisk said that Wegovy’s sales in the U.S. increased 467% year-over-year through the third quarter even though the company reduced the supply of the drug since May. Under the pharmacy benefit, Wegovy holds covered or better status for 53% of all insured lives, according to MMIT Analytics. About 31% of covered lives have preferred access to Wegovy, often with utilization management restrictions applied.
A KFF report released on Nov. 8 found that 3,959 Medicare Advantage plans are available for individual enrollment next year, the second-largest number of plans since 2010 and a 1% decrease from this year. Meanwhile, the average beneficiary will be able to choose from 43 plans, the same as this year's record high. Eighty-nine percent of MA plans will offer prescription drug coverage in 2024; while 83% will offer telehealth benefits; and at least 97% will offer some dental, vision, fitness or hearing benefits. The three largest MA insurers by enrollment are UnitedHealthcare (9.21 million members), Humana Inc. (5.83 million members) and CVS Health’s Aetna (3.38 million members).