Health Plan Weekly

TRICARE Program at a Glance

The U.S. Dept. of Defense recently awarded $136 billion in contracts for its TRICARE program that provides health care benefits to military service members, retirees and their families. The contract award for the West region went to TriWest Healthcare Alliance of Phoenix, which is partnering with Regence health plans and Health Care Service Corp. to administer the program. Humana Government Business Inc. will continue to serve the East region when the next contracts begin in 2024. Currently, Health Net Federal Services LLC, a subsidiary of Centene Corp., covers the West region with about 2.8 million beneficiaries, and Humana covers the East region with more than 6.8 million enrollees. In 2024, six states in the East region — Arkansas, Illinois, Louisiana, Oklahoma, Texas and Wisconsin, with a total of 1.5 million beneficiaries — will transfer to the West region in order to balance out the number of beneficiaries served by the two regions.

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Startup Insurer CEOs Talk Profitability Goals at J.P. Morgan Conference

During the J.P. Morgan Healthcare Conference on Jan. 11, chief executives of Bright Health Group, Inc., Clover Health Investments Corp. and Oscar Health, Inc. discussed their companies’ aims to achieve profitability this year or next year. Thus far, however, the companies have not had a profitable quarter since they went public in 2021.

For the first three quarters of 2022, the companies collectively had a net loss of more than $1.3 billion: Bright Health lost $691.3 million, Clover Health lost $254.8 million and Oscar Health lost $383 million.

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Enrollees in 2023 ACA Plans Face Higher Average Premiums, but Get Rich Subsidies

Nearly 11.5 million people selected or were automatically reenrolled in health plans for 2023 on HealthCare.gov as of Dec. 15, 2022, an 18% increase over the same time period in 2021, according to CMS. Although the average premium for benchmark silver plans (before accounting for tax credits) increased by 4.1% in 2023 after four years of declines, enrollees receiving subsidies may find their net premiums for low-cost bronze, silver and gold plans are lower than last year, according to a Kaiser Family Foundation analysis.

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2023 Outlook: Analysts Predict Another ‘Stable’ Year for Health Insurers

This year, a variety of headwinds and tailwinds are likely to buffet the health insurance industry, including inflation, a possible recession, the return of Medicaid eligibility checks, potential policy changes in Medicare Advantage, a split Congress, easing COVID costs and more. But the net effect of all those factors is likely to leave the sector on stable footing, analysts tell AIS Health.

“The tailwinds and headwinds change every year — that’s the case again for ’23. Overall, we think it’s balanced; that’s why we have a stable view,” says James Sung, associate director of insurance at S&P Global Ratings.

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Is Now the Time to Take All-Payer Claims Databases National? Some Policy Experts Say Yes

For years, all-payer claims databases (APCDs) have been popping up around the country, collecting claims and encounter data in order to help payers, providers, policymakers and others better understand and improve local health care markets. Currently, 18 states have an APCD and at least six are developing one, according to Manatt Health. But in a new report and during a recent virtual summit, the firm argues that the current patchwork of state APCDs isn’t up to the task of providing comprehensive, streamlined data that can help solve the pressing affordability, quality, equity and access issues facing the American health care system.

Instead, after engaging “more than 40 federal and state policymakers, regulators, researchers, and other health data leaders,” the Manatt report recommends building on the existing state-based APCD structure by creating a Federally Facilitated State Data Partnership model.

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Ruling on Transgender Care May Have Major Impact on Third-Party Administrators

A district court judge in Washington state ruled on Dec. 19 that Blue Cross and Blue Shield of Illinois violated the anti-discrimination provision of the Affordable Care Act when it served as a third-party administrator (TPA) of health benefits and refused to cover medically necessary gender-affirming care for a transgender boy.

The decision “is something that could have a big impact on administrators” of health benefits, David Kaufman, an attorney with Laurus Law Group LLC, tells AIS Health, a division of MMIT. It came one month after the court certified the case as a class-action lawsuit, meaning other individuals who had their gender-affirming care denied could potentially be involved, “so the case probably has a long way to go before it’s settled law,” according to Kaufman.

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News Briefs: Blues Plans Roll Out Contracting Org for Medical Benefit Drugs

A group of Blue Cross and Blue Shield affiliates has founded the Synergie Medication Collective, a medication contracting organization focused on improving affordability of clinically administered drugs that are covered under patients’ medical benefit. The goal of the organization is to establish “a more efficient contracting model” for things like multimillion-dollar gene therapies and infusible cancer drugs while “utilizing a transparent business model in collaboration with industry stakeholders.” The independent entity will go to market “in January of 2023,” according to a Jan. 5 press release, and is owned by the Blue Cross Blue Shield Association (BCBSA), Elevance Health, Blues-affiliate-owned Evio Pharmacy Solutions and Prime Therapeutics, and nine regional Blues plans. Pharmaceutical industry veteran Jarrod Henshaw will serve as Synergie’s CEO, and BCBSA President and CEO Kim Keck will be the organization’s initial board chair.

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MCO Stock Performance, December 2022

Here’s how major health insurers’ stock performed in December 2022. UnitedHealth Group had the highest closing stock price among major commercial insurers as of December 30, 2022, at $530.18. Humana Inc. had the highest closing stock price among major Medicare insurers at $512.19.

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By the Numbers: National Health Insurance Market in December 2022

Three years into the COVID-19 pandemic, enrollment in both commercial health coverage and public health insurance continued its growth. Managed Medicaid membership jumped from 61.4 million in December 2020 to 74.0 million in 2022, while Medicare Advantage (MA) enrollment reached 29.9 million this year, compared with 25.2 million in 2020, according to AIS’s Directory of Health Plans. Commercial health coverage gained 300,000 enrollees over the past year, yet several major health plans reported slight decreases in commercial enrollment, including Centene Corp. and CVS Health Corp.’s Aetna.

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Key Financial Data for Leading Health Plans — Third Quarter 2022

Here’s how major U.S. health insurers performed financially in the third quarter of 2022. Health Plan Weekly subscribers can access more health plan financial data — including year-over-year comparisons of leading health plans’ net income, premium revenue, medical loss ratios and net margins. Just email support@aishealth.com to request spreadsheets for current and past quarters.

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