Health Plan Weekly

As artificial intelligence software proliferates in the health care sector, a good deal of attention has focused on the ways that AI could make existing health disparities worse. Experts say that AI also has the potential to mitigate or reverse health disparities — so long as health care organizations, and insurers in particular, proactively and continuously counter biases in their current and future software platforms.

“We’re at this inflection point where we have new tools. We have new technology that actually may have that opportunity to address health inequality in a way we haven’t been able to before. But we’re at this inflection point where that same tool can actually amplify that bias, amplify the inequality that already exists,” said Maia Hightower, M.D., during a March 26 panel organized by the National Institute for Health Care Management (NIHCM) Foundation.

Sending informational emails helped lead to some California residents switching to superior Affordable Care Act exchange plans, according to a study published on March 29 in JAMA Health Forum. However, Marina Lovchikova, Ph.D., the trial’s lead author, points out that the vast majority of households remained in their original plans and the impact on health care utilization was minimal. This suggests that more can be done to make sure enrollees are fully aware of their options and eligibility for more generous plans, she tells AIS Health, a division of MMIT.

Lovchikova, a senior researcher at Covered California, says the state’s exchange is “trying to get people to the coverage that could be most affordable for them and increase the access for their coverage. Some methods the state employs are sending emails or doing other low-cost, so-called nudges, which attempt to inform residents of their options but not automatically enroll them in another plan without their consent.

Since last summer, major health insurers’ reports of unusually high outpatient care utilization have proven to be a thorn in the industry’s side — inflating medical loss ratios and forcing Humana Inc. to significantly downgrade its 2024 earnings outlook. And according to some Wall Street analysts, the trend isn’t likely to go anywhere soon.

With the COVID-19 pandemic winding down, “grandma has been locked in her house for the last three years; she’s ready to go on a cruise and she wants that new hip, she needs that new knee,” Deutsche Bank Managing Director George Hill said during the annual Wall Street Goes to Washington Roundtable on April 8, hosted by the Brookings Institution. That increased demand, he said, “has resulted in a surge in outpatient orthopedic procedures that we’ve seen, particularly among seniors, particularly impacting the Medicare Advantage books of business.”

Over the first 10 years of the Affordable Care Act marketplaces, enrollment nationwide has almost tripled, from 8 million individuals in 2014 to 21.4 million in 2024, according to an HHS report.

While the ACA initially envisioned the marketplaces to be developed by states, it also provided states with the option to participate in the federally facilitated marketplace, HealthCare.gov. In 2014, 14 states and the District of Columbia chose to operate their own state-based marketplaces (SBMs). In 2024, there are 19 SBMs.

Trade groups representing health insurers and insurance agents are giving mixed reviews to a recently finalized rule that reinstated strict limits on short-term, limited duration insurance (STLDI) plans.

The rule, first proposed in July 2023, sought to revive Obama administration-era standards regarding STLDI plans — which are exempt from Affordable Care Act consumer protections such as barring insurers from denying coverage to people with preexisting conditions. Both the Obama and Biden administrations were concerned that consumers often mistake such plans for comprehensive coverage, potentially leaving them with nasty surprises when they need care.

A panel of experts will recommend in a formal report to Congress that ground ambulance-related balance bills should be settled using a rate-setting benchmark rather than arbitration, according to one member of the panel; in addition, the report will recommend that Medicare should begin to cover care that is delivered by ambulance personnel but does not result in a hospital transport. The report is under review by CMS, and is expected to kick off another battle on Capitol Hill over surprise billing policy.

Balance or surprise billing generally occurs when a person unwittingly receives care from an out-of-network provider and is then billed by that provider for whatever balance remains after insurance reimbursement. According to a member of the panel, the report will recommend that balance bills for ground ambulance care should be banned in virtually all circumstances, including emergency transports to a hospital, interfacility transports and care delivered by EMTs in the field that does not result in a transport to a hospital.

Data sharing and staff contacts are the keys to improving collaboration between Medicaid managed care organizations and public health departments, according to California officials and plan staffers. Leaders from managed care plans say that close collaboration improves outcomes for high-needs populations who struggle with one or more social barriers to health.

“When you're looking at claims data, we're obviously not going to see a claim for homelessness. We’re not going to be able to capture that. But when we take our data and bump it against data that's available to some of the public health jurisdictions, and we find out that some of our members are facing housing instability, then that also gives us the ability to understand that maybe their health outcomes are directly being affected by these social determinants of health,” said Nishtha Patel, manager of care transformation at Inland Empire Health Plan (IEHP), during a March 21 Manatt LLP webinar. “No matter what we do intervention-wise, if we're not addressing those, their health outcomes are not ever going to improve.”

Although NeueHealth Inc. — formerly known as Bright Health Group Inc. — still owes a substantial sum of money to health insurers and is struggling to stay afloat, its CEO received a $1.95 million cash bonus last year, according to a new regulatory filing.

“It really is just a mockery of good governance and fairness at this point,” remarks Ari Gottlieb, principal of A2 Strategies and a prominent critic of Bright and other startup "insurtech" firms.

NeueHealth did not respond to AIS Health’s questions about the basis for the bonus earned by G. Mike Mikan, who has served as the firm’s president and CEO since April 2020.

CMS on April 2 finalized the 2025 Notice of Benefit and Payment Parameters for Affordable Care Act exchange plans. The rule extended the special enrollment period for people with household incomes up to 150% of the federal poverty level to enroll in coverage any month during the year. CMS also attempted to prevent coverage gaps for people switching plans by allowing people to enroll on the first day of the month after they select a plan. In addition, the rule streamlined the process for enrollment on federally facilitated and state-based marketplaces. And beginning in 2027, it will allow states for the first time can add routine adult dental care as an essential health benefit. More than 21 million people enrolled in ACA exchange plans this year.

Recent reports from Wall Street analysts are shining a spotlight on challenges faced by UnitedHealth Group and Humana Inc., which are major players in the Medicare Advantage market. In particular, the authors cited increased utilization and potential lower reimbursement as reasons for pessimism, and they said they would be closely watching what insurers say during their upcoming first-quarter earnings calls.

Analysts’ concerns echo the sentiments that UnitedHealth and Humana executives expressed during their fourth-quarter earnings calls in January. However, it remains to be seen whether these are short-term trends or will continue for a longer period of time.