Health Plan Weekly

News Briefs: Centene Will Sell Off Two PBM Assets

As part of its PBM restructuring efforts, Centene Corp. will sell two pharmacy benefits subsidiaries, Magellan Rx and PANTHERx, for approximately $2.8 billion in separate deals. Magellan Rx will be sold to Blue Cross and Blue Shield affiliate-owned PBM Prime Therapeutics for $1.35 billion, while specialty pharmacy PANTHERx will be sold to a group of private equity firms that includes The Vistria Group, General Atlantic and Nautic Partners for $1.45 billion. Both prices are preliminary and the deals must undergo antitrust review. The PANTHERx sale “is expected to close in the next two to four months,” according to a Centene press release, while Magellan Rx “is expected to close in the fourth quarter of 2022.” Centene executives have sought to sell the firm’s PBM assets for some time; new CEO Sarah London said in February that the firm planned to “reduce our three PBM platforms down to one and to focus...[on] clinical member and provider engagement.” After the deals, Centene will retain PBM Envolve Health, presumably to fulfill those functions. Meanwhile, Centene has spent millions to settle claims by state Medicaid programs that it overcharged them for prescription drugs.

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Court Will Rule Soon on ACA’s Preventive Coverage Mandate

Although the Affordable Care Act has now survived multiple legal challenges heard by the Supreme Court, the 12-year-old law does not appear to be home free yet. A case currently pending before a Texas district court — which could make it up to the highest court in the land — threatens to dismantle the ACA’s mandate that group and individual health plans must fully cover preventive services such as birth control and vaccines.

If the lawsuit is successful in striking down or weakening one of the ACA’s more popular provisions, it would also raise the question of whether private health plans would stop covering certain preventive services with zero cost sharing. According to industry experts, the answer isn’t so simple.

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Poor Mental Health Care Access Increases Systemic Costs

Health insurers have long struggled to administer behavioral health benefits, which won’t get easier any time soon: Demand for mental health services is high due to the opioid crisis and the mental health strains of the COVID-19 pandemic. Experts from clinical, financial and policy backgrounds say that coordinating behavioral health care with traditional medical benefits — and bringing behavioral health care providers into insurer networks — are both essential to managing costs and ensuring access to care.

Despite decades of policymaking that has attempted to streamline access to mental health care benefits, most notably through mental health parity, mental health care remains expensive and hard to access. (Several federal laws mandate mental health care parity: Health plans are not allowed to impose benefit limitations on mental health care that are more severe than limits placed on medical and surgical benefits.) What’s more, mental health care providers are usually siloed from other clinicians on a patient’s care team, which tends to exacerbate medical conditions and increase costs.

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Centene CEO London Addresses Issues With Medi-Cal Rx Launch

Sarah London, Centene Corp.’s new CEO, acknowledged during the insurer’s April 26 first-quarter earnings call that “there were challenges out of the gate” when the company’s Magellan Health unit took over California’s Medi-Cal Rx program in January. But, she added, “I think the team recovered incredibly well.”

London’s comments came after the California Department of Health Care Services (DHCS) said it is investigating Centene’s PBM practices following a California Healthline article earlier this month that detailed numerous issues with the launch. A DHCS spokesperson confirmed the investigation via email to AIS Health, a division of MMIT, but would not elaborate on details.

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Favorable Pharmacy Results Power Humana’s Solid Earnings

Humana Inc.’s financial performance in the first quarter of this year received mostly positive reviews from Wall Street. Revenue growth from the health insurer’s mail-order pharmacy business alongside modest care utilization allowed the firm’s executives to raise their end-of-year earnings guidance.

The firm took in $23.9 billion in total revenue in the quarter, an increase from $20.6 billion in the first quarter last year. Humana’s pretax income for the quarter was $1.2 billion, up from about $1 billion in the first quarter of 2021. The firm’s adjusted earnings per share also increased year-over-year, going up to $8.04 from $7.67.

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Key Financial Data for Leading Health Plans — Fourth Quarter 2021

Here’s how major U.S. health insurers performed financially in the fourth quarter of 2021. 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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News Briefs: CMS Finalizes Rule Mandating Standard ACA Exchange Plans

CMS on April 28 finalized the 2023 Notice of Benefit and Payment Parameters for Affordable Care Act exchange plans, cementing its proposal to require insurers to offer standardized plans on HealthCare.gov. In a provision opposed by the insurance industry at large, the Biden administration will require issuers offering Qualified Health Plans (QHPs) on the federal exchange to offer standardized plan options at every network type, at every metal level and throughout every service area where non-standardized options are offered, starting in 2023. Those plans also will be differentially displayed on HealthCare.gov “to help consumers make more informed choices about their coverage.” Another major provision included in the annual omnibus rule governing the ACA exchanges is the addition of new network adequacy standards that require QHPs to “ensure that certain classes of providers are available within required time and distance parameters.”

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Health Insurers Invest Billions in Affordable Housing Projects

Health care organizations across the country have poured billions into housing investments in recent years: In the past month, Kaiser Permanente and UnitedHealth Group both announced investments of over $100 million in affordable housing projects. Several health plans tell AIS Health that while they do expect a modest return on investment or reduction in costs from their efforts, they mostly see these expenditures as an act of altruism in line with their missions as stewards of public health.

According to the organizations themselves, total capital allocations to affordable housing investments by Kaiser Permanente, UnitedHealth Group and CVS Health Corp. amount to approximately $1.65 billion combined. A large portion of those funds are allocated to finance investments in affordable housing through the Low Income Housing Tax Credit (LIHTC), a financial instrument rolled out by the federal government in the late 1980s and early 1990s to encourage investment by the private sector in affordable housing.

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With Medicaid Cliff Looming, Payers Scramble to Limit Outflow

The end of the COVID-19 public health emergency (PHE) is likely to significantly downsize Medicaid enrollment around the nation, and managed care organizations (MCOs) must figure out how to keep enrollment steady and maintain continuity of coverage among members.

Since February 2020, fueled by a COVID-induced economic downturn and resulting federal policy changes, the Medicaid ranks have ballooned by 14.6 million members, a roughly 21% increase, nearing 86 million enrollees, according to the Kaiser Family Foundation (KFF).

As a condition of receiving enhanced federal funds during the PHE, states have been required to ensure continuous Medicaid and CHIP coverage for most enrollees by pausing eligibility redeterminations. A quartet of large for-profit plans that hold 40% Medicaid market penetration nationally — Anthem, Inc., Centene Corp., Molina Healthcare, Inc., and UnitedHealth Group — are all expecting “modest enrollment declines” once the PHE ends, according to a recent KFF issue brief.

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Anthem Raises Profit Forecast for 2022 After Promising 1Q

Anthem, Inc. reported strong first quarter financial results, prompting the insurer to raise its earnings guidance for the year. The company attributed the change largely to a lower-than-expected COVID-19 impact, as the Omicron variant and the long-term effect of delayed care during previous COVID peak periods was less severe than Anthem had originally projected in January.

For the first quarter, Anthem generated $8.25 in adjusted earnings per share (EPS), beating the Wall Street consensus of $7.82. The insurer increased its full-year EPS guidance to greater than $28.40, up from its previous EPS estimate of $28.25.

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