Health Plan Weekly

Limited Resources Thwart State Mental Health Parity Enforcement

While some state officials have had more success than others, most states struggle to enforce mental health parity requirements set by federal law, according to a new report from the Georgetown University Center for Health Insurance Reforms (CHIR) and the Robert Wood Johnson Foundation (RWJF). One of the report’s authors and a mental health patient advocate both say that states need more resources to enforce parity requirements.

State officials have the responsibility of enforcing federal statutes such as the Mental Health Parity and Addiction Equity Act (MHPAEA) in the individual and fully funded employer health plan markets. Many states also have their own parity statutes as well. However, as the report puts it, “federal and state regulators have found that enforcing the complex law is challenging. While insurers’ quantitative barriers to treatment such as cost-sharing or visit limits can be relatively straightforward for regulators to assess, certain ‘non-quantitative’ treatment limits [NQTLs], such as the use of prior authorization, provider reimbursement, and formulary design are much more difficult.”

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Studies Put Finer Point on Differences Between Medicare Advantage, Traditional Medicare

Among Medicare beneficiaries with complex care needs, those enrolled in Medicare Advantage had lower rates of hospital stays, emergency department (ED) visits and 30-day readmissions than those enrolled in traditional Medicare, according to a new JAMA study.

Based on an analysis of more than 1.8 million Medicare beneficiaries, the study found that MA beneficiaries enrolled in health maintenance organization plans and preferred provider organization plans both saw lower rates of hospitalizations and ED visits than traditional Medicare beneficiaries across all groups, but the difference was larger for those enrolled in HMO plans.

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News Briefs: Centene Expands ACA Marketplace Footprint for 2023

Centene Corp. will expand its ACA marketplace footprint by more than 60 counties across 12 states where it already has a presence in 2023, as well as enter Alabama for the first time, the company said on Oct. 17. The firm also changed the name of its ACA exchange branded plans from Ambetter to Ambetter Health, “reflecting its commitment to putting better health at the forefront of its mission.” In addition, Centene will offer a product in nine new states called Ambetter Health Virtual Access, which “supports affordable and convenient access to licensed virtual primary care providers as well as access to specialists, mental health providers, and other support services.”

Bright Health Group, Inc. — the startup health insurer that recently revealed it was pulling out of the Affordable Care Act exchanges and all but two Medicare Advantage markets — closed a $175 million investment round on Oct. 17, according to a Securities and Exchange Commission filing. In the transaction, the firm sold 175,000 shares of Series B Convertible Perpetual Preferred Stock. Bright’s recently announced market exits, meanwhile, are “expected to release excess regulated capital of approximately $250 million upon settlement of all medical liabilities and approval from state regulators,” the company has said.

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UnitedHealth 3Q Earnings Call: Execs Talk Redeterminations, Acquisitions, Inflation

During UnitedHealth Group’s recent conference call to discuss third-quarter 2022 financial results, executives discussed a variety of topics in addition to the company’s earnings — including broad-based trends like inflation and the looming return of Medicaid redeterminations, as well as UnitedHealth’s strategies for integrating a recent acquisition and furthering risk-based payment models.

Overall, equities analysts seemed satisfied with both UnitedHealth’s quarterly performance and its plans to overcome potential headwinds going forward.

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News Briefs: UnitedHealth 3Q Earnings Beat Wall Street Expectations

UnitedHealth Group on Oct. 14 reported adjusted earnings per share of $5.79, beating the Wall Street consensus estimate of $5.43. Driving that result was UnitedHealth’s medical loss ratio of 81.6%, which was meaningfully lower than the consensus estimate of 82.4%. The company's “solid performance was largely broad-based with both UHC [insurance division UnitedHealthcare] and Optum beating our segment earning estimates by 13.2% and 1.7%, respectively,” SVB Securities analyst Whit Mayo advised investors.

The Biden administration on Oct. 11 released its final rule fixing the so-called “family glitch” in the Affordable Care Act. A 2021 Kaiser Family Foundation analysis estimated that 5.1 million people fall into the family glitch, which “occurs when a worker receives an offer of affordable employer coverage for themselves but not for their dependents, making them ineligible for financial assistance for marketplace coverage.” In a statement on the final rule, HHS Secretary Xavier Becerra said that the final rule “resolves a flaw in prior ACA regulations to bring more affordable coverage to about one million Americans. Our goal is simple: leave no one behind and give everyone the peace of mind that comes with health insurance.”

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Struggling With Costs, Employers Seek New Benefit Designs

Medical costs are going up and employer plan sponsors are feeling the pressure, according to several recent surveys of health benefit purchasers. Large-group purchasers are pursuing a variety of strategies, including direct contracting and new coverage models, to offset rising medical costs and the anticipated impact of inflation on medical trend, while small-group participation seems to have grown in recent years and could see even more adoption through new coverage models.

Most surveys of plan sponsors found that purchasers, particularly large purchasers, expect medical trend around 6% next year:

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Bright Health’s Exchange Exit Casts Doubt About Startup’s Future

Bright Health Group, Inc., a startup health insurer that has struggled to reach profitability, said on Oct. 11 that it will fully exit the Affordable Care Act exchanges next year and only sell Medicare Advantage products in Florida and California.

“I believe this is regulator driven,” says Ari Gottlieb, principal of the consulting firm A2 Strategy Group, who has been following the performance of newly public startup insurers such as Bright Health, Oscar Health, Inc. and Clover Health Investments Corp. Gottlieb points to the fact that 2023 rates have already been finalized for exchange plans, and Bright Health went back and forth with insurance regulators over rates in states like Florida — suggesting that, until recently, it planned to be in the individual/family plan market next year.

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Experts, Report Offer Ways to Supercharge Slow-to-Grow PACE Model

As the U.S. population ages and as payers and providers increasingly embrace home-based care — especially in light of the COVID-19 pandemic — a program that one expert calls the “best-kept secret in health care” seems poised to finally have its moment in the sun. However, there are a variety of barriers that need to be tackled in order for Programs of All-Inclusive Care for the Elderly to significantly grow, and recent compliance issues at the largest PACE participant raise questions about the involvement of private equity-owned, for-profit companies.

The PACE model employs comprehensive medical care and social supports to help frail, elderly Americans remain at home when they otherwise would require a nursing home level of care. Eligible enrollees — who never have to pay cost sharing — receive health care services at an adult day center, which is staffed with interdisciplinary care teams and also offers classes, games and other wraparound services.

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As E-Brokers Struggle, Elevance Extends Lifeline to GoHealth

Elevance Health, Inc. last month invested $35 million in GoHealth, an e-broker for Medicare Advantage plans that has struggled this year and seen its stock market value plummet. Michael Abrams, managing partner of Numerof & Associates, tells AIS Health that the investment was “equivalent to a life-saver” for GoHealth.

GoHealth received a total of $50 million, with the other $15 million coming from a company referred to as GH 22 Holdings, Inc. in an SEC filing. A GoHealth spokesperson writes in an email to AIS Health, a division of MMIT, that GH 22 is “a significant partner” of GoHealth.

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COVID Booster Campaign Could Prevent Thousands of Deaths, Save Billions in Medical Costs

With the updated bivalent COVID-19 boosters available, federal investment in vaccination campaigns could save thousands of people from hospitalizations and deaths and avert billions of dollars in medical costs, The Commonwealth Fund predicted.

The study projected three scenarios: a baseline scenario where vaccination rates remain at the average rate in August 2022 — about 28 doses per 100,000 people per day — from September 2022 to March 2023. In the first vaccination campaign scenario, COVID booster uptake by the end of 2022 reaches the same level as influenza vaccination coverage seen in 2020–2021, and then remains at the baseline rate until the end of March 2023. This could prevent more than 75,000 deaths and generate $44 billion in medical cost savings over the course of the next six months, compared with the baseline scenario.

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