HHS is currently projecting that 17.4% of Medicaid and Children’s Health Insurance Program (CHIP) enrollees — or about 15 million people — will move out of those programs when the COVID-19 public health emergency (PHE) ends. States have been barred from conducting eligibility redeterminations for Medicaid and CHIP during the PHE, as a condition of receiving enhanced federal funding, but those eligibility checks will resume whenever the PHE ends. Of those expected to lose Medicaid/CHIP coverage, almost one third are expected to qualify for premium tax credits to help defray the cost of Affordable Care Act marketplace plans, and among those people, more than 60% can access a zero-premium plan.

In the latest round of rulemaking on the No Surprises Act (NSA), the 2020 law that bans most balance medical billing, providers won concessions from the Biden administration regarding the calculus arbitrators must use to decide billing disputes. One expert tells AIS Health, a division of MMIT, that the new regulation, which takes recent pro-provider court decisions into account, is likely to reduce the amount of cost savings the NSA generates for payers.

The NSA bans the practice of balance, or “surprise” billing. Surprise bills typically involved pricey emergency care, and frequently saddled patients with crippling amounts of medical debt — often tens of thousands of dollars. Patients were charged the cost of care delivered by providers outside their insurance network when the plan and provider couldn’t agree on a fair price for treatment. The law compels health plans and providers to attempt to work out the balance billing disputes between themselves.

Benefytt Technologies, Inc., a health insurance brokerage controlled by private equity firm Madison Dearborn Partners, LLC, will refund its customers $100 million after the Federal Trade Commission (FTC) found Benefytt knowingly defrauded consumers shopping for Affordable Care Act marketplace plans. Health care experts tell AIS Health, a division of MMIT, that similar schemes involving deceptive and exploitative sales tactics are now a common problem.

The FTC said in a press release that Benefytt misrepresented bundles of short-term, limited duration (STLD) plans and supplemental health insurance products as comprehensive plans that meet the ACA’s standard benefits requirements. Benefytt’s marketing practices were misleading, the FTC said, and involved “lying to consumers about their sham health insurance plans and using deceptive lead generation websites to lure them in.” According to the FTC complaint, Benefytt also “illegally charged people exorbitant junk fees for unwanted add-on products without their permission.”

Fresh off of touting its organic Medicaid growth during its second-quarter 2022 earnings call, Humana Inc. recently unveiled an acquisition that will help the insurer grow its Medicaid business inorganically as well. Industry analysts say it’s a sound strategic move, but they add that Humana’s growing Medicaid assets aren’t likely to eclipse its focus on Medicare Advantage anytime soon.

The Louisville, Ky.-based company said on Aug. 12 that it will purchase substantially all the assets of Inclusa, which provides long-term services and supports to about 16,600 older adults and adults with disabilities through Wisconsin’s Family Care program. Humana already has a Medicaid presence in Wisconsin, having purchased the insurer iCare there in 2020.

HHS on Aug. 16 approved the extension of Medicaid and Children’s Health Insurnace Program (CHIP) coverage for 12 months after pregnancy in Hawaii, Maryland and Ohio. Combined with previously approved state extensions made possible under the American Rescue Plan Act, 21 states and the District of Columbia now offer a full year of postpartum Medicaid/CHIP coverage. Separately, CMS issued a notice of proposed rulemaking on Aug. 18 that aims to require mandatory, annual state reporting of three quality measure sets: the Core Set of Children’s Health Care Quality Measures for Medicaid and CHIP; the behavioral health measures on the Core Set of Adult Health Care Quality Measures for Medicaid; and the Core Sets of Health Home Quality Measures for Medicaid. The quality measures “will allow us not only to identify health disparities but also to implement interventions based on the very data that make those disparities clear,” said CMS Administrator Chiquita Brooks-LaSure.

The four publicly traded startup health insurers — Oscar Health, Inc., Bright Health Group, Inc., Clover Health Investments Corp. and Alignment Healthcare, Inc. — continued to post losses in the second quarter of 2022, but two out of the four lost less money than they did in the prior-year period. Beyond their finances, however, some of the companies are making changes to their business strategies in a bid to set a stronger course for the future.

Medicare Advantage-focused Clover Health, for instance, revealed that CEO Vivek Garipalli will be replaced by Andrew Toy, the company’s current president, starting on Jan. 1, 2023. In an Aug. 8 news release, Clover said the move “is the culmination of a succession plan we’ve had in place since Andrew joined Clover as CTO and led the development of Clover Assistant,” referring to the company’s proprietary clinical decision-making tool.

With the Inflation Reduction Act (IRA) now signed into law by President Joe Biden, analysts are predicting that some — but not all — of its health care provisions will be a boon for the managed care industry.

In a new report, insurance industry-focused credit rating firm A.M. Best noted that insurers estimated 2 million to 3 million people would drop their Affordable Care Act exchange policies if enhanced subsidies — which were ushered in as part of coronavirus relief legislation — expired in 2023. The IRA prevented that outcome, however, by extending subsidies for three years. The increased financial aid for enrollees both eliminated the subsidy cliff for higher earning individuals and provided access to zero-premium plans for people on the lower end of the income scale, helping drive enrollment to a record high in 2022.

Six payers have signed a memorandum of understanding (MOU) to become the first members of the California Advanced Primary Care Initiative, a new program intended to expand the use of value-based primary care in the state.

The initiative is in its early stages, and plenty of work needs to be done to finalize the plans, according to participants in the program who spoke with AIS Health, a division of MMIT. But the agreement calls for the companies to work together to increase their investment in primary care, contract with providers in value-based arrangements, adopt measures that will be publicly released, and hold practices accountable for meeting benchmarks and reward them for strong performance.

UnitedHealthcare is rebranding a type of employer-sponsored plans previously known as Bind, promising “a new approach to health benefits that removes deductibles and provides clear upfront pricing information to people in advance of treatment.” Now known as Surest, the products are available to self-funded employer plans nationwide and fully insured customers with 51 or more employees in 11 states. The insurer aims to add up to five additional states where self-funded customers can access Surest plans by the end of the year, and notes that more than 150 employers are already using Surest.

Now that the Inflation Reduction Act (IRA) has surmounted the key hurdle of passing the Senate — and is expected to soon pass the House of Representatives as well — the Affordable Care Act exchange market is set for another late-season policy shift that could alter next year’s premium rates. However, experts tell AIS Health that the effect on carriers’ overall premium calculations won’t be as significant as the impact on consumers’ out-of-pocket insurance expenses.