Health Plan Weekly

What’s in a Name? Insurer Rebrands Reflect Diversification Push

Anthem, Inc. said recently that it will rename itself “Elevance” in a bid to be seen a diversified enterprise, known as much for its technology and business services branches as its traditional health insurance business. Anthem isn’t alone in its broad ambitions. The largest health insurance firms have all diversified their businesses, moves that are likely responses to the tight regulation and limited growth opportunities in health insurance for national-scale firms — and the encroachment of tech and investment firms into the health care sector.

The name Elevance, a combination of “elevate” and “advance,” isn’t official yet. Shareholders will vote on whether to adopt it during the firm’s May 18 investor meeting.

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CalOptima Aims for Real-Time Payments, Prior Auth Approvals

CalOptima, a Medi-Cal plan in Southern California, launched a five-year blueprint to cut through delays in care approvals and payments, as it seeks to deliver near-immediate claims processing and to put an end to prior authorization-related lags.

On March 21, CalOptima announced a $100 million investment in technology upgrades, which the Medicaid plan seeks to use to reduce barriers to care and to bridge divides — primarily centered on data-sharing — between the plan, providers and community partners.

The payer, which serves nearly 900,000 members in Orange County, also wants to get money into the hands of providers faster, with plans for an innovative “real-time claims processing” system.

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New Centene CEO London Will Bring Tech, Innovation Chops to Her Role

Centene Corp. on March 22 named Sarah London as its next CEO, effective immediately. London, who currently serves as the firm’s vice chairman, will fill the role held by Michael Neidorff for decades, though she has been part of a group of top executives who have handled day-to-day management of Centene since Neidorff took medical leave in late February.

In her previous management role, London was responsible for a “portfolio of companies independent of Centene’s health plans, designing differentiated platform capabilities, and delivering industry-leading products and services to third-party customers,” per a March 22 press release. Before coming to Centene, she worked for UnitedHealth Group’s venture capital arm, Optum Ventures, and its data analytics division.

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Millions Will Lose Medicaid Coverage After PHE Ends; Only Half of States Have Plans in Place

More than 14 million Medicaid enrollees could lose their coverage within six months when the COVID-19 public health emergency (PHE) ends, a Commonwealth Fund report projected. Meanwhile, Kaiser Family Foundation’s 50-state survey found that many states have not made key decisions on how to promote continuity of coverage. While the PHE is set to expire on April 16, HHS has said it would give at least 60 days’ notice before ending it, suggesting another extension is coming.

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News Briefs: 14.5M Enroll in Exchange Plans for 2022

The Affordable Care Act (ACA) exchanges have set new records for enrollment, with 14.5 million people enrolling or automatically reenrolling in health insurance during the 2022 open enrollment period, per CMS. New enrollments increased by 2.5 million, or 21%, compared to 2021. Due in part to the enhanced premium subsidies made available as part of the American Rescue Plan Act, the number of enrollees receiving advance premium tax credits (APTC) increased by 2.8 million compared to 2021. According to CMS, the average monthly 2022 premium for HealthCare.gov enrollees was $111. If consumers had not received the additional tax credits, the average monthly premium after APTC for HealthCare.gov consumers would have been 53% higher, or $170, per a press release issued on the ACA’s 12th anniversary. The enhanced APTCs are set to expire at the end of the 2022 plan year, though Congress has considered proposals to make them permanent.

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As Insurers Bet Big on Government Business, Challenges Remain

For the country’s major health insurers, an increasing amount of revenue and growth comes from business lines that serve government programs. Industry experts tell AIS Health that they don’t envision this changing anytime soon, but they do see ongoing business risks that will keep insurers on their toes.

“The aging of the U.S. population has had a positive impact on the senior products segment and has led to consistent growth in the segment’s revenues and earnings for health insurers, a trend that is expected to continue in 2022 and beyond,” noted a recent report from the insurance-focused credit rating firm A.M. Best. Medicare Advantage premiums reached $292.9 billion in 2020 — about 13.8% higher than 2019 and more than double that of 2012.

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Sutter Health Wins Antitrust Case Amid Stronger Enforcement

Sutter Health, the nonprofit hospital system that dominates the Northern California market, recently won a class action lawsuit brought by individuals and small-group plan sponsors who accused the hospital system of anticompetitive practices, including price gouging. Experts tell AIS Health that the trial shows the difficulty of limiting hospitals’ price-setting power when they consolidate, and that robust antitrust enforcement — the kind that ended a proposed hospital system merger in Rhode Island — is critical to keep prices down.

In the lawsuit, according to a website maintained by the plaintiffs’ council, “plaintiffs claim that Sutter forced upon health plans certain pricing and contractual terms, and those practices and terms violated state and federal antitrust and unfair competition laws. Plaintiffs claim this caused the health plans to pay more than they otherwise would for Sutter’s hospital services, and that this resulted in higher insurance premiums for class members whether or not they used Sutter hospitals.”

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What Would Be the Impact of Capping Private Plan Rates?

About half of non-maternity inpatient hospital admissions among large-group employer-sponsored plans were paid above 150% of Medicare rates, according to a recent analysis by Kaiser Family Foundation. To address high health care costs, some states have considered capping prices paid by private insurers at a multiple of Medicare rates. By analyzing in-network payment rates for inpatient hospital admissions, the study found that a cap set at 150% of Medicare rates could affect 36% of in-network spending in the large group market, while a cap at 300% could affect 13%. The study concluded that capping prices paid by employer-sponsored plans could be disruptive but could also make health care more affordable — “tradeoffs that warrant careful attention.”

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Biden Admin Officials Defend Standardized Plan Requirements

Although health insurers may not approve of all the recently proposed policies for the Affordable Care Act exchanges — in particular, the reintroduction of standardized plans — the Biden administration is sticking to its guns.

That was one of the main takeaways from a discussion during AHIP’s 2022 National Conference on Health Policy and Government Programs, which took place virtually from March 14 through 17. During a March 15 session, Ellen Montz, Ph.D., who is the deputy administrator and director of CMS’s Center for Consumer Information and Insurance Oversight, highlighted three parts of the 2023 Notice of Benefit and Payment Parameters (NBPP) that she said will reinforce CMS’s goal of making the exchanges more consumer friendly.

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News Briefs: New Interoperability Rule May Be on Horizon

Biden administration officials during the annual Healthcare Information and Management Systems Society (HIMSS) Conference said CMS intends to revamp its interoperability regulations. CMS Administrator Chiquita Brooks-LaSure said the Interoperability and Patient Access final rule issued in 2020 “did not quite hit the mark” because it didn’t require standardized application programming interfaces (APIs), FierceHealthcare reported. “Our interoperability rule wasn’t interoperable enough, and it led to many open questions about how data should be exchanged,” she added.

New research from the Kaiser Family Foundation (KFF) indicates that 36% of outpatient mental health and substance use disorder visits were delivered via telehealth in the six months ending in August 2021. Those visits spiked because of flexibilities and social distancing requirements implemented during the peak of the COVID-19 pandemic, KFF concluded.

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