Health Plan Weekly

The rise of artificial intelligence (AI) and machine learning within health care — from clinical decision-making tools to population health stratification efforts — is loaded with potential, but experts warn that embedded data flaws can heighten health disparities and stanch the promise of an equitable playing field for consumers.

As AI-fueled devices and algorithms gain in popularity and practical use, regulators are increasingly taking notice. Multiple agencies, including HHS, the FDA and the Office of the National Coordinator for Health Information Technology (ONC) are quickly adopting regulatory frameworks to address health equity within big data.

Medicare Advantage coverage denials by Aetna, the health insurance division of CVS Health Corp., totaled $416 million between 2014 and 2019, according to a new report published in the journal Health Affairs by researchers from CVS, the University of Pennsylvania and Harvard University. During that period, 1.4% of services, which would have added up to 0.68% of total spending, were denied.

Here’s how major health insurers’ stock performed in December 2021.

With the annual open enrollment period for Affordable Care Act marketplace plans about to close, HHS reports that more than 14.2 million people have signed up for plans since the OEP started on Nov. 1, 2021. That figure includes 10 million people selecting or being automatically enrolled in plans on HealthCare.gov through Jan. 12 and 4.2 million on the state-based marketplaces as of Jan. 8. The federal OEP for 2022 plans ends Jan. 15 — making it a month longer than signup periods during the Trump administration. HHS also released a report that detailed how the expansion of premium subsidies under the American Rescue Plan Act has led more customers to choose plans with lower deductibles.

The federal government may be spurred to action on several fronts, from seeking to maintain elevated health insurance exchange subsidies to further extensions of the COVID-19 public health emergency (PHE), which would have beneficial short- and long-term financial implications for health insurers in 2022.

Those are just two areas that, pending federal action, could deliver significant wins for health plans this year, according to a panel of experts from Avalere Health during the Jan. 6 webinar, Avalere 2022 Healthcare Industry Outlook: Advance Your Opportunity.

For health insurers that operate in the Affordable Care Act exchanges, 2022 is shaping up to be a relatively stable, profitable year with few regulatory surprises, health policy experts tell AIS Health. Still, there will be some regulatory uncertainty that plans must grapple with as well as a newly proposed rule effective in 2023 that imposes tighter controls on benefits and network design than even the Obama administration attempted.

That regulation is the Notice of Benefit and Payment Parameters (NBPP) 2023 Proposed Rule, released by the Biden administration on Dec. 28. Perhaps the biggest change included in the annual omnibus exchange rule — the move to require standardized ACA marketplace plans — was already known to the industry but still promises to make a significant impact.

UnitedHealthcare — which last summer drew the ire of provider groups when it announced plans to roll out more restrictive coverage policies for emergency care — is now making it clear that it has no plans to implement such a change.

In a letter sent Dec. 30 to the American Hospital Association (AHA), the insurer sought to reassure the trade group that “consistent with our prior communication in June 2021, UnitedHealthcare is not implementing any new policy regarding coverage criteria for emergency level care on January 1, 2022.”

For the Medicare Advantage industry, change wasn’t a major outcome of the Biden administration’s first year in office. But for 2022, MA organizations face a host of unknowns — such as potential risk adjustment and star ratings changes that could impact plan revenue — and challenges that include staying competitive in an increasingly rich benefits landscape. For AIS Health’s annual roundup of perspectives on the year ahead, industry experts weigh in on how doing business in 2022 might differ from previous years.

AIS Health: What do you view as some of the biggest challenges or uncertainties facing MAOs in 2022?

Although the pandemic-driven economic crisis led to a massive increase in unemployment, loss of commercial health coverage has not been as great as predicted, and enrollment has rebounded over the past year. Meanwhile, the launch of a special enrollment period for the federal health insurance exchange and the temporarily expanded premium subsidies in the individual market led to membership growth in managed Medicaid and exchange plans, according to AIS’s Directory of Health Plans. Among the top five Blue Cross Blue Shield plans, all but BCBS of Illinois saw enrollment increases compared with December 2020.

Humana Inc. said it is decreasing its net membership growth estimate for its individual Medicare Advantage products, sending the insurer’s stock tumbling. In a Jan. 6 filing with the Securities and Exchange Commission, Humana said it now expects to add 150,000 to 200,000 members to its individual MA plans in 2022, down from a range of 325,000 to 375,000 members. The company said its revised estimate “is primarily attributable to higher than anticipated terminations during the AEP [annual election period], combined with the expectation of higher than originally projected terminations for the remainder of 2022.”