Health Plan Weekly

UnitedHealth Will Fight DOJ Move to Block Change Healthcare Deal

The U.S. Dept. of Justice (DOJ) on Feb. 24 sued to block UnitedHealth Group’s proposed $13 billion acquisition of Change Healthcare Inc., arguing that the deal would stymie competition not only in commercial health insurance markets but also the market for technology that allows insurers to process claims and reduce health care costs.

UnitedHealth has already indicated that it will challenge the legal action taken by the DOJ and attorneys general from Minnesota and New York — setting the stage for the first legal fight to save a major deal involving a health insurer since the failed Anthem/Cigna and Humana/Aetna tie-ups.

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© 2024 MMIT

Potential Policy Changes Loom as Ground Ambulance Costs Rise

The cost of emergency ground ambulance trips has risen considerably in recent years, according to recent research, and experts tell AIS Health that payers have limited power to push back. Nevertheless, the issue has caught the eye of policymakers amid a larger push to increase health care cost transparency and eliminate surprise medical billing, signaling that change may be on the horizon.

From 2017 to 2020, average charges and allowed amounts for both basic life support (BLS) and advanced life support (ALS) emergency ground ambulance transport increased, according to a new white paper from the nonprofit claims-data research organization FAIR Health.

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© 2024 MMIT

Maine Will Combine Individual, Small-Group Insurance Markets

Maine will merge its small-group and individual exchange health insurance markets starting in plan year 2023. Experts tell AIS Health, a division of MMIT, that the move is a bid to stabilize small-group premiums, which have gone up in recent years.

According to a Feb. 15 press release from the state’s Bureau of Insurance, “the merger, which will pool the risks of the two markets and roll the Small Group coverage into the Maine Guaranteed Access Reinsurance Association (MGARA), is projected to reverse the trend of steady premium increases and declining enrollments in Maine’s Small Group Market, while supporting continued stable pricing in the Individual Market.”

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© 2024 MMIT

AHIP Will Prioritize Telemedicine, Health Equity Post-Pandemic

On Feb. 23, health insurer trade group AHIP hosted a virtual State of the Industry presentation, reviewing progress made in 2021 and important issues for the health insurance industry as it looks to a world beyond the COVID-19 pandemic.

Matt Eyles, president and CEO of AHIP, opened the conversation with a look at the organization’s 2021 initiatives and hopes for 2022. Eyles stressed the importance of the No Surprises Act, which aims to protect consumers from surprise medical bills. The legislation went into effect on Jan. 1, but it is currently the subject of a number of lawsuits filed by organizations including the American Hospital Association and American Medical Association. “AHIP continues to fight and protect the law,” Eyles said during the presentation.

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© 2024 MMIT

Judge Backs Texas Providers in Surprise Billing Suit

Texas providers have notched their first win in the legal battle over the No Surprises Act (NSA), the federal law that bans surprise billing — though the Biden administration can appeal the decision. In a lawsuit brought by the Texas Medical Association (TMA), Judge Jeremy Kernodle of the federal Eastern District of Texas on Wednesday struck down regulations issued by the Biden administration that providers allege favor insurers at their expense in balance-billing scenarios.

The NSA requires payers and providers to work out the balance billing disputes between themselves. If that fails, an HHS-approved independent arbitrator will decide between two payment amounts: one submitted by the provider and one by the insurer. Arbitrators then pick between one of the two proffered amounts using criteria designed by the Biden administration.

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© 2024 MMIT

Small-Group Insurance Market Remains Stable Under ACA

About half of small-firm employees worked for an establishment that offered health insurance from 2013 to 2020, and the small-group market has remained relatively stable since the implementation of the Affordable Care Act, according to a recent Urban Institute study. Employee coverage rates at small firms — which have fewer than 50 employees — dropped 2 percentage points, from 57.1% in 2013 to 55.1% in 2020. Meanwhile, employees’ contributions to single and family coverage in the small-group market rose during the study period by 2.3 and 6.0 percentage points, respectively. Though many people anticipated that small firms would transition to self-insurance to avoid ACA’s regulations, small firms were much less likely than larger firms to offer a self-insured plan between 2013 and 2020.

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© 2024 MMIT

News Briefs: CMS Unveils Change to Direct Contracting Model

CMS on Feb. 24 released plans to revamp the Global and Professional Direct Contracting model, which allows participants to share risk and receive capitated payments for serving fee-for-service Medicare beneficiaries. Democrats like Washington Rep. Pramila Jayapal and Massachusetts Sen. Elizabeth Warren have criticized the model for transforming “the care of a traditional Medicare beneficiary to care typically seen in a private Medicare Advantage (MA) plan despite the fact that the patient chose not to enroll in an MA plan,” in Jayapal’s words. However, in good news for insurers like Clover Health, which are counting heavily on direct contracting revenue, CMS appears to still allow health insurers to apply for the renamed ACO Realizing Equity, Access, and Community Health (REACH) Model. As part of the overhaul, CMS promised greater “participant vetting, monitoring and transparency,” more promotion of provider leadership and governance, and a larger focus on health equity, among other changes.

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© 2024 MMIT

Big Insurers Change Little About Coverage of At-Home COVID Tests

A little more than a month after the Biden administration directed private health plans to fully cover at-home COVID-19 tests, insurers now have additional clarity from regulators about how to operationalize that mandate. Still, the country’s largest insurers do not appear to have significantly changed their approaches for covering at-home COVID tests since mid-January — with some still requiring members to submit claims for reimbursement rather than setting up more consumer-friendly direct-coverage pathways.

A Jan. 10 guidance document issued by the administration stated that by Jan. 15, all private group and individual health plans had to start covering up to eight over-the-counter, at-home COVID-19 tests per month for each covered member without imposing cost sharing or utilization management requirements. Previously, pandemic relief legislation required insurers to cover only diagnostic tests that were processed by a lab and ordered by a health care professional.

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© 2024 MMIT

Will High Prices Follow Private Equity Investment in Primary Care?

Primary care practices are consolidating at a rapid pace: Independent physician practices are combining on their own, and growth-oriented, outside investors — such as private equity funds, health insurers and health systems — are taking stakes in practices or buying them outright. Experts tell AIS Health, a division of MMIT, that the impact of such deals will vary, but warn that consolidation and investment by private equity firms has raised prices across the board in other areas of health care.

According to a July 2021 report by investment bank Provident Healthcare Partners, 41 primary care transactions worth over $2 billion closed in 2020, a higher deal volume than any year since 2010. Meanwhile, 2019 set a record for capital invested, with $5.1 billion spread across 26 primary care deals. At the time, investors were on pace to shatter both records in 2021: 31 primary care deals worth $4.8 billion had been announced when the report was published. A February 2022 Provident report made note of several major transactions in the last quarter of 2021:

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If Direct Contracting Model Dies, MA Startups Could Suffer

Some Medicare Advantage insurers could take a hit if HHS decides to cancel an increasingly controversial care delivery model that allows participants to share risk and receive capitated payments for serving fee-for-service (FFS) Medicare beneficiaries.

The Global and Professional Direct Contracting (GPDC) model fully launched in April 2021, with 53 Direct Contracting Entities (DCEs) participating. Although most DCEs were provider-led organizations such as Iora Health, some MA insurers also threw their hats into the ring, including startup Clover Health; Humana Inc., under the CenterWell brand name; and Anthem, Inc., under the CareMore brand name.

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© 2024 MMIT