Colorado received permission from the Biden administration on June 23 to go ahead with the final element of its so-called “public option,” the Colorado Option. Experts tell AIS Health, a division of MMIT, that the program’s design is likely to deliver more premium savings than Washington state’s public option — and that the savings could make their way to the commercial market, especially if Individual Coverage Health Reimbursement Arrangements (ICHRAs) make further inroads in the Centennial State.

Experts tell AIS Health that the Colorado Option is innovative and could produce substantial premium savings, in large part because it has aggressive premium reduction goals. Starting in 2023, premiums for Colorado Option plans must be 5% lower than 2021 premiums, ultimately resulting in 15% cuts in premiums in 2025. After that, starting in "2026 and each year thereafter" premiums may increase "above the premium in the previous year by no more than medical inflation, relative to the previous year," per a summary of the law from the state legislature.

Grappling with rising premiums, a tough labor market and COVID-fueled health challenges, plan sponsors are focusing on key benefits as they prepare for the 2023 benefits cycle. That includes a concerted focus on behavioral health services and health equity, working to improve telehealth access and implementing strategies aimed at managing the total cost of care.

As adverse mental health conditions have increased sharply during the pandemic, behavioral health solutions, such as expanded access via network design and an expansion of virtual channels, figure to be prominent among purchasers’ needs, according to purchasing experts and benefits consultants interviewed by AIS Health.

The Supreme Court voted 6-3 to overturn the constitutional right to abortion established in Roe v. Wade. The ruling, released on Friday, will allow states to fully ban abortion without exceptions for rape, incest or the life of the mother. Experts predict that maternal mortality could increase by as much as 21% nationwide if abortion is banned nationally.

The Federal Trade Commission (FTC) ratcheted up regulatory pressure on PBMs once again, announcing that it will apply more scrutiny to PBMs' rebating practices, particularly regarding insulin. The move follows the agency's announcement earlier this month that it would investigate PBM business practices and consolidation. In an official policy statement, the agency wrote that “some have suggested that high rebates and fees to PBMs and other intermediaries may incentivize higher list prices for insulin” and that “rebate and fee agreements may incentivize PBMs and other intermediaries to steer patients to higher-cost drugs over less expensive alternatives.” Actions the agency said it would pursue include cracking down on exclusionary rebates and intensifying scrutiny of formulary design.

CMS recently approved Maine, Minnesota, New Mexico and Washington, D.C., to offer 12 months of postpartum coverage through Medicaid and Children’s Health Insurance Program (CHIP) extensions, adding an additional 15,000 enrollees annually with extended coverage from 60 days to 12 months after pregnancy. In total, nearly 253,000 people in 14 states and D.C. have gained such access as a result of the American Rescue Plan Act (ARPA).

Starting on April 1, states were able to apply “to extend Medicaid postpartum coverage to 12 months via a state plan amendment,” according to the Kaiser Family Foundation. So far, Connecticut, Indiana, Kansas, Maryland, Massachusetts, North Carolina, Pennsylvania, Washington and West Virginia have also submitted the extension proposals.

AHIP’s annual conference — AHIP 2022, convened in Las Vegas — was the first in-person gathering of the health insurance trade group since COVID-19 arrived in the United States — so the health care professionals who gathered there had even more than usual to discuss. AHIP 2022 featured dozens of panels on a variety of subjects, but two themes stuck out: social determinants of health (SDOH) and the digital transformation wrought by interoperability and transparency mandates.

SDOH are the factors outside the health care system and clinical care that impact patient health — a group of social ills like racism, hunger and housing insecurity. Those needs are usually more pronounced in disadvantaged groups with limited access to health care. Presenters from health plans and other areas of the health care sector discussed how strategies like data analytics, community health workers and modifications to benefit design can improve health outcomes related to SDOH. Some 14 panels addressed issues like social health, equity and hunger directly, and many other panelists made mention of SDOH challenges during their presentations or answered audience questions on the subject.

During its investor update on June 17, Centene Corp. announced it had increased its adjusted diluted full-year earnings per share (EPS) guidance to between $5.55 and $5.70, up from its April range of between $5.40 and $5.55. The health insurance company also raised its projected annual premium and service revenues by $2 billion to between $134.3 billion and $136.3 billion.

Centene’s executives attributed much of the increase to its better-than-expected performance, particularly in the health insurance exchange market, as well as the delay in the restart of Medicaid eligibility redeterminations.

Amid what the Centers for Disease Control and Prevention (CDC) is calling an “epidemic” of sexually transmitted infections (STI), the California Department of Insurance issued a mandate to a portion of health insurers operating in the state that would ban medically unnecessary limits on test screenings.

On June 1, Insurance Commissioner Ricardo Lara announced that his office would crack down on insurers that are “arbitrarily refusing to cover necessary treatments,” according to a press release. The federal Affordable Care Act (ACA) forbids health insurers from limiting STI screenings for people at elevated risk of infection and does California state law, giving Lara’s department wide latitude for enforcement.

During the pandemic, all 50 states and Washington, D.C., issued licensure waivers that allowed out-of-state clinicians to perform telehealth with patients across state lines. By analyzing telehealth usage by Medicare beneficiaries from 2017 to 2020, researchers found that out-of-state telehealth made up only a small percentage of all outpatient visits during the first year of the pandemic, though the percentage varied by state, according to a recent study published in Health Affairs.

The number of out-of-state telehealth services jumped from 17,286 in the first quarter to 171,754 in the second quarter of 2020, and then slightly declined. Before 2020, less than 1% of out-of-state new patient visits occurred via telehealth nationwide, while in 2020, the number jumped to 6%.

The Supreme Court ruled that HHS incorrectly altered the 340B drug program, with Justice Brett Kavanaugh finding that “absent a survey of hospitals’ acquisition costs, HHS may not vary the reimbursement rates only for 340B hospitals; HHS’ 2018 and 2019 reimbursement rates for 340B hospitals were therefore unlawful.” Kavanaugh’s opinion found in favor of the American Hospital Association, which brought a suit against HHS over the changes. “When the original [changes] went into effect in 2018, CMS cut Medicare 340B reimbursements by ~30% for most outpatient drugs, leading to ~$1.6B in savings for the first year,” wrote Citi analyst Jason Cassorla in a note to investors. HHS may have to make retroactive payments to hospitals to make up for the savings, Cassorla noted.

Scrutiny of health care sharing ministries (HCSMs) is growing, with Colorado becoming the second state to require the entities to submit health care financial data to insurance departments amid stepped-up scrutiny from regulators nationwide. Meanwhile, a Florida health system filed a lawsuit challenging the common practice among HCSMs of pushing members to conceal their sharing ministry enrollment when dealing with providers’ billing departments, which Orlando Health contends is an effort to “illegitimately secure the reduced ‘charity rate.’”

HCSM supporters contend that the religious organization-affiliated ministries provide a less expensive alternative to health insurance for members who agree to comply with faith-based lifestyle restrictions and pledge to “share” medical costs among members. But critics say the programs provide no guarantees of coverage and are exempt from much insurance oversight, while still being marketed in many cases by brokers with terminology such as provider networks and benefit design names that mimic traditional insurance.