ACA Exchanges

News Briefs: ACA Plan Signups Totaled 21M During 2024 Open Enrollment

More than 21 million people selected or were automatically reenrolled in health plans during the most recent Affordable Care Act open enrollment period (OEP). That’s according to one of four reports issued by HHS on March 22 marking the 10-year anniversary of the ACA. HHS also said that 5.1 million more people signed up for coverage during the 2024 OEP compared to the 2023 OEP, representing a 31% increase. Another report found that over 45 million people now have coverage thanks to the creation of the ACA marketplaces and Medicaid expansion -- “the highest total on record.”

The Oregon Health Authority (OHA) on March 14 began a review of UnitedHealth Group’s proposed acquisition of Amedisys Inc., a home health provider. Amedisys disclosed the OHA’s review in a March 19 Securities and Exchange Commission filing. UnitedHealth made a $3.26 billion unsolicited offer for Amedisys last June, shortly after Amedisys had agreed to merge with Option Care Health, Inc., a home infusion provider. Amedisys’s shareholders approved the UnitedHealth deal in September, but the transaction is subject to regulatory approval. In a preliminary analysis published this month, the OHA wrote “this transaction has the potential to reduce competition in Oregon’s market for home health and hospice services and other health care markets in the state.”

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Requiem for a CO-OP: ‘Common Ground’ Finds New Partner in CareSource

Since 2021, just three consumer operated and oriented plans (CO-OPs) have remained operational out of the original 23 nonprofit insurers created by the Affordable Care Act. Now, one of the three survivors — Common Ground Healthcare Cooperative (CGHC) — is poised to shed its CO-OP identity and combine forces with CareSource, a Medicaid-focused insurer based in Ohio.

In a Feb. 27 press release, CGHC said it was “financially healthy and on track to repay” all loans that it’s received from the federal government.

“Even so, it’s challenging as a nonprofit startup to support necessary investments in operations and diversification while keeping premiums affordable for our members,” CEO Cathy Mahaffey said.

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Actuaries Back Move to Undo 2018 Association Health Plan Rule

The American Academy of Actuaries has urged the Biden administration to follow through on its proposal to rescind a controversial 2018 rule that granted more regulatory leeway to association health plans (AHPs). Rescinding the 2018 AHP regulations will protect consumers and strengthen the actuarial health of the Affordable Care Act exchanges, according to Academy Senior Health Fellow Cori Uccello and a February public comment letter from the organization.

The comments by the professional association are in response to a December 2023 regulatory proposal that followed through on long-expected plans to rescind the 2018 rulemaking. Those regulations, put forward by the Trump administration, significantly loosened the requirements that apply to AHPs and their close cousins, multiple employer welfare arrangements (MEWAs). The 2018 rule was never implemented, however, because it was largely blocked by a summary judgment issued as a result of litigation by 11 states and the District of Columbia.

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AHIP Panelists: Medicaid Redetermination Glitches Shine Light on Clunky Processes

Nearly a year into the massive nationwide effort to reverify Medicaid eligibility after a pause in redeterminations during the COVID-19 pandemic, about 40% of renewals have yet to occur. With millions of people estimated to have lost coverage because of administrative or procedural reasons, states have an opportunity to work with managed care organizations and other health care providers to innovate and improve existing processes that aren’t working, according to panelists at a recent session of AHIP’s 2024 Medicare, Medicaid, Duals & Commercial Markets Forum, held March 12 to 14 in Baltimore.

“This is still very much in progress,” and “these next few months are going to be very important,” declared panelist Kate Honsberger, a director with NORC at the University of Chicago. States as of April 1, 2023, were allowed to begin disenrolling people from Medicaid who no longer qualify, but they have 12 months to complete eligibility redeterminations, which may have kicked off at different times depending on the state.

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Oscar, Clover, Alignment Make Progress Toward Profitability

The software-focused startup insurers known as “insurtechs” last year made tangible strides toward reaching profitability, according to their full-year earnings reports, backing up their executives’ statements that 2024 may see break-even results or better.

Financial institutions generally took a positive view toward Oscar Health Inc., Alignment Healthcare Inc. and Clover Health Investments Corp., but some analysts tempered their praise by pointing out holes in the firms’ growth and profitability strategies.

One former insurtech, the erstwhile Bright Health Group, Inc., exited the insurance business altogether, and now operates as a care delivery-focused business under the name NeueHealth.

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News Briefs: Biden’s State of the Union Touches on ACA, Drug Pricing Reform

President Joe Biden’s health care agenda figured prominently in his State of the Union address on March 7. Regarding the Inflation Reduction Act, the president said he wants to increase the number of drugs subject to Medicare price negotiations to 50 per year, up from 20 under current law. Biden also said he wants to expand the IRA’s $2,000 annual out-of-pocket cost cap for prescription drugs and $35 monthly copay cap for insulin to commercial plans, as they currently only apply to Medicare Part D. Additionally, the president vowed to defend the Affordable Care Act from repeal attempts and make the expanded subsidies that are set to expire after 2025 permanent.

The White House on March 5 unveiled a “strike force” aimed at cracking down on unfair and illegal pricing, focusing on sectors including prescription drugs and health care, food and grocery, housing, and financial services. Set to be chaired by the Dept. of Justice and Federal Trade Commission, the strike force “will strengthen interagency efforts to root out and stop illegal corporate behavior that hikes prices on American families through anti-competitive, unfair, deceptive, or fraudulent business practices,” the Biden administration said. The White House simultaneously announced that its Competition Council will soon unveil new actions aimed at slashing credit card late fees, combating high internet costs and supporting small farmers; previously, the council helped drive HHS actions such as cracking down on problematic Medicare Advantage marketing practices.

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Rethinking Reinsurance: Study Illuminates Tradeoffs of Popular Waivers

While reinsurance programs have become popular among states hoping to stabilize their individual insurance markets, a new study makes a compelling case that the premium reductions attributed to such programs may not be as helpful as they seem.

States can apply for and implement reinsurance programs via Section 1332 waivers, which allow them to waive certain Affordable Care Act rules in order to test marketplace innovations — provided they adhere to strict guardrails. Reinsurance works by subsidizing insurers’ highest-cost claims, allowing them to charge lower premiums overall.

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Panelists: CMS Prior Authorization Rule Should Help, But More Is Needed

The rule that CMS finalized last month regarding prior authorization (PA) should help streamline the increasingly scrutinized process and lead to faster decisions, according to panelists who spoke during a KFF webinar on Feb. 22. However, they noted that regulation did not apply to employer-sponsored plans or state-based exchange plans and did not address how PA decisions are made and the clinical criteria plans use in determining which procedures are subject to PA.

Troyen Brennan, M.D., former chief medical officer at CVS Health Corp. and Aetna, noted that the rule did not include prescription medications, which are often subject to PA — a process that draws the ire of providers who worry that delays could worsen patient outcomes. The CMS Interoperability and Prior Authorization Final Rule also required insurers to have a PA application programming interface (API), where providers can access information, although the regulation did not require them to disclose PA data on medications.

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Premium Rate Review: A Look at State Authority

Most states have authority to review premium rates for comprehensive, Affordable Care Act-compliant health plans in the individual and small group markets, while only a few have such authority in the large group market, according to an analysis published by the Georgetown University Center on Health Insurance Reforms. Additionally, the analysis found that while a “healthy minority of states” have the authority to question the rates that insurers negotiate with providers and suppliers, many struggle to actually do so.

The ACA, enacted in 2010, established the health insurance rate review program that requires the review and disclosure of “unreasonable” rate increases. As of August 2023, 43 states have authority to review and require changes to or disapprove proposed rates in the individual market, whereas only 26 states had such authority in 2010. Eight states — Arizona, California, Idaho, Indiana, Missouri, Montana, Texas and Wisconsin — have authority to require insurers to review proposed rates in the individual market, but they cannot require changes or disapprove the rates. Thirty-eight states currently have prior authority over rates in the small group market.

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Many States Can Conduct Robust Rate Reviews; Why Aren’t More Doing So?

Although a “healthy minority” of states have the authority to conduct enhanced reviews of proposed premium rates — in which they evaluate the rates that health insurers negotiate with providers — just a small handful are doing so, according to a new analysis.

A variety of barriers are preventing state regulators from fully flexing their rate-review muscles, including industry opposition, according to one of the researchers who produced the analysis. And although that opposition historically has included insurers, there’s an argument to be made that the sector should change its tune.

“I think the health plans should embrace this kind of regulation, because when you look at the hospital sector and how increasingly consolidated it is, and how so many hospitals and health systems are using their market power to demand ever-higher reimbursement rates in the commercial market…health plans are really powerless to push back, because these hospitals are must-have participating providers” in health plan networks, says Sabrina Corlette, co-director of Georgetown University’s Center on Health Insurance Reforms (CHIR).

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