ACA Exchanges

Health insurer trade groups agree that it’s a good idea to reinstate strict limits on short-term, limited-duration insurance (STLDI) plans, according to their official comments on a proposed rule from the Biden administration. But their views diverge on the proposed regulation’s treatment of fixed indemnity insurance and other supplemental coverage.

The proposed rule in question — issued on July 7 by HHS and the Labor and Treasury departments — answered a growing chorus of calls to crack down on STLDI amid concerns that many consumers mistake them for comprehensive coverage. Meant to bridge a gap in insurance coverage, STLDI plans are exempt from the Affordable Care Act’s consumer protections, such as the ban on charging higher rates for sicker people and the requirement that plans must cover a prescribed set of “essential benefits.”

Bright Health Group, Inc. — the struggling “insurtech” firm that is in the process of pulling out of the health insurance business entirely — disclosed recently that it has failed to deliver $380 million to other health plans that it’s required to pay under the Affordable Care Act’s risk adjustment program. The firm therefore has entered into a repayment agreement with the federal government.

In a press release, Bright touted the agreement as a sign the company is making “significant progress” toward the wind down of its ACA exchange business. Bright stopped offering ACA plans in all 15 states in which it operated starting in 2023 amid ongoing financial troubles.

Idaho is the first state to complete its Medicaid eligibility redeterminations process, the state’s Medicaid agency announced on Sept. 8. The state “processed 153,196 renewals, and 31,900 were determined eligible, and 121,296 were ineligible,” according to a post from the state’s Dept. of Health and Welfare (DEW). DEW added that the resumption of redeterminations is “a large and important undertaking that DEW has taken very seriously.” To handle redeterminations, “we committed more than 300 eligibility staff to the effort and an additional 42 staff from our call center.” The news is somewhat surprising, as Idaho paused redeterminations earlier this year due to what KFF termed “technical difficulties.” CMS has warned state Medicaid agencies not to disenroll Medicaid members too quickly.

Oscar Health, Inc. on Sept. 6 announced that it added two new executives to its leadership team from CVS/Aetna, the former employer of Oscar CEO Mark Bertolini. Kerry Sain joined the firm in August as executive vice president of the technology platform +Oscar, and Steven Kelmar will assume the role of executive vice president and chief of staff to the CEO later this month, Oscar said. Before coming to Oscar, Sain was Aetna’s chief commercial growth officer, while Kelmar was chief of staff, executive vice president and head of strategy for the office of the chairman and CEO at Aetna, as well as senior vice president of strategy implementation at CVS Health. Bertolini was Aetna’s CEO prior to its acquisition by CVS Health Corp. in 2018; after the deal closed, he served on CVS Health’s board until leaving in 2020.

Two patient advocacy groups are declaring victory after Blue Cross Blue Shield of North Carolina made midyear formulary changes that shifted several HIV treatments from higher to lower tiers, meaning patients can access them at much lower cost-sharing levels.

In an Aug. 31 press release, the HIV+Hepatitis Policy Institute and the North Carolina AIDS Action Network pointed out that the move came after they filed discrimination complaints with the North Carolina Dept. of Insurance and HHS’s Office for Civil Rights arguing that the Blue Cross NC formulary violated the Affordable Care Act’s prohibitions against discriminatory plan design. The formulary in question is the Blue Cross and Blue Shield of North Carolina Essential Formulary, which applies to ACA marketplace plans sold in the state.

Two patient advocacy groups are declaring victory after Blue Cross Blue Shield of North Carolina made midyear formulary changes that shifted several HIV treatments from higher to lower tiers, meaning patients can access them at much lower cost-sharing levels.

In an Aug. 31 press release, the HIV+Hepatitis Policy Institute and the North Carolina AIDS Action Network pointed out that the move came after they filed discrimination complaints with the North Carolina Dept. of Insurance and HHS’s Office for Civil Rights arguing that the Blue Cross NC formulary violated the Affordable Care Act’s prohibitions against discriminatory plan design. The formulary in question is the Blue Cross and Blue Shield of North Carolina Essential Formulary, which applies to ACA marketplace plans sold in the state.

The Biden administration on Aug. 29 released its long-awaited list of the first 10 drugs that will be subject to price negotiation in the Medicare program, representing the first major step toward implementing the most ambitious drug-pricing reform in the Inflation Reduction Act (IRA).

While the new price-negotiation program will apply only to Medicare — not employer-based or individual market plans — industry experts say it will almost certainly affect the commercial insurance market indirectly. But they tell AIS Health, a division of MMIT, that exactly what the impact will look like hasn’t fully come into focus.

CMS is growing increasingly concerned that people, particularly children, are being disenrolled from Medicaid and Children’s Health Insurance Program (CHIP) coverage even though they still meet eligibility requirements. The agency said it sent a letter to officials in all 50 states, Washington, D.C., Puerto Rico and the U.S. Virgin Islands requiring them to determine if they have an eligibility systems issue and, if so, to correct the problem and reinstate coverage to the affected people. Since states were allowed to resume Medicaid redeterminations in April after a multiyear pause due to the COVID-19 pandemic, CMS said it “has learned of additional systems and operational issues affecting multiple states, which may be resulting in eligible individuals being improperly disenrolled. These actions violate federal renewal requirements and must be addressed immediately.”

A survey of people enrolled in Affordable Care Act marketplace plans in California found that 28% had difficulty paying their premiums in 2021, according to a study published last month in Health Affairs. While that is an improvement from 40% in a similar sample of enrollees in 2017, Vicki Fung, Ph.D., the study’s lead author, tells AIS Health that more could be done to help people choose affordable coverage and determine whether they are eligible for cost-sharing subsidies.

Fung notes that health insurers could help people with consumers’ decisions, including coordinating with agents and brokers that insurers work with and steering people who are eligible for generous subsidies toward purchasing a similar plan via the ACA exchange rather than off-marketplace.

Fixed indemnity insurance plans — which pay a set amount when a policyholder is hospitalized or has another major medical event — are facing heightened scrutiny amid concerns that people who buy these policies mistakenly believe that they’re comprehensive health insurance.

The health insurance industry’s largest trade group, however, argues that fixed indemnity products play an important role in the marketplace and that newly proposed restrictions on those plans will have costly consequences.

“Every American deserves access to affordable, comprehensive, high-quality coverage and care. But the costs associated with getting sick or recovering from an injury continue to escalate year after year,” AHIP says in an Aug. 14 post on the group’s website. Fixed indemnity products address that problem by “helping cover out-of-pocket costs for specified services and other expenses during a time of serious illness, or following an injury,” the post states.