AIS’s Directory of Health Plans

Datapoint: CDPHP Selects New PBM

Capital District Physicians' Health Plan, Inc. (CDPHP), a provider-founded nonprofit insurer in New York, on May 12 selected Capital Rx as its new pharmacy benefits manager, swapping out CVS Caremark. The new contract will begin in January 2023. Capital Rx focuses on drug price transparency, using a pricing model based on CMS’s National Average Drug Acquisition Cost. CDPHP currently serves 391,238 members in New York, with 41.4% enrolled in commercial risk-based products.

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Datapoint: Oscar to Exit Two States

Startup insurer Oscar Health will exit the individual market in two states, Arkansas and Colorado, for the 2023 plan year, according to remarks by CEO Mario Schlosser at the company’s first-quarter 2022 earnings call. Schlosser said regulatory changes and difficulty attracting members drove the decision. Oscar is currently the eighth-largest individual risk-based insurer, with 567,838 members as of the fourth-quarter of 2021.

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Datapoint: Sentara to Open Community Care Centers, Launch New Model

Norfolk, Virginia-based nonprofit health system Sentara Healthcare is launching a new model of care and opening new community care centers to better serve uninsured and Medicaid populations in Virginia and North Carolina. The initiative also includes mobile health buses and new partnerships that will provide placement for unhoused patients discharged from Sentara hospitals. Sentara, which operates a system of 12 hospitals, has a robust health insurance unit, currently serving 871,670 members in its Optima Health and Virginia Premier products.

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Datapoint: Centene to Sell Two Specialty Pharma Businesses

Centene Corp. last week entered an agreement to sell two of its recent specialty pharmacy acquisitions, Magellan Rx and PANTHERx Rare, in separate deals totaling $2.8 billion. Magellan Rx will be sold to Blues PBM powerhouse Prime Therapeutics, while will go to a consortium of The Vistria Group, General Atlantic, and Nautic Partners, pending regulatory approval. Centene is currently the fourth-largest insurer in the U.S., with 21,213,845 members.

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Datapoint: Supreme Court Tosses Work Requirements Case

The United States Supreme Court on April 18 vacated judgments in a case challenging Medicaid work requirements in Arkansas and New Hampshire. The dispute will return to lower courts, with the Supreme Court advising them to “dismiss the case as moot.” While work requirements were a pillar of the Trump administration’s CMS, they never truly got off the ground, with Biden’s CMS revoking approval in all 12 state programs. Arkansas currently serves 953,586 Medicaid beneficiaries, to New Hampshire’s 213,845.

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Datapoint: Bright Health Faces Scrutiny, $1M Fine in Colorado

In an interview with the Denver Gazette, Colorado Division of Insurance Commissioner Michael Conway said he nearly banned Bright Health from operating in the state, and would have forced an immediate shut-down fueled by member and provider complaints. Instead, the division fined the startup $1 million. Bright Health is the second-largest individual insurer in Colorado, with 61,423 members.

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Datapoint: Medicaid Expansion Reduced ER Use in Montana

A new report from the Montana Healthcare Foundation found that the state’s Medicaid expansion reduced emergency room visits by 10 to 30%, as more people were able to use outpatient services. The state expanded Medicaid in 2016, and currently serves 353,760 lives, about one-third of the overall population.

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Datapoint: MA Penetration Tops 46%

The Medicare Advantage penetration rate reached 46.2% as of April 2022, according to a data release from CMS. Enrollment in original Medicare (fee-for-service) was 30,582,826 in April, compared to 29,188,064 in Medicare Advantage.

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Datapoint: Kansas Overpaid MCOs by Nearly $200 Million, Medicaid Audit Finds

Kansas’ Office of the Medicaid Inspector General earlier this month reported that the state paid more than $190 million in eligible claims to its contracted MCOs for home and community-based services. The audit, which tracked services rendered from January 2018 to April 2021, found nearly 3,000 beneficiaries did not have claims filed for a year or more, and should have been removed from the waiver program. Kansas’ three Medicaid MCOs (Aetna, Centene Corp. and UnitedHealthcare) currently serve 469,012 lives.

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Datapoint: Bright Health to Exit Six States

Startup insurer Bright Health will exit the individual and group risk markets in Illinois, New Mexico, Oklahoma, South Carolina, Utah and Virginia for the 2023 plan year. Those markets made up less than 5% of Bright Health’s revenue, according to a press release. Bright Health currently serves 588,350 individual members, with Florida, North Carolina and Colorado as its three largest markets.

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