Health Plans

Datapoint: Missouri Supreme Court Reinstates Medicaid Expansion

July 27, 2021

The Missouri Supreme Court last week cleared a path for the state’s voter-approved Medicaid expansion to take effect, ordering the state legislature to fund the program. Previously, Republicans in the state Senate refused to budget for expansion. Missouri currently serves 1,080,576 Medicaid beneficiaries, and an additional 275,000 people will become eligible via expansion.

The Missouri Supreme Court last week cleared a path for the state’s voter-approved Medicaid expansion to take effect, ordering the state legislature to fund the program. Previously, Republicans in the state Senate refused to budget for expansion. Missouri currently serves 1,080,576 Medicaid beneficiaries, and an additional 275,000 people will become eligible via expansion.

Source: AIS’s Directory of Health Plans

Datapoint: Clover Health Plots 2022 Medicare Expansion

July 26, 2021

Startup insurer Clover Health recently unveiled plans for its 2022 Medicare Advantage (MA) service area expansion, adding 101 new counties to its roster. Most of the new counties are in states Clover already has a presence in, but the insurer will take on an expansion to Alabama, launching in seven counties. Clover Health currently serves 65,978 MA members, up 16.5% from July 2020.

Startup insurer Clover Health recently unveiled plans for its 2022 Medicare Advantage (MA) service area expansion, adding 101 new counties to its roster. Most of the new counties are in states Clover already has a presence in, but the insurer will take on an expansion to Alabama, launching in seven counties. Clover Health currently serves 65,978 MA members, up 16.5% from July 2020.

Source: AIS’s Directory of Health Plans

Insurers Push Again for Action on High COVID Test Prices

July 23, 2021

Just one day after the Biden administration extended the public health emergency (PHE) through mid-October, AHIP published a report arguing that price-gouging on COVID-19 tests continues to be a problem. Crucially, that issue was created when pandemic relief legislation removed health insurers’ ability to hold down out-of-network charges for COVID tests, the trade group says.

Health policy experts who have studied COVID test prices and pandemic relief legislation say that AHIP’s findings are not at all off base. However, there may be little chance of addressing insurers’ concerns anytime soon.

Just one day after the Biden administration extended the public health emergency (PHE) through mid-October, AHIP published a report arguing that price-gouging on COVID-19 tests continues to be a problem. Crucially, that issue was created when pandemic relief legislation removed health insurers’ ability to hold down out-of-network charges for COVID tests, the trade group says.

Health policy experts who have studied COVID test prices and pandemic relief legislation say that AHIP’s findings are not at all off base. However, there may be little chance of addressing insurers’ concerns anytime soon.

“The laws, as Congress enacted, very clearly encourage price gouging on COVID tests, so it’s no surprise that it continues,” says Loren Adler, associate director of the USC-Brookings Schaeffer Initiative for Health Policy.

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What Can Payers Do When Hospitals Overuse Trauma Codes?

July 23, 2021

The growth in hospital trauma center designations has coincided with increases in improper “trauma alert” coding and billing, leading to astronomical bills for patients and payers. This finding, reported in an investigation by Kaiser Health News (KHN), means payers will have to step up their scrutiny of emergency claims, experts say.

Trauma centers are special designations given to hospitals that can provide the highest standard of care in cases of severe, time-sensitive injuries. They employ a specially trained, highly experienced team of doctors and nurses who can scramble to attend to a severely wounded patient in minutes. Traditionally, these teams were stationed in one of several local hospitals and activated when EMTs requested they be ready as soon as the ambulance arrived at the emergency room door.

The growth in hospital trauma center designations has coincided with increases in improper “trauma alert” coding and billing, leading to astronomical bills for patients and payers. This finding, reported in an investigation by Kaiser Health News (KHN), means payers will have to step up their scrutiny of emergency claims, experts say.

Trauma centers are special designations given to hospitals that can provide the highest standard of care in cases of severe, time-sensitive injuries. They employ a specially trained, highly experienced team of doctors and nurses who can scramble to attend to a severely wounded patient in minutes. Traditionally, these teams were stationed in one of several local hospitals and activated when EMTs requested they be ready as soon as the ambulance arrived at the emergency room door.

However, growth in the number of high-level trauma centers has boomed in recent years. According to the American College of Surgeons, the number of Level I and II trauma centers — the highest designations — grew from 305 in 2008 to 567 in 2020. Yet the volume of emergency room visits has been fairly stable, according to federal data. So why have so many hospitals sought high-level trauma center designations?

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Analysts View Anthem’s 2Q More Favorably Than Market

July 23, 2021

Anthem, Inc.’s stock took a dive after its second-quarter 2021 earnings conference call on July 21, surprising equities analysts who saw the large Blue Cross Blue Shield insurer’s financial performance and outlook as relatively solid.

Jefferies’ David Windley, in a note issued to investors on the evening of July 21, attributed the “negative reaction” regarding Anthem’s results to “fear of the unknown.” The insurer’s management “didn’t bless growth above target range for ’22, despite several favorable indicators,” Windley acknowledged, and “it offered a couple of start-up headwinds” related to recent contract wins, “though nothing big enough to overwhelm unwinding COVID headwinds and already conservative balance sheet in ’21.”

Anthem, Inc.’s stock took a dive after its second-quarter 2021 earnings conference call on July 21, surprising equities analysts who saw the large Blue Cross Blue Shield insurer’s financial performance and outlook as relatively solid.

Jefferies’ David Windley, in a note issued to investors on the evening of July 21, attributed the “negative reaction” regarding Anthem’s results to “fear of the unknown.” The insurer’s management “didn’t bless growth above target range for ’22, despite several favorable indicators,” Windley acknowledged, and “it offered a couple of start-up headwinds” related to recent contract wins, “though nothing big enough to overwhelm unwinding COVID headwinds and already conservative balance sheet in ’21.”

Ultimately, “investors seem to think [management] is not telling us something,” he added. “We’d call it conservatism ahead of ’22 budget completion and would buy the weakness.”

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Regional MAOs Keep Watch on ‘Bad Actors’ in Marketing Space

July 23, 2021

While the COVID-19 pandemic complicated many smaller Medicare Advantage organizations’ efforts to connect with members during the Medicare Annual Election Period (AEP) last fall, reports of aggressive and misleading marketing practices also resulted in the unintentional disenrollment of individuals from their plans, which not only hurts from a revenue perspective but can negatively impact their star ratings. According to several sources who spoke with AIS Health, a division of MMIT, these tactics were more egregious than usual during the 2021 AEP and the Open Enrollment Period (OEP) that ran from January through March, when members who selected an MA plan in the fall may make a one-time coverage switch.

“We’ve always seen some very aggressive marketing practices, especially from some of the large, national players. But over the last two years, and especially in the last six months, it’s gone from aggressive marketing tactics to what many plans would qualify as teetering on the side of deceptive marketing practices. And it’s not just one large player,” says a source who works with health plans and asked not to be identified for this article.

While the COVID-19 pandemic complicated many smaller Medicare Advantage organizations’ efforts to connect with members during the Medicare Annual Election Period (AEP) last fall, reports of aggressive and misleading marketing practices also resulted in the unintentional disenrollment of individuals from their plans, which not only hurts from a revenue perspective but can negatively impact their star ratings. According to several sources who spoke with AIS Health, a division of MMIT, these tactics were more egregious than usual during the 2021 AEP and the Open Enrollment Period (OEP) that ran from January through March, when members who selected an MA plan in the fall may make a one-time coverage switch.

“We’ve always seen some very aggressive marketing practices, especially from some of the large, national players. But over the last two years, and especially in the last six months, it’s gone from aggressive marketing tactics to what many plans would qualify as teetering on the side of deceptive marketing practices. And it’s not just one large player,” says a source who works with health plans and asked not to be identified for this article.

In his work with the RISE Association, where he formerly served as executive director and is now an emeritus director working with members of RISE’s Medicare Member Acquisition & Experience community, Kevin Mowll says several regional plans after the last AEP expressed concern about so-called lead generators that sell consumers’ information to large brokerages like an electronic marketing organization (EMO) or a field marketing organization (FMO), both of which work with numerous national MA sponsors.

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