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Health Plan Weekly Strategic Business, Financial and Regulatory Analysis of the Health Insurance Industry Health Plan Weekly Insurers Sound Alarm Over Increasingly Pricey COVID-19 Tests Nov. 25, 2020 With the COVID-19 pandemic getting worse than ever, health insurers are VOLUME 30 | NUMBER 48 facing an uncertain level of exposure to testing costs. That’s because payers and plan sponsors are on the hook for the entire cost of coronavirus tests — which can vary widely — and they could be required to pay for even more testing depending on the Insiders: Biden May 4 strategy that the Biden administration plans to pursue. Revisit Payer Price Transparency Rule The Families First Coronavirus Response Act and the Coronavirus Aid, Relief and Economic Security (CARES) Act require plan sponsors to pay all in- and out- 5 HHS Raises Eyebrows of-network claims for diagnostic and antibody testing services. The CARES Act says With Promises That New those claims must be paid at a listed “cash price,” which essentially allows labs to Rebate Rule Won’t Hike name a price for test processing. Premiums, Spending And costs for out-of-network testing seem to be increasing, according to a survey of claims data prepared by America’s Health Insurance Plans (AHIP). The 6 Chart: Executive Compensation Data for survey, which was conducted in October, found that the average price for out-of- Top Health Insurers in network COVID-19 tests has increased by 10% since July, and that about 23% of 2019 all claims for COVID-19 tests processed by commercial insurers are out-of-network. Of those test claims, 47% had prices that “significantly exceed” $185, the average 8 News Briefs cost for out-of-network tests analyzed in the white paper. continued on p. 4 States Look Beyond Reinsurance to Protect Individual Markets Reinsurance programs can help lower premiums in the individual insurance market, but they’re not enough by themselves — states will need to experiment Don’t miss the valuable benefits with broader measures to impact underlying health care costs, particularly for un- for HPW subscribers at subsidized individual market enrollees, a report from The Commonwealth Fund AISHealth.com — articles, concludes. infographics and more. Log in at However, such programs could be a tough sell as states tighten their budgets AISHealth.com. If you need assistance, email support@ because of the COVID-19 pandemic, says study author Justin Giovannelli, an asso- aishealth.com. ciate research professor and project director at Georgetown University’s Center on Health Insurance Reforms. “Reinsurance has meaningfully lowered premiums for middle-income folks who Managing Editor aren’t eligible for federal premium tax credits,” Giovannelli tells AIS Health. “But Leslie Small it’s no silver bullet — it doesn’t do much for other populations facing affordability [email protected] barriers. States looking to make a broader impact should consider implementing Senior Reporter Peter Johnson other policies in tandem with — or even in lieu of — reinsurance.” Data Reporter The Commonwealth Fund report found that all 12 states that have imple- Jinghong Chen mented a reinsurance program in the individual market have been able to lower Executive Editor premiums. However, the effect on marketplace enrollment is less clear, with some Jill Brown Kettler states showing declines in enrollment and others demonstrating small increases or remaining level. Published by AIS Health, Washington, DC. An independent publication not affiliated with insurers, vendors, manufacturers or associations. 2 Health Plan Weekly November 25, 2020 Other policy options may have edges, that will continue to be the found that states’ reinsurance programs a bigger effect, Giovannelli says. For barrier to additional improvements in receive substantial funding from the example, a state coverage subsidy pro- affordability in this market.” federal government, with pass-through gram is more flexible than reinsurance, Giovannelli points out that the dollars available through section 1332 since it can provide assistance broadly Biden administration also could reverse waivers that allow states to test changes or to targeted populations, and it can Trump-era rules on non-ACA-com- to their individual insurance markets. be designed to address premiums and pliant insurance policies: “There are In 10 of the 12 states where programs cost sharing. However, states consider- serious problems with how these prod- have commenced operations, waiver ing any of these options likely will need ucts are marketed. They typically don’t funding covers the majority of program federal support, he says. work for folks with preexisting condi- costs, making the programs viable, the That federal support may not be tions, and they undermine the afford- report said. Two more states — New forthcoming, says Avalere Health con- ability of comprehensive coverage. I Hampshire and Pennsylvania — will sultant Chris Sloan, who notes that the would hope the Biden administration start operating reinsurance programs likely Republican-controlled Senate would restore limits on these products in 2021. would block additional funds for stabi- and close regulatory loopholes that lizing the Affordable Care Act (ACA) allow them to game the markets.” Frankly, many states need a strong and the individual market. That lack Most of the erosion in individual “ reinsurance program to sustain a of dedicated additional funding for viable unsubsidized market, and reinsurance has been one of the largest market enrollment over the last few years has occurred in the unsubsidized could use some additional funding to obstacles since the federal reinsurance improve cost-sharing affordability, population, Sloan says. “Frankly, many program ended in 2016, Sloan tells particularly for lower income states need a strong reinsurance pro- AIS Health. individuals. “While the Biden administration gram to sustain a viable unsubsidized market, and could use some additional will be able to tailor [section] 1332 Eight of the 12 states currently funding to improve cost-sharing af- waiver rules in order to encourage operating a reinsurance program rely fordability, particularly for lower in- states to pursue reinsurance programs at least in part on insurer assessments come individuals.” or public options, it won’t be able to to finance their own obligations, while make funding simply appear,” he says. The funding for reinsurance is five have used general appropriations “Regardless of the tweaks around the key. The Commonwealth Fund report to cover some or all state costs, the report said. “But states have increas- Health Plan Weekly (ISSN: 2576-4365) is published 52 times a year by AIS Health, 2101 L Street, NW, Suite ingly pursued other funding sources,” 300, Washington, D.C. 20037, 800-521-4323, www.AISHealth.com. the authors wrote. “Two states with Copyright © 2020 by Managed Markets Insight & Technology, LLC. All rights reserved. On matters of fair use, individual mandates — New Jersey you may copy or email an excerpt from an article from HPW. But unless you have AIS Health’s permission, it violates federal law to copy or email an entire issue, share your AISHealth.com password, or post content on and Rhode Island — use the penalty any website or network. Please contact [email protected] for more information. dollars they collect to fund reinsurance. Health Plan Weekly is published with the understanding that the publisher is not engaged in rendering legal, Pennsylvania, which recently assumed accounting or other professional services. If legal advice or other expert assistance is required, the services of a responsibility for its ACA marketplace competent professional person should be sought. from the federal government, will Subscriptions to HPW include free electronic delivery and access to all content online at www.AISHealth.com. finance its new reinsurance program To renew your annual subscription, please order online at www.AISHealth.com. For subscriptions for five or with savings generated by running its more users, contact [email protected]. coverage portal more efficiently.” Senior Reporter, Peter Johnson; Managing Editor, Leslie Small; Executive Editor, Jill Brown Kettler Other states, including Maryland, Colorado and New Jersey, replaced EDITORIAL ADVISORY BOARD: Michael Adelberg, Principal, Faegre Drinker Consulting; Brian Anderson, the expiring federal health insurance Principal, Milliman, Inc.; Pat Dunks, Principal and Consulting Actuary, Milliman, Inc.; Adam J. Fein, Ph.D., tax with state-based taxes on health President, Pembroke Consulting, Inc.; Bruce Merlin Fried, Partner, Dentons; John Gorman, Founder and Chairman, Nightingale Partners LLC insurers with plans to use the money to help fund reinsurance and forthcoming Contact [email protected] if you’d like to review our rates for group subscriptions. November 25, 2020 Health Plan Weekly 3 coverage subsidy programs, the report For example, “aggressive antitrust Several states are experimenting said. enforcement and scrutiny of mergers with tactics to improve the individ- At the same time, many individual and acquisitions of all sizes would be ual market risk pool, Anderson says. states are facing severe budget crises an action that the Biden administration For example, Maryland is working to tied to the COVID-19 pandemic, could take without congressional sup- enroll currently uninsured individ- making it unlikely that they could shift port,” Anderson tells AIS Health. “The uals whose subsidy eligibility would money from their general funds
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