Tagged Insurers

New Rules Try To Shore Up Individual Health Insurance Market In 2018

While Congress continues to struggle with how to “repeal and replace” the Affordable Care Act, the Trump administration today unveiled its first regulation aimed at keeping insurers participating in the individual market in 2018.

“These are initial steps in advance of a broader effort to reverse the harmful effects of Obamacare, promote positive solutions to improve access to quality, affordable care and ensure we have a health system that best serves the needs of all Americans,” Tom Price, secretary of the Department of Health and Human Services said in a Twitter message.

But the new rule, which had been widely expected, was actually begun by the outgoing Obama administration. In part, it is an effort to address complaints by insurers that consumers were “gaming” the system to purchase coverage only when they were sick and then dropping it when they were healthy.

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To combat that, the regulation makes it harder for patients to sign up outside of annual open enrollment periods and would allow insurers to collect past-due premiums before starting coverage for a new year. It would also shorten the annual enrollment period by half, from three months to 45 days, ending right between Thanksgiving and Christmas. And it would give insurers more flexibility in the types of plans they offer and return regulation of the size and adequacy of health care provider networks to the states.

But it remains unclear whether the action will be too little, too late to ensure insurance is available next year. That would be necessary to keep congressional Republicans’ promises that people “do not get the rug pulled out from under them” during the transition to a new program, as House Speaker Paul Ryan (R-Wis.) says frequently.

On Tuesday, Humana announced it would stop selling policies in the health exchanges at the end of this year, and on Wednesday Mark Bertolini, the CEO of Aetna, suggested his firm might follow suit, repeating GOP charges that the individual market exchanges are in a “death spiral” where only sick people buy coverage.

While Humana was not a major player in the state exchange market — it only sold policies in 11 states for 2017 — its exit could leave at least 16 counties in Tennessee, including Knoxville, with no insurance company offering policies on the health exchange, according to data from the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.)

That alarmed Sen. Lamar Alexander (R-Tenn.), chairman of the Senate Health, Education, Labor and Pensions Committee, who has been one of the leading voices in Congress advocating a slower repeal and replace strategy.

“Yesterday’s news from Humana should light a fire under every member of Congress to work together to rescue Americans trapped in the failing Obamacare exchanges before they have no insurance options next year,” Alexander said in a statement.

Last year Aetna’s Bertolini also cited losses in the market as the reason for the company’s scaling back participation in the exchanges, although in an unrelated case, a judge’s ruling later said the decision had at least as much to do with pushing federal officials to allow Aetna to merge with Humana. On Monday that merger was officially called off after being blocked by a judge.

The new rules were greeted with cautious optimism by insurance industry trade groups.

“While we are reviewing the details, we support solutions that address key challenges in the individual market, promote affordability for consumers, and give states and the private sector additional flexibility to meet the needs of consumers,” Marilyn Tavenner, president and CEO of America’s Health Insurance Plans, said in a statement.

The Alliance of Community Health Plans, which represents nonprofit insurers, called the regulation “a promising first step.” But in a statement, president and CEO Ceci Connolly warned that the rule “does not resolve all of the uncertainty for plans and patients alike. Without adequate funding it will be extremely difficult to provide high-quality, affordable coverage and care to millions of Americans.”

Groups representing patients, however, were less happy with the changes. They argue that the rules could result in higher out-of-pocket costs.

Ron Pollack, executive director of the consumer group Families USA, said the new administration “is deliberately trying to sabotage the Affordable Care Act, especially by making it much more difficult for people to enroll in coverage.”

Sick people are likely to jump through any hoops required to get coverage, but healthy people are less inclined to sign up when it is more difficult. So by making it harder for healthy people to enroll, said Pollack, “they are creating their own death spiral that would deter young adults from gaining coverage, thereby driving up costs for everyone.”

And the American Cancer Society said that the new rules could hurt cancer patients in particular — for example, when they need to purchase new coverage after becoming too sick to work or moving to be closer to health providers. The proposed changes “would require documentation that is often challenging to quickly obtain,” and could “delay a patient’s treatment and jeopardize a person’s chance of survival,” said a statement from Chris Hansen, president of the society’s Cancer Action Network.

Unless the new administration changes the date, insurers must decide by May 3 if and where they will sell insurance for next year on the state exchanges.

Meanwhile, the Republican-led Congress remains in a deadlock between conservatives in the House, who want to repeal the health law as soon as possible, and moderates in the Senate like Alexander, who want to wait until there is agreement on what will replace it.

“We should just do what we said we would do,” Rep. Raul Labrador (R-Idaho) told reporters on Tuesday.

Conservatives say, at a minimum, Congress should pass the partial repeal bill it passed in 2015 that President Barack Obama vetoed. That measure would eliminate the expansion of the Medicaid program, financial help for people to purchase insurance, the penalties for not having coverage, and all the taxes that pay for the program, among other things.

“Why would it be difficult to get [the Senate] to vote for something they already voted for?” asked Rep. Mark Meadows (R-N.C.).

But congressional budget scorekeepers in January said that bill, which has no replacement provisions, could result in a doubling of premiums and 32 million more people without insurance.

And Republicans in the Senate, as well as President Donald Trump, continue to say that repeal and replace should take place simultaneously.

“I thought we were embarked on an effort to replace it,” said Sen. John McCain (R-Ariz.).

Categories: Insurance, Repeal And Replace Watch, Syndicate, The Health Law

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California Regulator Slams Health Insurers Over Faulty Doctor Lists

California’s biggest health insurers reported inaccurate information to the state on which doctors are in their networks, offering conflicting lists that differed by several thousand physicians, according to a new state report.

Shelley Rouillard, director of the California Department of Managed Health Care, said 36 of 40 health insurers she reviewed — including industry giants like Aetna and UnitedHealthcare — could face fines for failing to submit accurate data or comply with state rules.

Rouillard said she told health plan executives in a meeting last week that such widespread errors made it impossible for regulators to tell whether patients have timely access to care in accordance with state law.

“I told the CEOs it looks to me like nobody cared. We will be holding their feet to the fire on this,” Rouillard said in an interview with California Healthline. “I am frustrated with the health plans because the data we got was unacceptable. It was a mess.”

The state wasn’t assessing the accuracy of online provider directories that are used by consumers. But the new report suggests that insurers may be misrepresenting which providers they have under contract or are unable to collect accurate information.

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Flawed provider directories are a longstanding problem industrywide, and the proliferation of narrow networks on the Obamacare insurance exchanges and in employer health plans has sparked numerous consumer complaints.

Outdated and inaccurate provider lists can hinder patients from getting treated and, in some cases, lead to huge unforeseen medical bills when people unwittingly go out of network for care.

California officials discovered the latest problems while reviewing annual reports filed by insurers. In those reports, insurers submitted two sets of provider lists, one used during the year to measure patient access and the other a year-end tally. Often they were dramatically different.

UnitedHealthcare, the nation’s largest health insurer, listed 9,135 primary-care doctors on the provider list used during the year who were absent from year-end list — a discrepancy of 45 percent.

Cigna, another big insurer, named 8,572 on the one list who were not on the other, a 36 percent discrepancy. For Anthem Blue Cross, the discrepancy was 8,165 primary-care physicians, or 36 percent, and for Blue Shield of California it was 4,371 primary-care doctors, or 22 percent.

In another instance, the state said Aetna counted the same cardiologists in one county more than 160 times, inflating the number of specialists overall by 2,293. That overstated the list of specialists by 82 percent.

Overall, for seven insurers, the two sets of lists differed by 50 percent or more for in-network specialists.

Rouillard said provider directories can fluctuate over time, so some small variations between one list used during the year and another at year’s end would be expected. But she said the wildly different figures that were reported raised red flags and made it impossible to know whether enough doctors were available to see patients.

Some of these issues are not new. In 2015, California’s managed care agency fined Anthem $250,000 and Blue Shield of California $350,000 for overstating the breadth of their doctor networks.

Both Anthem and Blue Shield of California declined to comment on the state’s most recent findings. Aetna said it was still reviewing the state’s analysis.

Other health insurers referred questions to an industry trade group. Charles Bacchi, chief executive of the California Association of Health Plans, said some mistakes may have been made but emphasized that measuring patient access to physicians is difficult.

“Health plans are committed to providing timely access to health care and we believe that we provide that successfully,” Bacchi said. “Clearly this report demonstrates that we have work to do to improve our survey responses, and health plans are committed to working with the department to address it.”

Under California law, patients must get urgent care appointments within 48 to 96 hours. Primary-care visits must be scheduled within 10 business days and appointments with a specialist must come within 15 business days.

Yet many consumers continue to struggle to find in-network doctors to meet their needs.

David Discher of Redwood City, Calif., said he tried most of last year to find doctors who would take his Anthem Blue Cross insurance. The 39-year-old suffers from psoriatic arthritis and requires regular infusion treatments.

The Anthem directory for consumers listed three rheumatologists in his area. One doctor’s phone was disconnected and the other two were no longer accepting his Anthem plan, Discher said. His joint pain and swelling worsened while he waited nearly two months to see a specialist.

“It boggles my mind that insurers can’t keep their list up to date,” Discher said. “There is no excuse for how messy it is. Health insurers are engaged in false advertising.”

Consumer outrage over provider directories led to passage of a state law last year that requires insurers and medical providers to ensure the lists are accurate and regularly updated. It also requires health plans to reimburse consumers who are charged out-of-network prices because of an inaccurate provider list.

This latest review by regulators stemmed from a 2014 law sponsored by state Sen. Ed Hernandez (D-West Covina) that required insurers file reports to the state to combat problems with provider lists and barriers to care. He and consumer advocates urged regulators to step up enforcement against insurers that are violating the law.

“Their inability to accurately document which providers are in their networks raises serious questions about the reliability of these networks,” said Hernandez, chairman of the Senate Health Committee.

The state report analyzed data for 2015, and it applied to people in employer plans, individual policies and Medicaid.

Only four health plans submitted information without substantial errors. Two were full-service health plans, Community Health Group and Inland Empire Health Plan. The two others specialize in behavioral health: Human Affairs International of California and Managed Health Network.

The next round of reports from insurers on patient access and provider lists are due next month.

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Categories: California, California Healthline, Insurance, Syndicate

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