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  • 20 Apr 2023 10:06 AM | Anonymous

    I.PURPOSE


    This memorandum details the filing timelines for issuers offering:

    • individual or small group1non-grandfathered health insurance coverage2; or
    • coverage of pediatric dental services under Exchange-certified Stand-Alone Dental Plans (SADPs).

    It applies to coverage with plan or policy years beginning in calendar year 2024. Hereafter, these policies are referred to as 2024 Plans and 2024 SADPs, respectively.


    II.FILING TIMELINES FOR 2024 PLANS AND 2024 SADPs


    South Carolina has a Federally Facilitated Marketplace (FFM). However, this Department retains responsibility for the review and approval of forms and rates for 2024 Plans and 2024 SADPs sold on and off the FFM.


    The Center for Consumer Information and Insurance Oversight (CCIIO) sets QHP application and single risk pool rate submission timelines annually, which are summarized in the Key Dates for Calendar Year 2023: Qualified Health Plan (QHP) Data Submission and Certification; Rate Review; and Risk Adjustment (posted by CMS on March 28, 2023).

    These federally imposed deadlines are the basis for the filing timeline summarized in this Memorandum. We are requesting that issuers submit filings for 2024 Plans and 2024 SADPs by the following dates:

    Health Insurance Issuers Seeking QHP Certification (excluding SADPs)

    QHP Application Deadline:                                                June 14, 2023

    Submit Rate/ Form Filing in SERFF by:                               June 9, 2023

    Submit Binder in SERFF Plan Management by:                  June 9, 2023

    Submit Rate Filing Justification in URR Module5by:            June 9, 2023     
    SERFF/ URR5System Dispositions Deadline:                August 16, 2023
    State QHP Certification Recommendations Due:     September 20, 2023


    Dental Issuers Seeking SADP Certification (including SADPs that will be offered strictly outside of the FFM and/or FF-SHOP)
    QHP Application Deadline:                                                 June 14, 2023
    Submit Rate/ Form Filing in SERFF by:                                June 9, 2023
    Submit Binder in SERFF Plan Management by:                   June 9, 2023
    SERFF Dispositions Deadline:                                         August 16, 2023
    State QHP Certification Recommendations Due:      September 20, 2023


    Health Insurance Issuers Writing Solely Outside of the FFM
    Submit Rate/ Form Filing in SERFF by:                                  July 7, 2023
    Submit Binder in SERFF Plan Management by:                     July 7, 2023
    Submit Rate Filing Justification in URR Module by:                July 7, 2023
    SERFF/ URR5System Dispositions Deadline:                October 16, 2023


    Open Enrollment for 2024 Plans begins:                       November 1, 2023


    III.FILING REQUIREMENTS FOR 2024 PLANS & 2024 SADPs


    Our continued goal is to provide issuers with the maximum amount of time possible to develop their filings to get better quality, more complete submissions at the beginning of the process.


    With that in mind, we ask that issuers be mindful of the following items relative to the upcoming filing period:

    • Filings cannot be reviewed until the associated binder is also submitted.
    • The Department will only accept one filing per 2024 Plan/SADP issuer per market segment.
    • The Department will provide two weeks for issuers to respond to initial objections on rate objections and one week on form objections. Approximately 30 days prior to the federally imposed disposition deadlines, response time frames will be limited to one week or less in some cases. Extensions will not be granted unless there is an extraordinary circumstance.
    • Prior to filing, issuers should review all objections and requests from prior years.The current filing should be amended accordingly to expedite the review of the filing.
    • When the final guidance is released, we will post the 2023 Filing Requirements (for 2024 Plans) chart on our website.Changes, updates, and new requirements for PY 2024 will be outlined in this document.It is imperative that the most recent guidelines are followed to maintain accuracy and completeness of the filing.
    • The Department will publish additional guidance as necessary on its LA&H webpage under the PPACA Resources heading, which may be accessed at doi.sc.gov/lah.
    • The information in this Memorandum is based on the Final Key Dates for Calendar Year 2023. Please check our website often for the latest updates
    IV.QUESTIONS

    Issuers should regularly check the LA&H webpage (doi.sc.gov/lah) for additional materials relative to the filing and review process.Please note that all materials will be listed under the PPACA Resources heading.


    Questions should be submitted via email to lahmail@doi.sc.gov and include the company name and  primary point of contact (with phone number and email address).

  • 7 Apr 2023 9:03 AM | Addie Thompson (Administrator)

    For decades, U.S. hospitals have generally stonewalled patients who wanted to know ahead of time how much their care would cost. Now that’s changing — but there’s a vigorous debate over what hospitals are disclosing.

    Under a federal rule in effect since 2021, hospitals nationwide have been laboring to post a mountain of data online that spells out their prices for every service, drug, and item they provide, including the actual prices they’ve negotiated with insurers and the amounts that cash-paying patients would be charged. They’ve done so begrudgingly and only after losing a lawsuit that challenged the federal rule.

    How well they’re doing depends on whom you ask.

    The rule aims to pull back the curtain on opaque hospital prices that may vary widely by hospital for the same service or even within the same hospital. The expectation is that price transparency will boost competition, giving consumers and employers a way to compare prices and make informed choices, ultimately driving down the cost of care. Whether that will happen is not yet clear.

    Insurers and large employers are also required to post their negotiated prices with all their providers, under separate rules that took effect last summer.

    Hospitals have made “substantial progress,” according to an analysis by the federal Centers for Medicare & Medicaid Services of 600 randomly selected hospitals that was published in the journal Health Affairs last month. The agency looked at whether hospitals had met their obligation to post price information online in two key formats: a “shoppable” list of at least 300 services for consumers, and a comprehensive machine-readable file that incorporates all the services for which the hospital has standard charges. This file should be in a format that allows researchers, regulators, and others to analyze the data.

    CMS found that 70% of hospitals published both lists in 2022. An additional 12% published one or the other. By contrast, the agency’s previous progress assessment in 2021 found that just 27% of 235 hospitals had both types of lists.

    The 2022 analysis “represents a marked improvement,” said Dr. Meena Seshamani, deputy administrator and director of the Center for Medicare at CMS, in a statement. But she also said the advances are still “not sufficient” and CMS will continue to use “technical assistance and enforcement activity” so that all hospitals “fully comply with the law.”

    The American Hospital Association said the CMS assessment demonstrated the progress hospitals had made under very challenging circumstances as they grappled with the covid-19 pandemic.

    “These are complicated policies that went into effect in the most complicated time in hospitals’ history,” said Molly Smith, group vice president for policy at the trade association. “And we have seen increases in compliance over the past 18 months.”

    Some groups that have looked at the hospitals’ posted price data, though, were less upbeat. In an analysis published last month, Patient Rights Advocate examined 2,000 hospitals’ listings and found that only 489 of them, 24.5% of the total, were compliant with all the requirements of the rule. An earlier analysis in August 2022 found that 16% met all the requirements.

    The advocacy group’s analysis covered not only the two types of lists that CMS looked for but also checked whether the hospitals included required data on specific types of standard charges for every service offered, such as the gross or “chargemaster” charge before any discounts are applied, the discounted cash price, and the negotiated charge by insurer.

    Although most hospitals have published files online, too often the data is incomplete, illegible, or not clearly associated with specific health plans or insurers, said Cynthia Fisher, founder and chair of Patient Rights Advocate, which promotes health care price transparency.

    “As hospitals continue to post incomplete files with swaths of missing prices, patients are unable to accurately compare prices across hospitals and across plans to make the best health care decisions and protect themselves from overcharges,” Fisher said. Such hospitals were considered noncompliant in the PRA analysis.

    The hospital association faulted PRA’s analysis. The contracts that hospitals have with health plans vary substantially from one to the next, and prices are not always based on a simple dollar amount, said Terry Cunningham, AHA’s director of policy. They might be based on a bundle of services or on volume, for example, he said.

    “It’s both frustrating and problematic for these other organizations to be weighing in, saying, ‘This cell shouldn’t be blank,’” Cunningham said.

    In their 2020 lawsuit, hospitals argued that they should not be required to disclose privately negotiated prices, and maintained that doing so would confuse patients and lead to anti-competitive behavior by insurers.

    Last summer, price transparency requirements took effect in the health insurance industry as well, complementing and providing a cross-reference tool for what hospitals have posted. The insurer transparency requirements are even broader than those for hospitals: Insurers and self-funded employers must list every negotiated rate they have with every doctor, hospital, and other health care providers.

    Some critics charge that data isn’t user-friendly either. Sens. Maggie Hassan (D-N.H.) and Mike Braun (R-Ind.) sent a letter March 6 to CMS Administrator Chiquita Brooks-LaSure encouraging the agency to take steps to close “technical loopholes” such as large files and a lack of standardization that make it difficult to use the data they’re reporting.

    That’s where pricing platforms like Turquoise Health come in. The data becoming available from hospitals and insurers is a vast treasure trove the company is mining to devise user-friendly tools that consumers and businesses can use to discover and compare prices.

    In its own analysis of how effective hospital price transparency efforts were in 2022’s third quarter, Turquoise Health found that 55% of the more than 4,900 acute care hospitals that posted machine-readable files were “complete,” meaning they posted the cash, list, and negotiated rates for a “significant quantity” of items and services. Twenty-four percent of hospitals were judged to be “mostly complete.” (The analysis didn’t evaluate the second type of posting, the list of shoppable services.)

    According to Chris Severn, Turquoise Health co-founder and CEO, the company uses a scoring algorithm of 60 variables to assess how complete a hospital’s file is.

    “What you end up with is a more nuanced look at these files that hopefully takes into consideration shades of gray,” Severn said, rather than a simple pass-fail rating.

    Regardless of the differences in how the hospital disclosures are evaluated, experts generally agree that CMS should require data be reported in a standardized format for ease of comparison and enforcement. CMS has developed a template, but hospitals aren’t required to use it.

    For price transparency to work, enforcement also needs consistent attention, experts say. The Biden administration increased the maximum potential penalty to more than $2 million annually per hospital for 2022. Still, last year CMS penalized just two hospitals for noncompliance even though 30% of hospitals didn’t meet the requirement to post both a machine-readable file of prices as well as a shoppable list.

    CMS provided technical assistance to many hospitals to help them come into compliance, said Seshamani, and it also plans stronger enforcement actions.

    She said the agency will “continue to expedite” the time frame hospitals have to reach full compliance after submitting a corrective action plan, which indicates they have fallen short on some posting requirements. “CMS also plans to take aggressive additional steps to identify and prioritize action against hospitals that have failed entirely to post files,” she said.


  • 7 Apr 2023 9:02 AM | Addie Thompson (Administrator)

    March 29 (Reuters) - UnitedHealth Group Inc (UNH.N) said on Wednesday its insurance unit will reduce the use of prior authorization process by 20% for some non-urgent surgeries and procedures.

    Under this process, Healthcare providers get coverage approval for certain non-emergency procedures.

    The reductions will begin in the third quarter and will continue through the rest of the year for most commercial and Medicare Advantage as well as Medicaid businesses.

    The company will implement in early next year a national Gold Card Program for care providers that meet eligibility norms, ending the need for prior authorization for most procedures. It would apply for most UnitedHealthcare members.

    "We will continue to evaluate prior authorization codes and look for opportunities to limit or remove them while improving our systems and infrastructure," said Anne Docimo, chief medical officer of UnitedHealthcare.

    The company said it plans to remove prior authorization requirements in certain types of medical equipment like orthopedic support devices and some genetic tests used for diagnosis.

    The U.S. Centers for Medicare & Medicaid Services had last year issued a proposed rule to simplify the process, which doctors said causes administrative burden to patients and doctors.


  • 5 Apr 2023 12:30 PM | Addie Thompson (Administrator)

    During the tech giant’s annual healthcare event on Tuesday, Google also shared an a updated version of its medical artificial intelligence that can answer clinical questions at an “expert” level.

    Google announced slew of new health initiatives on Tuesday, including bolstering Search to help Medicaid enrollees during redeterminations, an updated version of its medical artificial intelligence that can answer clinical questions and a digital health app development infrastructure.

    Among the other announcements during the tech giant’s annual healthcare event, Google said it will make Medicaid information easier to find on Search for people looking to re-enroll once states resume their eligibility checks. The checks, which were paused during the COVID-19 public health emergency, will resume in April and could cause some 18 million Americans to lose Medicaid coverage.

    When consumers search for a Medicaid-related term on Google, they’ll see a new Renewal tab which will include results on the renewal guidelines in their state, and other information on Medicaid like contact information or the log-in to their state portal. The update will roll out it in the coming weeks, according to a spokesperson.

    Google also plans to highlight providers that are community health centers offering free or low-cost care on search, building on a search engine feature that shows consumers available appointment times for select providers.

    Google frequently cites data that most people use the internet first when checking symptoms or researching medical information. In late 2021, the company wove additional information into practices’ business profiles, including whether they accept Medicare and what languages they offer services in.

    Google launched the booking functionality last year. It shows appointments for CVS MinuteClinics and links with scheduling tools like Kyruus and Stericycle so their provider users can integrate their appointment times into the search engine.

    The bookings functionality only shows appointments at specific practices and does not aggregate across providers.

    On Tuesday, Google said it was expanding the network of qualified partners in the U.S. who can show their appointment availability directly on Search, and make it simpler for them to self-onboard, in the coming months.

    AI and app development

    Google also announced a number of updates to AI projects.

    In partnership with Mayo Clinic, Google has been testing how AI can support planning for radiotherapy, a common cancer treatment. Google said it will soon publish research on the findings of a study into AI’s efficacy in “contouring,” a process where clinicians draw lines on a CT scan to separate healthy tissue from areas of cancer that can take up to seven hours for one patient.

    Google and Mayo Clinic are also formalizing their partnership to explore further research, along with model development and commercialization, according to Greg Corrado, who leads health AI at Google.

    Also on the AI front, Google has invested in medical large language model research to develop AI tools that can retrieve medical information and accurately answer medical questions. Its model, called Med-PaLM, recently ​​​​performed at an “expert” doctor level on medical exam questions, scoring 85%. That’s an 18% improvement from Med-PALM’s previous performance and a result that “far surpasses similar AI models,” Corrado wrote in a blog post on the news.

    However, there’s more work to be done to ensure Med-PaLM will work in real-world settings, said Alan Karthikesalingam, a research lead at Google. An evaluation of the AI found significant gaps when it comes to the complexity of medical questions answered and meeting product excellence standards.

    Google also announced a number of new partners for AI research, including Kenya-based nonprofit Jacaranda Health on ultrasound delivery for expectant mothers, Chang Gung Memorial Hospital in Taiwan on ultrasound for breast cancer detection and nonprofit Right to Care on AI-powered chest x-ray screening to help with tuberculosis in Africa.

    The tech giant introduced a suite of open-source infrastructure built on an interoperable data standard to make it easier for developers to quickly build healthcare apps.

    Despite disbanding its health-specific unit in 2021, Google has remained active in the healthcare industry, launching tools to help healthcare companies make their medical images more actionable through AI and machine learning and inking a deal with major EHR vendor Meditech to embed its clinical software tools into the records of U.S. hospitals.




  • 4 Apr 2023 2:22 PM | Addie Thompson (Administrator)
    As women continue to die due to pregnancy or childbirth each year in the United States, new federal data shows that the nation’s maternal death rate rose significantly yet again in 2021, with the rates among Black women more than twice as high as those of White women.

    Experts said the United States’ ongoing maternal mortality crisis was compounded by Covid-19, which led to a “dramatic” increase in deaths.

    The number of women who died of maternal causes in the United States rose to 1,205 in 2021, according to a report from the National Center for Health Statistics, released Thursday by the US Centers for Disease Control and Prevention. That’s a sharp increase from years earlier: 658 in 2018, 754 in 2019 and 861 in 2020.

    That means the US maternal death rate for 2021 – the year for which the most recent data is available – was 32.9 deaths per 100,000 live births, compared with rates of 20.1 in 2019 and 23.8 in 2020.

    The new report also notes significant racial disparities in the nation’s maternal death rate. In 2021, the rate for Black women was 69.9 deaths per 100,000 live births, which is 2.6 times the rate for White women, at 26.6 per 100,000.

    The data showed that rates increased with the mother’s age. In 2021, the maternal death rate was 20.4 deaths per 100,000 live births for women under 25 and 31.3 for those 25 to 39, but it was 138.5 for those 40 and older. That means the rate for women 40 and older was 6.8 times higher than the rate for women under age 25, according to the report.

    The maternal death rate in the United States has been steadily climbing over the past three decades, and these increases continued through the Covid-19 pandemic.

    Questions remain about how the pandemic may have affected maternal mortality in the United States, according to Dr. Elizabeth Cherot, chief medical and health officer for the infant and maternal health nonprofit March of Dimes, who was not involved in the new report.

    “What happened in 2020 and 2021 compared with 2019 is Covid,” Cherot said. “This is sort of my reflection on this time period, Covid-19 and pregnancy. Women were at increased risk for morbidity and mortality from Covid. And that actually has been well-proven in some studies, showing increased risks of death, but also being ventilated in the intensive care unit, preeclampsia and blood clots, all of those things increasing a risk of morbidity and mortality.”

    The American College of Obstetricians and Gynecologists previously expressed “great concern” that the pandemic would worsen the US maternal mortality crisis, ACOG President Dr. Iffath Abbasi Hoskins said in a statement Thursday.

    “Provisional data released in late 2022 in a U.S. Government Accountability Office report indicated that maternal death rates in 2021 had spiked—in large part due to COVID-19. Still, confirmation of a roughly 40% increase in preventable deaths compared to a year prior is stunning new,” Hoskins said.

    “The new data from the NCHS also show a nearly 60% percent increase in maternal mortality rates in 2021 from 2019, just before the start of the pandemic. The COVID-19 pandemic had a dramatic and tragic effect on maternal death rates, but we cannot let that fact obscure that there was—and still is—already a maternal mortality crisis to compound.”

    During the early days of the pandemic, in 2020, there was limited information about the vaccine’s risks and benefits during pregnancy, prompting some women to hold off on getting vaccinated. But now, there is mounting evidence of the importance of getting vaccinated for protection against serious illness and the risks of Covid-19 during pregnancy.

    The Covid-19 pandemic also may have exacerbated existing racial disparities in the maternal death rate among Black women compared with White women, said Dr. Chasity Jennings-Nuñez, a California-based site director with Ob Hospitalist Group and chair of the perinatal/gynecology department at Adventist Health-Glendale, who was not involved in the new report.

    “In terms of maternal mortality, it continues to highlight those structural and systemic problems that we saw so clearly during the Covid-19 pandemic,” Jennings-Nuñez said.

    “So in terms of issues of racial health inequities, of structural racism and bias, of access to health care, all of those factors that we know have played a role in terms of maternal mortality in the past continue to play a role in maternal mortality,” she said. “Until we begin to address those issues, even without a pandemic, we’re going to continue to see numbers go in the wrong direction.”

    ‘This is a problem in our country’

    Some policies have been introduced to tackle the United States’ maternal health crisis, including the Black Maternal “Momnibus” Act of 2021, a sweeping bipartisan package of bills that aim to provide pre- and post-natal support for Black mothers, including extending eligibility for certain benefits postpartum.

    As part of the Momnibus, President Biden signed the bipartisan Protecting Moms Who Served Act in 2021, and other provisions have passed in the House.

    In the United States, about 6.9 million women have little or no access to maternal health care, according to March of Dimes, which has been advocating in support of the Momnibus.

    The US has the highest maternal death rate of any developed nation, according to the Commonwealth Fund and the latest data from the World Health Organization. While maternal death rates have been either stable or rising across the United States, they are declining in most countries.

    “A high rate of cesarean sections, inadequate prenatal care, and elevated rates of chronic illnesses like obesity, diabetes, and heart disease may be factors contributing to the high U.S. maternal mortality rate. Many maternal deaths result from missed or delayed opportunities for treatment,” researchers from the Commonwealth Fund wrote in a report last year.

    The ongoing rise in maternal deaths in the United States is “disappointing,” said Dr. Elizabeth Langen, a high-risk maternal-fetal medicine physician at the University of Michigan Health Von Voigtlander Women’s Hospital. She was not involved in the latest report but cares for people who have had serious complications during pregnancy or childbirth.

    “Those of us who work in the maternity care space have known that this is a problem in our country for quite a long time. And each time the new statistics come out, we’re hopeful that some of the efforts that have been going on are going to shift the direction of this trend. It’s really disappointing to see that the trend is not going in the right direction but, at some level, is going in the worst direction and at a little bit of a faster rate,” Langen said.

    “In the health care system, we need to accept ultimate responsibility for the women who die in our care,” she added. “But as a nation, we also need to accept some responsibility. We need to think about: How do we provide appropriate maternity care for people? How do we let people have time off of work to see their midwife or physician so that they get the care that they need? How do all of us make it possible to live a healthy life while you’re pregnant so that you have the opportunity to have the best possible outcome?”




  • 4 Apr 2023 2:22 PM | Addie Thompson (Administrator)

    In most states, beneficiaries who lose Medicaid coverage when the public health emergency ends are likely to transition into employer-sponsored health plans, according to a study funded by AHIP from NORC at the University of Chicago (NORC).

    NORC used the Urban Institute’s public health emergency Medicaid coverage loss estimates and historic data from the Current Population Survey (CPS) Annual Social and Economic Supplement (ASEC).

    The researchers recategorized the data, taking into account respondents’ coverage type in year one and year two of the transition, supplementing data for smaller states, and applying a hierarchy of coverage types to distribute respondents with multiple coverage sources. When respondents had multiple coverage types, the researchers prioritized first employer-sponsored coverage, then uninsurance, CHIP, nongroup coverage, and other public coverage, respectively.

    Dig Deeper

    When the researchers blended these two data sources, the study found that individuals who lose their Medicaid coverage after the end of the public health emergency will transition into employer-sponsored health plans in most states.

    More than half of the beneficiaries who lose Medicaid coverage will transition to employer-sponsored health plan coverage in every state except for Georgia (48.9 percent), according to the dashboard associated with the report. The state with the highest share of beneficiaries going into employer-sponsored health plans after the public health emergency was Delaware (57.1 percent).

    Overall, more than one in five beneficiaries who lose Medicaid coverage will become uninsured. Seven states had a 23.1 percent expected uninsurance rate or higher: Arizona (23.5 percent), Florida (23.1 percent), Maine (23.3 percent), New Mexico (23.1 percent), North Carolina (23.2 percent), South Carolina (26.2 percent), and Texas (24.5).

    Delaware had the lowest uninsurance rate projection, but it was still above 15 percent. The First State may see 17.7 percent of its beneficiaries become uninsured after the public health emergency.

    Altogether, 54 percent of beneficiaries will end up in employer-sponsored health plans, 21 percent will become uninsured, 15 percent will gain CHIP coverage, seven percent will join nongroup coverage, and three percent will get other public payer coverage.

    These estimates were close to the Urban Institute estimates except for the CHIP and other public payer coverage projections. Urban Institute expected that 18 percent of beneficiaries would turn to CHIP coverage and only one percent would fall under other public coverage.

    Around 18 million Medicaid beneficiaries will lose their coverage in the first 14 months after the public health emergency ends, according to the Urban Institute.

    In response to the threat of coverage loss after the public health emergency ends, AHIP has partnered with numerous organizations to introduce a new coalition. The coalition’s website consolidates CMS guidance around the redetermination process. The coalition itself encourages information-sharing between stakeholders.

    A separate, state-based analysis from the Kaiser Family Foundation found that states that saw significant Medicaid enrollment gains during the coronavirus pandemic could experience the biggest drop in enrollment after the public health emergency ends.


  • 4 Apr 2023 2:21 PM | Addie Thompson (Administrator)

    In case you haven't heard, COVID-19’s public health emergency (PHE) and national emergency (NE) are coming to a close. The Biden administration announced that both emergencies will terminate on May 11, 2023. In addition to the cessation of various group health plan obligations to provide certain COVID-19-related items/services without cost-sharing under the PHE and the end to the extended deadlines under the NE’s “outbreak period,” the PHE’s expiration will also lead to the unwinding of Medicaid continuous coverage protection.

    Starting as early as February 2023, state agencies in charge of Medicaid may begin the process of redetermining which Medicaid participants may no longer be eligible and, consequently, dropped from Medicaid starting April 1, 2023. The exact timing will vary by state. More information regarding when a particular state will begin this re-evaluation process may be found here(opens a new window).

    Key Takeaways

    • The Medicaid redetermination process will result in numerous individuals losing their current Medicaid coverage.

    • Loss of Medicaid coverage is a HIPAA special enrollment right, allowing individuals to return to employer-sponsored coverage mid-year if they provide notice within 60 days.

    • Bottom line: Employers may see a significant uptick in covered employees and family members in the coming months.

    Background

    The Families First Coronavirus Response Act, passed in early 2020, increased federal Medicaid funding for states that agreed to allow anyone already enrolled or who became enrolled in Medicaid during the PHE to remain enrolled throughout the PHE, even if their eligibility status changed. This continuous coverage rule increased Medicaid enrollment by roughly 30% to approximately an additional 18 million participants. Legislation passed late last year allows states to redetermine eligibility and begin involuntary terminations. It is estimated that roughly 6 million individuals who lose Medicaid coverage will be eligible for coverage under an employer-sponsored health plan.

    Effect on Employer-Sponsored Medical Plans

    Losing Medicaid triggers a HIPAA special enrollment right in employer-sponsored medical plans. And, for many employers who allow employees to pay medical premiums on a pre-tax basis through a cafeteria plan, it is also a qualifying election change event. Generally, the window for notifying the plan of losing Medicaid eligibility is 60 days. However, keep in mind that we are still in the Outbreak Period (think NE) through July 10, 2023, so the 60-day window is temporarily extended for anyone losing Medicaid before that date.

    Lockton Comment: For example, if an employee were to lose Medicaid eligibility effective April 1, they would (under pre-covid rules) have until May 30th to enroll in their employer-provided medical plan, assuming they are otherwise eligible. This year, however, with the extra padding of time under the NE, their 60-day clock to exercise the HIPAA special enrollment right will not start ticking until the end of the Outbreak Period on July 10, 2023, bringing their deadline to Sept. 8, 2023 (July 10 plus 60 days).

    Bring In the Actuaries

    From an actuarial perspective, Lockton’s Actuarial Practice anticipates the impact will likely vary greatly from employer to employer, depending on the employer’s situation. The Medicaid redetermination process would be a non-event for some employers, while others could see a significant impact. Here are points that Lockton’s actuaries recommend employers consider:

    • New members joining a plan due to no longer being eligible for Medicaid could be spread over the next 12 to 18 months.

    • Federal regulators estimate that 5-6 million people who lose Medicaid coverage will seek enrollment in employer-sponsored health plans. This concurs with other CMS data stating that 15-18 million will lose coverage, and 30-40% will seek coverage through employer-sponsored plans. This represents a potential increase of approximately 3% to the total amount of people currently participating in private insurance (~160M).

      • Using this as a starting point, we could expect nationwide employer-sponsored plan membership to increase by 3%.

      • The members coming on to the plan would be expected to have similar costs as those currently on the plan unless other information is available from the client about these members. Thus, the additional members would be expected to result in an increase of 3% cost for employer-sponsored plans.

    • Based on an employer’s specific situation, the impact could be very close to zero (not noticeable among other changes in membership throughout the year); the impact could also be much higher than 3% for employers that were more affected by the pandemic.

    • It is believed that those people impacted by the end of the PHE and NE are more likely those whose employment was also impacted during the pandemic (food service, hospitality, service industries).

    • Employers that were able to move employees to remote working situations during the pandemic and/or didn’t experience a significant loss of workers are not likely to be impacted by this redetermination. These will typically be white-collar industries and those with higher compensated employees.

    Lockton Comment: We recommend that employers review historical waiver percentages pre-pandemic and currently. If the percentage of employees that waived coverage pre- to post-pandemic increased, it is an indicator that an influx of new enrollees could impact the plan. Consideration should also be given to additional dependents being added to the plan for employees currently enrolled.

    There is no information available to help determine how many of an employer’s employees are currently on Medicaid. If somehow an employer had that information, it is expected that about 13% of Medicaid enrollees will be disenrolled, and only about 26% of those will enroll in private insurance (with the rest either re-enrolling in Medicaid based on qualifications or going uninsured).

    Again, for most employers, we do not expect this to be an event to cause any noticeable increase in cost or enrollment; however, for specific employers in certain industries, there could be a cost increase due to the number of new enrollees that should be considered in financials on top of the standard trend.


  • 21 Mar 2023 12:22 PM | Addie Thompson (Administrator)

    Aetna is leveraging its parent company's retail stores to let Medicaid members know they may need to renew their coverage. 

    Kelly Munson, president of Aetna Medicaid, a CVS Health company, told Becker's CVS retail stores have a chance to reach all Medicaid members when they walk into a store, regardless of if they are members of Aetna or another managed care plan. 

    "Regardless of payer, CVS can be supportive of all the Medicaid members that are walking in the door," Ms. Munson said. "We have messaging in the stores that plays over the sound system, videos that remind members they need to be looking for redeterminations, and we have QR codes they can scan so they can know and understand what their next move is." 

    Up to 18 million people nationwide could lose their Medicaid coverage beginning April 1, according to estimates from the Robert Wood Johnson Foundation. Some Medicaid members will lose coverage because they make too much income to qualify for the program, while others may be dropped for administrative reasons. 

    Read more about how Aetna is reaching members ahead of redeterminations here.


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