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CMS Efforts to Ensure Network Adequacy and Alter Risk-Adjustment Payments

Posted by Susan Donegan on Fri, Sep 30, 2016

CMS is aware that some states may struggle more than others in developing strategies that ensure network adequacy, especially those with large rural populations. So, CMS is teaming up with Medicaid directors to create a guidance that will read more like a best-practices document, James Golden, director of the agency's division of managed-care plans, said at the Medicaid Health Plans of America conference. (Modern Healthcare, 9/22/16)

HHS’s proposed Notice of Benefit and Payment Parameters for 2018 could alter the way risk adjustment and other tenets of ACA exchanges work, but the provisions, to keep carriers on the exchanges or bring back those that have left, failed to impress Wall Street or ease concerns of insurers. One major analyst said the sheer complexity of the formulas used by HHS is one of the reasons few health plans make money on public marketplaces. (Health Business Daily, 9/20/16)

Urban Institute researchers found that, in more than three-quarters of states and 80 percent of the large metropolitan areas they studied, total premiums were lower in an average marketplace plan than in employer-provided plans. "It's not that these markets are necessarily outrageously expensive -- in the vast majority of cases they're not," said Linda Blumberg, a senior fellow in the health policy center of the Urban Institute. However, most people who receive health insurance through their employers directly pay only a portion of the premium each month. The rest is paid by the employer, as part of workers' compensation. (Washington Post, 9/19/16)

President Barack Obama urged U.S. insurers offering coverage next year on the exchanges to step up their efforts to enroll those who remain uninsured, especially younger and healthier Americans. His administration will help find and enroll those who still lack coverage, with a particular focus on enrolling young adults. (Fortune, 9/13/16)

Blues Plans Updates:

Blue Cross Blue Shield of Tennessee, the state’s largest health insurer, announced plans to exit the federal health exchanges in Nashville, Memphis and Knoxville next year. The insurer cited considerable losses and the ongoing uncertainties on the individual health marketplaces created under the Affordable Care Act (ACA) as reasons for the withdrawal. (Insurance Business America, 9/27/16)

Blue Cross Blue Shield of Nebraska (BCBSNE) plans to discontinue its ACA products due to poor financial performance threatening the payer’s responsibility “to remain stable and secure.” (Fierce Healthcare, 9/26/16)

Blue Cross Blue Shield of North Carolina (BCBSNC), has announced that it will continue offering ACA exchange plans. (Fierce Healthcare, 9/26/16)

Tags: Healthcare, health reform, ACA, healthcare exchanges, HIX

 

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