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Insurers and ACA Marketplaces Over Time

Posted by Laura McMullen on Thu, Jun 15, 2017

We’re approaching CMS’ June 21 deadline for Qualified Health Plan applications and rate table templates for plans to be sold on or the state marketplaces. So, it seems like a good time to look back over the last four years and see how the mix of insurers participating in the exchanges changed between 2014 and 2017.

ACA.pngThe Kaiser Family Foundation’s Health Reform blog has a nice summary here that includes interactive maps. Data for this analysis was gathered from, state exchange enrollment websites, and insurer rate filings to state regulators.

Year by year overview

  • 2014: on average 5 insurers participated in each state, ranging from 1 insurer in New Hampshire and West Virginia to 16 in New York.
  • 2015: on average 6 insurers participated in each state, ranging from 1 in West Virginia to 16 in New York.
  • 2016: on average 5.6 insurers participated in each state, ranging from 1 in Wyoming to 16 in Texas and Wisconsin. The mix of carriers in each state changed a lot in 2016 as CO-OPs failed and new plans entered the market.
  • 2017: on average 4.3 insurers participated in each state, ranging from 1 in Alabama, Alaska, Oklahoma, South Carolina and Wyoming to 15 in Wisconsin.

Other findings from the analysis

  • There are fewer choices in most counties. In 2017, 58% of enrollees (living in about 30% of counties) had a choice of three or more insurers, compared to 85% of enrollees (living in about 63% of counties) in 2016.
  • Rural areas have fewer insurers than metro areas. In 2017, metro areas have 2.5 insurers vs. 2 insurers in rural areas. 87% of 2017 enrollees live in metro areas.
  • Many counties are served by one carrier, most likely a Blue Cross Blue Shield or Anthem plan. In 2017, about 21% of enrollees (living in 33% of counties) have access to just one insurer on the marketplace (up from 2% of enrollees living in 7% of counties in 2016).

How has the mix of insurers impacted your network? Has your network participation in the ACA changed over the last four years?

Tags: health insurance, Affordable Care Act, ACA. healthcare exchanges, Healthcare, ACA, health insurance co-ops

CO-OPs and Integrated Health Care Delivery Systems Exiting Insurance Market

Posted by Laura McMullen on Wed, Dec 21, 2016

ACA.pngOne of the intended effects of the Affordable Care Act was to open up the insurance marketplace to new competitors. In 2015, we examined CO-OPs and integrated health care delivery systems to learn more about their business models and positioning. Both types of companies are leaving the market now without having reached the critical mass of members and premium needed to compete against the larger, more established insurance companies operating in their service areas.

Here are the stats on CO-OPs, according to

  • 5 of the 23 CO-OPs that were originally chartered under the Affordable Care Act will be operational in 2017.
  • 2 of the remaining CO-OPs are working with outside investors to stay in business: New Mexico Health Connections is currently profitable and working with Raymond James, a NY investment firm, to raise a substantial amount of funding to continue operations and Evergreen Health in MD is working with private equity investors to transition from a non-profit CO-OP to a for-profit entity.
  • CO-OPs owe more than $130 million to the 2015 Affordable Care Act risk adjustment program that distributes payments from health insurers with lower-risk enrollees to health insurers with higher-risk enrollees. This program was created “to prevent insurers from designing plans that appeal only to healthy enrollees, and to ensure that premiums reflect benefit levels, rather than the overall health of a plan’s enrollees.”

Integrated health care delivery systems are winding down their operations too, as reported in the Denver Post.

  • Catholic Health Initiatives, Tenet Healthcare Corp., WellStar Health System (GA), and Piedmont Healthcare (GA) have all sold or shut down their insurance operations after steep losses.
  • High start-up costs to compete against well-established carriers and low membership contributed to their decisions.
  • Ascension Health (St. Louis) and Northwell Health (Great Neck, NY) remain in the insurance business.
  • “McKinsey & Co. said in a 2015 report that while hospital-owned insurers covered just 8% of the nation’s insured, 20 of those 107 insurers accounted for two-thirds of that total.”

How do these plan shut-downs affect your business? Are the providers in these networks already in your networks? Do you want to add them?

Tags: health insurance, Affordable Care Act, ACA, provider networks, health insurance co-ops

The Role of Technology in Expanding Vision Tests

Posted by Laura McMullen on Wed, Aug 10, 2016

This summer, my daughter found out she will need glasses soon, my cousin’s daughter got glasses, and my mom had cataract surgery – I’ve worn glasses since I was a kid so eye exams and buying glasses and contact lenses is always a topic in our house.  

eye_exam.jpgTechnology has made a big impact on vision care. The latest trend is apps to test your vision. When I looked at the iTunes store, I found 10 apps in a search for “eye exam medical” and in Google Play, I found more than 50. They have names like Eye Exam – Eye Test, Eye Test, and Eye Exam. Some of them were created by eye care professionals and others by tech experts. These apps use mobile devices to check for visual acuity, color blindness, astigmatism, and macular degeneration. When you look at the reviews, people rave about the convenience and low price. The results aren’t a prescription that you can use to get eyeglasses or contact lenses. 

Another trend is websites that let you refract your own eyes and send the results to an eye doctor to be certified. Once the results are certified, you can use them to get eyeglasses or contact lenses. Opternative and EyeXam are two of the biggest sites. Opternative markets directly to patients and encourages them to use their prescriptions at any retail location. The results are signed by a board-certified ophthalmologist licensed in the patient’s state. EyeXam markets to eye care providers as a way to attract new patients and to patients as a way to connect with an eye care provider. 

The American Optometric Association is concerned that apps and websites like these are operating without proper medical supervision and recently sent a formal complaint to the FDA. A recent article in Employee Benefit News summarized the AOA’s position: 

  • Self-serve apps and websites can give “inaccurate or misleading information and may miss deeper health issues.” 
  • These apps and websites confuse refraction test and exams. According to, a refraction test checks to see that light is bending properly when it passes through the cornea and retina of the eye. The results of this test tell the eye care provider what correction is required to make your vision 20/20. Self-serve apps offer refraction not exams. 
  • More comprehensive adult eye exams should be available to all consumers similar to the pediatric vision benefits required by the Affordable Care Act. 

SHRM estimates that 87% of employers offer vision benefits to their employees and eye exams and refraction tests are the services that people with vision benefits use most frequently. More complicated conditions such as low vision caused by diabetes are usually covered by medical plans.  

More vision tests would seem to mean more people looking for glasses and contact lenses. How do you think these trends will impact your network? 

Tags: health insurance, Affordable Care Act, Vision, Vision insurance, employee benefits

New Plans Being Added While Existing Plans Are Coming Off the Exchanges

Posted by Laura McMullen on Fri, Jul 29, 2016

We’re reading about exchange plan comings and goings and the impact of the ACA on the federal budget. Here’s a roundup of interesting datapoints, perspectives, and news.

Aetna and Gateway Health are forming an accountable care organization and releasing a new individual insurance plan to sell on in time for the 2017 open enrollment period. The new plan Aetna Leap offers lower overall out-of-pocket costs for members who see providers within the new Aetna Whole Health–Gateway Health network. (Healthcare Finance, 7/15/16)

7 ... of the 23 original Consumer Operated and Oriented Plans (CO-OPs) under the ACA will sell coverage on the exchanges this fall, with the remainder on the financial ropes. (AIS Health Business Daily, 7/26/16, Click here to read the INSIDE HEALTH INSURANCE EXCHANGES article in which this datapoint appeared — "With 16 CO-OPs Out, MCOs May See Smaller Risk-Adjustment Payouts" Free for HEX subscribers; $17 for non-subscribers.) For a refresher on CO-OPs, take a look at our blog postfrom 10/15.

Humana Inc. plans to greatly reduce the plans it offers through public health insurance exchanges and stop offering coverage in “substantially” all other individual markets next year. The health insurer said “individual business remains very challenging.” With the change, Humana said its 2017 “presence for its individual offerings is expected to cover no more than 156 counties across 11 states, down from 1,351 counties across 19 states in 2016.” (Business Insurance, 7/21/16)

The federal government's deficit for this year is expected to be $600 billion, or about $16 billion lower than what was predicted this past February, according to amid-year analysis released Friday by the White House. Lower-than-expected enrollment in the Affordable Care Act's public health insurance exchanges shaved $6 billion off federal spending. (Modern Healthcare, 7/15/16)

Questions about access and consumer preferences continue to be in the news as the debate about the future of the Affordable Care Act continues. House Ways and Means hearings on July 12 resulted in lawmakers agreeing that the ACA isn’t working as intended and that enrollment is lower than anticipated. (AIS Health Business Daily, 7/25/16)

Access to healthcare remains a challenge through the Affordable Care Act and commercial health plans, according to a study in the July issue of Health Affairs. The study investigated two questions: first, no matter the nominal size of a network, can patients gain access to primary care services from providers of their choice in a timely manner? Second, how does access compare to plans sold outside insurance Marketplaces? (Managed Healthcare Executive, 7/22/16)

43% ... of young adults (age 18 to 34) are willing to consider a network without their current provider for a lower premium, according to a recent survey by the Deloitte Center for Health Solutions. (AIS Health Business Daily 7/27/16, Click here to read the HEALTH PLAN WEEK article in which this datapoint appeared — "Insurers Are Learning the Do's And Don'ts for Selling to Millennials" Free for HPW subscribers; $17 for non-subscribers.)

Tags: Affordable Care Act, ACA, healthcare exchanges, HIX

Voluntary Ancillary Growth is a By-Product of ACA

Posted by Laura McMullen on Fri, Jun 24, 2016

Business is booming for insurance companies specializing in ancillary benefits for employer groups – and the mandated benefit requirements of the Affordable Care Act are driving the growth. A 2016 study of Form 5500 Schedule A data by analytics firm, miEdge, valued the market at more than $1 billion in 2015, a gain of 3.32% over the previous year.

Employee Benefit Advisor interviewed four ancillary companies with double-digit growth to learn more about their strategies to capitalize on this trend. Click here to read the article. Here are some highlights:

  1. Medical premiums are still growing in part due to mandated benefit provisions in the Affordable Care Act. Brokers and employers are looking for ways to offer comprehensive benefits without raising overall cost and voluntary ancillary options fit right in.
  2. Private exchanges make it easier to offer a mix of voluntary and employer-paid benefits from multiple carriers. Employees are comfortable with e-commerce so online enrollment is business-as-usual.
  3. Pediatric dental care is required by the ACA creating a new market for dental benefits. More interest and education about dental has opened the door to other ancillaries, such as vision (often sold with dental) and even legal plans.

Employee Benefit Advisor reported “the top five grossers in voluntary benefits, according to miEdge, were Delta Dental of Rhode Island (up 105.59% and over $40 million), Delta Dental of Illinois (up 99.34% and over $46 million), Combined Insurance Company of America (up 82.03% and over $81 million), Hyatt Legal Plans (up 21.12% and over $15 million), and Principal Financial Group (up 20.83% and over $14 million).”

How is your company capitalizing on this trend?

Tags: Affordable Care Act, Ancillary benefits, ACA, insurance companies, employee benefits, HIX

CO-OPs: early casualties in the marketplace

Posted by Laura McMullen on Tue, Oct 27, 2015

We explored the health insurance CO-OPs that were created under the Affordable Care Act in a blog post earlier this year. There were 23 in 26 states at the beginning of 2015 and, as of October 16, eight had ceased operations, according to Employee Benefit News, and will not sell plans for 2016 on the public exchanges. The Commonwealth Fund reports that the CO-OPs received $2.44 billion in public funds and enrolled 500,000 people collectively.

Why Are CO-OPs Failing?

In a statement on their website, the National Alliance of State Health CO-OPs (NASHCO) attributes the closures to the CMS decision to pay 12.6% of the 2014 risk corridor. The statement goes on to mention lower ACA enrollment projections, consolidation of the health insurance market, and unexpected risk adjustment obligations as additional factors in the closure of CO-OPs in Tennessee, Colorado, and Oregon.

The failure of nearly one-third of CO-OPs “reflects a combination of factors: low pricing and higher utilization than expected against those prices; inability to leverage competitive prices from providers; greater than anticipated losses from risk adjustment; and most recently and acutely, much less payment than expected from risk corridors,” explains Katherine Hempstead, a director at the Robert Wood Johnson Foundation in Princeton, N.J., in Employee Benefit News.

What Are Risk Corridors?

In a brief called Explaining Health Care Reform: Risk Adjustment, Reinsurance, and Risk Corridors, the Kaiser Family Foundation explains that risk corridors are a three-year program to “limit losses and gains beyond an allowable range” in the first three years of the ACA as people with pre-existing conditions enroll. HHS does this by charging Qualified Health Plans (QHPs) that have lower than expected claims and distributing the funds to QHPs that have higher than expected claims. The methodology allows for shortfalls in collections and government funding, stating “if risk corridors collections for a particular year are insufficient to make full risk corridors payments for that year, risk corridor payments for the year will be reduced pro rata to the extent of any shortfall.” For 2014, $362 million were collected from plans with expenses below their allowed rate and $2.87 billion was needed to pay all of the QHPs with expenses above the allowed rate leading to the 12.6% reimbursement rate. Many carriers have large receivables based on these calculations that they are not going to collect. For CO-OPs, with smaller budgets and less in reserves, an uncollectible receivable can be devastating.

Risk Adjustment Obligations and Other Regulations

The Kaiser Family Foundation brief explains that risk adjustment is a permanent program designed to protect against adverse selection and risk selection by “redistributing funds from plans with lower-risk enrollees to plans with higher-risk enrollees.” Payments are calculated based on actuarial risk scores. In some cases, CO-OPs were able to attract healthier people and became liable for large risk adjustment payments. The lower-than-anticipated risk corridor payments and restrictions on outside investment made these payments a larger problem for CO-OPs than for other insurers.

The Pew Trusts Stateline blog noted that CO-OPs had other restrictions to contend with:

  • Obstacles to obtaining outside financing as a condition of the federal loan
  • Inflexible pay-back requirements
  • Parameters around how the borrowed funds could be spent, including prohibitions on advertising
  • Limited opportunities for new investment

A Competitive Market: Lower Enrollment Projections and Increased Merger Activity

Original estimates from the White House and Congressional Budget Office expected as many as 20 million people purchasing health insurance on exchanges while the latest estimates are just 10 million. The Washington Post reports that some of the obstacles preventing people from enrolling are:

  • The cost of plans even with government subsidies
  • The value of current plans based on a year of usage
  • The difficulty of reaching uninsured people – about half are young adults, more than one-third are minorities, and 80% have less than $1,000 in savings

Recent surveys of employers found that they view the mergers as a mixed blessing: better negotiating leverage will drive down provider cost for insurers ultimately lowering premiums but larger insurers will reduce competition ultimately increasing premiums.

CO-OP Failures As Part of the Bigger Picture

The CO-OP 30% failure rate is in line with the failure rate reported by the Bureau of Labor Statistics for health care and social assistance companies after two years. Health care and social assistance have been among the industries with the highest survival rates historically – across all industries the failure rate is 90%, according to Forbes magazine.

In fact, there aren’t many new entrants in the health insurance industry because of the barriers to entry. On September 15, 2015, the New York Times reported that “only two for-profit companies that were not already health insurers have entered the state marketplaces so far: Oscar, a New York-based upstart with a Silicon Valley flair and plans to take on California and Texas in 2016, and ZoomPlus, which just received approval to sell policies in Oregon.”

Health insurance is a complicated business made even more so by the changing regulatory environment. What impacts are you seeing in your top and bottom markets from risk corridors and risk adjustment obligations?

Tags: health insurance, Affordable Care Act, healthcare reform, ACA, healthcare exchanges

Discount networks benefit providers and consumers

Posted by Laura McMullen on Tue, Jul 21, 2015

dscount_plansDiscount plans offer pre-arranged discounts at participating providers and offices. These programs are not insurance. The Federal Trade Commission explains the difference between discount plans and health insurance this way:

  • If you buy a health insurance plan, it generally covers a broad range of services, and pays you or your health care provider for a portion of your medical bills.
  • With a medical discount plan, you generally pay a monthly fee to get discounts on specific services or products from a list of participating providers. Medical discount plans don’t pay your health care costs.

The Affordable Care Act changed the market for medical plans by requiring people to buy health insurance, although medical discount plans are still available. Dental and vision discount plans are widely available for purchase. Prescription discount plans are also available for those who qualify.

The companies that manage these plans have a variety of relationships with the providers in their networks. Here are some examples:

  • Insurance Carriers: Assurant, Careington, Aetna’s Vital Savings program. Insurance companies offer discount plans using their PPO networks as a way to generate more cash business for their providers and make popular non-covered services available to their members. LASIK and teeth whitening are examples of services that are often purchased using discount plans. Typically discount plans define eligible services by vertical industry, such as alternative medicine, dental, or vision.
  • Discount Program Organizations: AmeriPlan, Access to Healthcare Network, Patriot Health, Discount networks are purpose-built and sold in the open market. Providers like these plans because there is less paperwork, fewer rules, and payment is received when services are rendered. Members like them because they can choose any provider in the network, there are no deductibles or maximums, and there are no waiting periods. While these plans can’t be coordinated with Medicare or Medicaid, they can be used in conjunction with many commercial plans. These plans are usually organized by vertical.

Prescription Assistance Programs are included in the discount plan category, although they are a little different. They often have application processes that require approval from health care providers and are affected by income level and the cost of the medication needed. is a clearinghouse sponsored by the biopharmaceutical research companies that help connect qualifying patients with the program that’s best for them.

Do the providers in your network value discount plans as a way to diversify their income streams and attract new patients? How do your members feel about discount plans as a supplement to their insurance plans?

Tags: health insurance, Affordable Care Act, ACA, provider networks, insurance companies, dental discount plans, discount health plans, medical discount plans, vision discount plans, health care provider

Focusing on vision networks

Posted by Laura McMullen on Tue, Jul 07, 2015

A few years ago, we published a whitepaper called Clearing Up the Vision Market. Since then, the demand for vision networks has increased significantly with the number of people who take a vision plan when it’s offered growing from 78% in 2012 to 83% in 2013 in a 2014 SHRM study on vision care, so we decided to take another look.

As of March 2015, there are 48,000 optical locations in the top 10 national vision networks. They fall into two categories: independent eye care professionals (ECPs) and retail chains.

  • ECPs are defined by VisionWatch as having three or fewer locations with an ophthalmologist, optometrist, an optician, or an optical retailer on site. Nearly all ECPs are small businesses.  According to a whitepaper sponsored by Vision Source, ECPs are typically single location operations with less than $1.5 million in annual revenue and 12 or fewer employees. They have been in practice on average for 20 years.
  • Retail chains have 4 or more locations and may or may not have an ophthalmologist or an optometrist on site. The best-known brands in this category are widely available, such as LensCrafters, Pearle Vision, Walmart, and Costco.

ECPs make up two-thirds of locations and 45% of market share while retail chains are the rest. A recent Bain and Company study shows the second most influential factor (after cost) in selecting a managed vision care plan is the retail network the plan provides. This helps explain why retail chains account for 55% of vision sales, with only one-third of the locations.

A Consolidating Market

In a recent Wall Street Journal blog post, Optometrists Catch FFL’s Eye, Thomas Puckett of merger and acquisition advisory firm HPC Puckett & Co., said “There aren’t many operators with over 100 locations, but there are quite a few independents with under 50 locations. It is logical for businesses to consolidate in a geographic area.”

Private equity firms are projecting that the number of retail outlets will drop by half over the next five years through consolidation. Investors are most interested in firms valued at $10 to $50 million and the expected growth from the Affordable Care Act and the aging US population makes the industry even more attractive.

Other Vision Network Trends

A recent review of the top 10 national vision networks in NetMinder found some interesting trends:

  • Vision networks are growing. The number of unique providers in these networks grew about 8% annually from 2011 to 2015. Unique locations grew more slowly (3% annually) and access points grew more quickly (11% annually). This is most likely because retail chains, such as Pearl Vision or Lenscrafters, generate more revenue with fewer locations.
  • Some ECPs practice at many locations. On average, ECPs are listed in provider directories at 2.4 locations with a range of 1.6 to 3.2 locations. This could be the beginning of a trend toward overstated access in vision networks. We see about 25% access point inflation in dental PPO networks and have put a validation process in place using claim data to adjust counts. We are watching vision networks closely to see if a similar filter is needed. 
  • vision_networksECPs are joining more networks. In March 2011, the average ECP participated in 2.5 networks. By March 2015, that count was up to 3.7 networks. This shift is quite dramatic: five years ago 75% of eye care providers in these networks were in 1-3 networks and now only 53% are while 15% are in 7-10 networks.

Are you seeing these trends play out in your network? Are vision benefits in demand among your customers and their employees?

Tags: network providers, Affordable Care Act, optical retail, Vision, Vision insurance, healthcare benefits, Managed Care, employee benefits, vision networks, practicing locations

TPAs move beyond claims and eligibility

Posted by Laura McMullen on Thu, Jun 11, 2015

Large employer groups, unions, associations, and other plan sponsors are all looking for ways to minimize healthcare costs. Historically, one way is to self-fund to keep the administrative costs low and allow for customization of benefits offered. One of the ripple effects of the Affordable Care Act is that smaller groups are investigating self-funding as well. When groups self-fund, they commonly turn to third-party administrators to provide the services and expertise needed to establish and maintain the plan.


Third-party administrators and cost management experts work on behalf of employers and other groups to keep claims costs low. In addition to reporting on claims, eligibility, utilization, and other dimensions to help employers manage costs, they also aggregate and manage networks.Using supplemental networks can extend healthcare benefits to employees who don’t work in centralized locations and improve employee morale.

In 2013, Business Insurance ranked the largest TPAs that specialize in employee benefits. The top five were:

Third-party administrators commonly re-price claims by recalculating billed medical charges based on the rates and rules a PPO has negotiated with supplemental networks. They also directly negotiate with providers to ensure that all claims are discounted. These networks are often a combination of risk and non-risk PPOs, depending on the plans that are being offered to the group’s members. When there is a combination, it is important to make sure that all providers are properly contracted to offer discounts to members.

Another way that TPAs factor into the changing network landscape is to provide the claims administration, eligibility management, and other back office functions hospitals and health systems need when they start to sell to groups and individuals. This has become an important service in removing the barriers for new entrants into the healthcare market.

How can you leverage your TPA relationships to expand your sales and/or network reach?

Tags: health insurance, Affordable Care Act, health reform, consumer choice, employee benefits, third party administrators, TPAs

The impact of integrated health care delivery systems is growing

Posted by Laura McMullen on Thu, May 28, 2015

Hospitals have always had informal networks of nearby physicians with admitting privileges as well as staff physicians. And some hospitals and health systems, particularly those that self-insure, have long required employees to access care within their organization to help control costs. With a new set of incentives in the Affordable Care Act that encourage providers to focus on outcomes instead of activity, these practices came together to reduce the barriers to entry in the health insurance industry and create new entities that compete for premium dollars.

Cutting Out the Middlemen

hospitalLarge hospitals and local or regional health systems have formed insurance companies that sell plans to employer groups and individuals, i.e. North Shore – Long Island Jewish Hospital’s CareConnect or UPMC in western Pennsylvania. Dr. Kenneth L. Davis, CEO and president of Mount Sinai Health System in New York, said, “Inevitably the large systems are going to move to take part of the premium dollar,” in an article in the Fiscal Times after the 2014 Health Care Forum in Washington, DC, sponsored by The Atlantic. He went on to discuss the importance of “retaining more and more of the health care premiums paid by consumers is essential to providing a full spectrum of care.” For example, St. Luke’s Hospital, part of the Mount Sinai Health System, lost $14 million in its psychiatric program in 2013 and needs to be subsidized by revenue from other parts of the system. Offering insurance coverage is another way to do that.

Partnering to Compete

Some insurance companies own hospitals, other facilities, and physician groups which are included in their networks, for example Kaiser Permanente or Willamette Dental Group. Others choose to create new companies such as the joint venture between Anthem and seven Southern California hospitals when they formed Vivity Health Plan. Vivity is priced below Anthem’s standard HMO plan and includes the big academic medical centers consumers want access to, according to the LA Times. This new market entrant could take business away from Kaiser Permanente in the large Southern California market.

Too Big to Fail?

Another approach is for hospitals to merge. There were 95 hospital mergers and acquisitions in 2014, according to The ObamaCare Effect: Hospital Monopolies in the Wall Street Journal. Two acquisitions are being challenged in state court:

How does this trend play out in your network? Does hospital consolidation make it easier to set up a narrow network? Or is this an opportunity to add more locations and providers through the physician groups that are included in integrated health care delivery systems?

Tags: health insurance, narrow networks, Affordable Care Act, health reform, consumer choice, insurance companies





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