By Karen Davenport Under the Affordable Care Act (ACA), insurers must provide rebates to enrollees when their spending on clinical services and quality improvement, as a proportion of premium dollars, falls below a minimum threshold known as the “medical loss ratio” (MLR). Federal regulators have discovered some insurers are gaming the system by misallocating expenses or inflating their spending on…
…among small employers, it is important to note that it may not reflect the rise of level-funded plans, which market a self-funded plan combined with a low attachment point stop-loss policy. Many small employers may not realize that level funded plans are effectively self-funded plans. Over the long term, it will be important for stakeholders to continue monitoring coverage trends…
…from a health care provider. However, this has not stopped several payers from imposing this requirement (see Table). Meanwhile, some forms also contain explicit warnings about insurance fraud for anyone who submits inaccurate information on their reimbursement request. This, combined with confusion about what exactly they are being asked to attest to, could have a chilling effect on many consumers’…
…reluctance to adopt these models suggests that they will need greater incentives to transition their practices away from FFS and towards value-based APMs. These could be carrots – such as financial support for the necessary infrastructure or technical assistance – or sticks – such as the threat of loss of network status or reductions in reimbursement rates. Given the political…
…not be required to reconcile premium tax credits on their tax returns. BBB proposes a major change in the marketplace enrollment process by allowing low-income individuals to enroll year-round, whereas enrollment is typically restricted to the annual open enrollment period or special enrollment opportunities that are triggered by certain life events like loss of employer coverage. In addition, the BBB…
…financial incentives for completing the screening. Similarly, 15 percent of large firms and 5 percent of small firms reduced their standards for receiving a financial incentive in health-contingent programs. And while the proportion of employers offering programs to help employees lose weight or stop smoking, or offering other lifestyle or behavioral coaching, remained steady, half of these firms made changes…
…disproportionately in counties that had fewer marketplace insurers in 2018. Counties that gained insurers from 2018 to 2021 were more likely than counties that did not gain insurers during this period to have: a limited number of insurers or a monopolist insurer in 2018; a loss of insurers from 2016 to 2018, and a Republican state government. They were also…
…48-year old “Jen” who takes a generic medication for high cholesterol and has an unspecified heart condition. Both were in a one-person household with an annual income of $20,000 and searching for new coverage because of a loss of employer coverage and a planned move to Texas. in an ACA plan with low premiums and out-of-pocket costs during the COVID-19…
…(some argue that number could be even larger). If these individuals are not successfully transitioned into other forms of coverage, it could lead to a dramatic increase in uninsured, erasing the significant progress that has been made in the last year to boost coverage rates. The loss of Medicaid coverage is likely to disproportionately affect Black and Latino/a individuals, exacerbating…
…the impact of the loss of ARPA subsidies, but they will not entirely protect consumers from the financial hit. Individuals in states without state-specific assistance will be even more vulnerable to loss of coverage and access to care. Ultimately, the budgetary impact of the ARP’s more generous subsidies may create political obstacles to extending the benefit. However, as this study…
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