Feds of­fer some re­lief as ACA roll­out con­tin­ues

Modern Healthcare - - SPECIAL REPORT -

Health in­sur­ers con­tinue to im­ple­ment and re­spond to nu­mer­ous aspects of the fed­eral health re­form law. At the same time, they also seek to gain more con­trol over the cost and qual­ity of care by align­ing them­selves more closely with providers.

Reg­u­la­tions from Washington are defin­ing how in­sur­ers do busi­ness in 2011 and be­yond. Health plans con­tinue to gear up for an­tic­i­pated full im­ple­men­ta­tion of the law in 2014, un­less le­gal chal­lenges to the law suc­ceed. That means, in in­di­vid­ual states, in­sur­ers are par­tic­i­pat­ing in and watch­ing closely the de­vel­op­ment of health in­sur­ance ex­changes, which will start in 2014. In­sur­ers are also re­act­ing to In­sti­tute of Medicine rec­om­men­da­tions, re­leased in Oc­to­ber, on es­sen­tial ben­e­fit pack­ages that in­sur­ers must pro­vide to mem­bers who pur­chase cov­er­age through the ex­changes. To the re­lief of in­sur­ers, the rec­om­men­da­tions call for flex­i­bil­ity and the need to strike a bal­ance be­tween af­ford­abil­ity and com­pre­hen­sive­ness of cov­er­age.

Sev­eral high-pro­file deals with providers high­light in­sur­ers’ de­sire to gain more con­trol over the cost and qual­ity of care. Unit­ed­health Group an­nounced in Septem­ber that it would ac­quire the op­er­a­tions of Monarch Health­care in Irvine, Calif., an independent prac­tice as­so­ci­a­tion with 2,300 physi­cians. Monarch is en­gaged in sev­eral ac­count­able care or­ga­ni­za­tion pro­grams— in­clud­ing with Unit­ed­health Group com­peti­tor Well­point. Mean­while, Well­point in Au­gust com­pletes its $800 mil­lion pur­chase of Care­more Health Plan, Cer­ri­tos, Calif., a Medi­care man­aged-care plan that op­er­ates 26 clin­ics in Western states. Well­Point says it will ex­pand this model of com­mu­nity care de­liv­ery to ben­e­fi­cia­ries.

Other high­lights:

Cov­er­age op­tions for the unin­sured are ex­pand­ing through health re­form. Some 2.3 mil­lion young adults are added to their par­ents’ health plans as a re­sult of the law, ac­cord­ing to the Kaiser Fam­ily Foun­da­tion. And mem­ber­ship in state high-risk in­sur­ance pools picks up. In Cal­i­for­nia, which has one of the largest pro­grams, en­roll­ment hits 5,000 peo­ple. The govern­ment’s pro­gram to help em­ploy­ers con­tinue to pro­vide health ben­e­fits to early re­tirees is prov­ing so pop­u­lar that it pays out $4 bil­lion out of $5 bil­lion al­lo­cated, ac­cord­ing to the CMS.

Start­ing in 2011, some health plans must cover pre­ven­tive ser­vices at no cost to pa­tients. Along with the re­quire­ment that in­sur­ers cover de­pen­dents up to age 26, this proves to be one of the more pop­u­lar pro­vi­sions of the Pa­tient Pro­tec­tion and Af­ford­able Care Act.

The cost of cov­er­age con­tin­ues to rise. Av­er­age an­nual pre­mi­ums for fam­ily cov­er­age in 2011 top $15,000, up 9% over the prior year, ac­cord­ing to the Kaiser Fam­ily Foun­da­tion. Health pre­mi­ums con­tinue year-overyear to out­pace wages and in­fla­tion.

De­spite ef­forts to ex­pand cov­er­age, the num­ber of Amer­i­cans with­out health in­sur­ance rises from 49 mil­lion in 2009 to 49.9 mil­lion in 2010, ac­cord­ing to U.S. Cen­sus fig­ures re­leased this fall.

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