Health plans and TPAs
Health plans are insurance policies that private companies or government programs offer to cover healthcare costs for enrolled individuals. Third-party administrators manage and process insurance claims for these health and employee benefit plans, often serving as intermediaries among healthcare providers, payers and beneficiaries.
Top Stories
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13 Dec 2024
High health costs force small employers to up cost-sharing
As small businesses struggle to keep up with rising healthcare costs, many have increased cost-sharing for their workers in both single and family coverage. Continue Reading
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01 Nov 2024
ACA open enrollment for 2025: What you need to know
CMS pursued proven outreach strategies for ACA open enrollment 2025, sought to lower costs for consumers, and announced that the number of ACA plans had increased. Continue Reading
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05 May 2021
How Messaging Steers ACA Enrollees to Enhanced Silver Plans
States can leverage email and postal communications to improve awareness about enhanced silver plans among eligible Affordable Care Act enrollees. Continue Reading
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04 May 2021
How Payers Can Improve Attachment Processes in Claims Management
Exchanging attachments is one part of the claims management process that payers can improve upon to save time and money for both payers and their provider partners. Continue Reading
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27 Apr 2021
HHS, 23 Orgs Boost ACA Enrollment Outreach in Black Communities
HHS redoubled its Affordable Care Act enrollment outreach efforts in Black communities by partnering with national organizations. Continue Reading
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23 Apr 2021
Top 3 Policies to Reduce Uninsurance in the ACA Coverage Gap
As policymakers seek ways to diminish the ACA coverage gap, three policy moves stand out as potential paths forward, but each comes with its own challenges. Continue Reading
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20 Apr 2021
Medicare Beneficiaries Strongly Satisfied with Coverage in 2019
In the year preceding the coronavirus pandemic, Medicare beneficiaries were in good health and were satisfied with their healthcare coverage and spending. Continue Reading
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19 Apr 2021
Cost-Sharing Burden Limits Access to Care for Medicare Members
Medicare members who do not qualify for Medicaid face over $1,000 in additional out-of-pocket costs annually, resulting in a care access barrier. Continue Reading
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13 Apr 2021
Medicaid, CHIP Enrollment Increased After 2 Years of Decline
The increase in Medicaid and CHIP enrollment was largely due to the economic and regulatory impacts of the coronavirus and impacted Medicaid enrollment more than CHIP. Continue Reading
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08 Apr 2021
3 Types of Funding for Employer-Sponsored Health Plan Claims
There are three ways to fund employer-sponsored health plan claims—the self-insured, level-funded, and fully-insured models—and the insurer-employer dynamics and risk differ in each. Continue Reading
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07 Apr 2021
5 States With Highest SEP Enrollment Rejected Medicaid Expansion
Special enrollment period enrollment levels are displaying more diversity and higher volume than previous years’ special enrollment periods during the same timeframe. Continue Reading
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07 Apr 2021
New Mothers Experience Uninsurance, Care Disparities Post-ACA
A key aim of Medicaid expansion is to reduce uninsurance and care disparities, but one in three new mothers on Medicaid still faces uninsurance before or after pregnancy. Continue Reading
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23 Mar 2021
Healthcare Literacy May Be Higher For Male Medicare Beneficiaries
Female and male Medicare beneficiaries differ strongly in their confidence related to Medigap and Medicare Advantage enrollment processes and overall understanding of these plans. Continue Reading
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18 Mar 2021
How Medicaid Managed Care Orgs Can Confront Care Disparities
Medicaid managed care organizations are particularly well-positioned to address health inequities across social determinants of health, local infrastructure, technology, and more. Continue Reading
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16 Mar 2021
6 Key Considerations for an Integrated Dual Eligible Program
An integrated dual eligible program would be complicated to establish, but worthwhile for beneficiaries, according to the most recent MACPAC report. Continue Reading
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15 Mar 2021
Payer Boosts MA Chronic Kidney Management Access, Patient Outcomes
Cigna MA members in 18 states now have access to a home-based chronic kidney disease management program that aims to improve patient outcomes. Continue Reading
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08 Mar 2021
Special Enrollment Period Boosts ACA Enrollment by 200k Enrollees
The special enrollment period opened up two weeks prior to this announcement in order to curb coverage losses brought on by the coronavirus pandemic. Continue Reading
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05 Mar 2021
How Medicaid Work Requirements Could Impact Low-Income Women
Medicaid work requirements already have a fraught history, but data from Kaiser Family Foundation indicates that these policies could have a particularly significant impact on women. Continue Reading
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04 Mar 2021
OBGYNs Face Challenges When Providing Care To Medicaid Members
OBGYN care for Medicaid members poses several challenges to providers, such as lower reimbursement rates and prior authorization for prescriptions. Continue Reading
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03 Mar 2021
Middle-Income Enrollees Still Face High Costs with ACA Subsidies
The Affordable Care Act subsidies may have contributed to a 17 percent decrease in out-of-pocket healthcare spending and a nearly 30 percent decrease in catastrophic spending. Continue Reading
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03 Mar 2021
Medicaid Managed Care Shows Marginal Increase in Preventative Care
To reach the CMS goal preventative care rates among children enrolled in Medicaid Managed Care plans, stakeholders must promote care access. Continue Reading
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25 Feb 2021
Aetna Challenges Oklahoma Medicaid Managed Care Contract Picks
The Medicaid managed care contracts went to Centene, UnitedHealthcare, Humana, and Blue Cross and Blue Shield of Oklahoma, but Aetna says the process was subjective. Continue Reading
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25 Feb 2021
Rescinding ACA May Worsen Racial Health Disparities, COVID-19
If pre-existing condition protections are removed from the ACA, COVID-19 infection may lead to further racial health disparities in coverage. Continue Reading
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24 Feb 2021
NC Medicaid Program Audit Reveals Improper Medicaid Payments
Failures in the department’s provider enrollment and re-verification processes and a lack of checks on disciplined providers resulted in improper Medicaid payments. Continue Reading
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19 Feb 2021
MA Members Could See High Out-of-Pocket Costs For COVID-19
As payers eliminate cost-sharing waivers for COVID-19 hospitalizations, high out-of-pocket costs could burden Medicare Advantage beneficiaries. Continue Reading
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18 Feb 2021
COVID-19 Lowered Medicare Care Utilization Across Races, Services
Asian seniors experienced the greatest drop in fee-for-service Medicare utilization, compared to Black, Hispanic, and White Medicare beneficiaries. Continue Reading
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18 Feb 2021
ACA Medicaid Expansion Increases Young Adult Coverage, Health Equity
Underserved adults ages 19 to 25 benefited most from Medicaid expansion, showing how public insurance can promote health equity and care access. Continue Reading
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03 Feb 2021
Medicare Increases Access to Care, Affordability for Seniors
Once eligible for Medicare, the percent of 66-year-olds who experienced barriers in care access was halved and 46 percent fewer seniors avoided care due to healthcare costs. Continue Reading
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02 Feb 2021
Oklahoma Announces Contracts for Medicaid Managed Care Program
The state chose Centene, UnitedHealthcare, Humana, and Blue Cross and Blue Shield of Oklahoma to lead its Medicaid managed care program. Continue Reading
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01 Feb 2021
47% of Uninsured Americans Did Not Explore ACA, Medicaid Options
Many uninsured Americans did not consider Medicaid or plans on the Affordable Care Act marketplace, assuming that they were ineligible or would not qualify for subsidies. Continue Reading
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27 Jan 2021
Medicaid Expansion Could Have Reduced COVID-19 Uninsurance
Medicaid expansion could prove most useful for the thousands of young adults without insurance coverage during the pandemic. Continue Reading
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26 Jan 2021
How Payers Can Make Medical Billing More Streamlined, Transparent
Payers can use simplified billing formats, customizable payment models, and technology to untangle the medical billing process. Continue Reading
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26 Jan 2021
4 Medicaid Eligibility, Enrollment Processes States Must Address
Medicaid eligibility and enrollment processes have become backlogged due to the pandemic, so CMS has outlined states’ priorities after the public health emergency ends. Continue Reading
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25 Jan 2021
Nevada Explores Potential State Public Option Models, Impacts
As the nation’s new president, a proponent of the public option, takes office, the Silver State is investigating state-based public option models. Continue Reading
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21 Jan 2021
Payers Denied 17% of 2019 In-Network Claims on ACA Marketplace
The report calls for changes in Affordable Care Act marketplace transparency data reporting policies in order to support transparency efforts across the marketplace. Continue Reading
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15 Jan 2021
CMS Rule Targets Prior Authorization with Interoperability
The final rule prioritizes data sharing to ensure quality coordinated care and access to health information as part of CMS’ focus on interoperability. Continue Reading
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14 Jan 2021
ACA, Medicaid Expansion Reduced Income Inequality, SDOH By 10%
The ACA reduced income inequality within and between social determinant of health categories, especially for states with Medicaid expansion. Continue Reading
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12 Jan 2021
6 Strategies to Evolve the Affordable Care Act Marketplaces
The Affordable Care Act marketplaces have an opportunity to collaborate, share information, and streamline various state processes by effectively implementing technology. Continue Reading
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11 Jan 2021
CMS Approves Nation’s First Block Grant To Cut Medicaid Spending
The block grant retains the major components of the Tennessee Medicaid program’s original proposal. Continue Reading
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08 Jan 2021
CMS Outlines Medicaid Social Determinants of Health Flexibilities
The new social determinants of health roadmap details how states can access federal funding for their social determinants of health and value-based care strategies. Continue Reading
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29 Dec 2020
GAO: CMS Oversight, Data Needed on State Medicaid Payment Arrangements
As state reliance on provider taxes and local government funds for Medicaid payments grows, GAO calls for CMS data on state Medicaid financing. Continue Reading
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24 Dec 2020
Medicaid Cuts May Affect Children’s Long-term Health Outcomes
Medicaid cuts to address COVID-19 deficits could prove costly as childhood coverage leads to better financial, educational, and health outcomes. Continue Reading
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21 Dec 2020
CMS Says 8.2M Americans Enrolled on ACA Federal Exchange for 2021
Enrollment increased 6.6 percent over 2020 open enrollment on the Affordable Care Act federal exchange. Continue Reading
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03 Dec 2020
Medicaid MCO Enrollment Continued Rising Through September 2020
Economic factors and maintenance of eligibility requirements continued to drive Medicaid managed care organization enrollment higher. Continue Reading
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01 Dec 2020
CMS Proposes Reduced Exchange User Fees To Lower ACA Premiums
The strategy builds on previous years’ efforts to decrease Affordable Care Act premiums by lowering exchange user fees. Continue Reading
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25 Nov 2020
3 Solutions for High-Cost Payer-Coverage for Low-Income People
Targeted Medicaid expansion, bolstering state contributions to Affordable Care Act marketplace subsidies, or a hybrid of these options may help increase payer coverage affordability. Continue Reading
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18 Nov 2020
New Aetna Pilot Aims To Improve Medicaid Member Engagement, SDOH
Aetna targets better Medicaid member engagement and improved social determinants of health by communicating with members through pharmacists. Continue Reading
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17 Nov 2020
Individual Insurance Market Premiums Cover Widely-Used Services
Two-thirds of individual health insurance market premiums cover widely used services including inpatient care, outpatient facility costs, and prescription drugs. Continue Reading
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16 Nov 2020
How Medicaid Expansion Helps Incarcerated Persons Amid COVID-19
Medicaid expansion combined with policies to support Medicaid coverage post-release can ensure that previously incarcerated persons receive care during the coronavirus pandemic. Continue Reading
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13 Nov 2020
CMS Announces Medicare Coverage for Short-Term COVID-19 Therapy
Medicare coverage will apply only to the infusion process and will be used to deliver the therapy to healthcare workers first. Continue Reading
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11 Nov 2020
Unemployed Turn to Affordable Care Act Health Plans for Coverage
Many unemployed Americans who lose their employer-sponsored health plans turn to the Affordable Care Act health plans and public payers. Continue Reading
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10 Nov 2020
Medicaid Expansion Improves Key Prenatal, Postpartum Indicators
Women with Medicaid coverage in Medicaid expansion states were more likely to have a preconception consultation with a provider than they were before state expanded Medicaid. Continue Reading
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04 Nov 2020
Multiple Chronic Conditions, Race Impact Diabetes Medicare Spending
Medicare spending for patients with diabetes can be strongly influenced by the patient’s race and additional chronic conditions, but not necessarily as expected. Continue Reading
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04 Nov 2020
Differences in Medicaid Expansion, Nonexpansion Program Policies
In particular, Medicaid expansion states have more policies addressing immigrant eligibility to their Medicaid programs, as opposed to nonexpansion states. Continue Reading
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30 Oct 2020
How the Coronavirus Pandemic Impacted Medicare Home Healthcare
Medicare home healthcare has been pivotal during the coronavirus pandemic, but it still needs to undergo changes to fully meet beneficiaries’ needs. Continue Reading
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29 Oct 2020
Do State Medicaid Programs Receive As Much As They Give to Feds?
Since federal funding distribution is so contentious, the Urban Institute analyzed whether state contributions to the federal treasury match the Medicaid funding they receive. Continue Reading
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28 Oct 2020
Louisiana’s Population of Uninsured Children Jumped 28.2% in 2019
Louisiana’s children in lower-income families between zero percent and 137 percent of the federal poverty level were hardest hit by this historic increase. Continue Reading
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27 Oct 2020
Pros, Cons of Individual Coverage Health Reimbursement Arrangements
Individual coverage health reimbursement arrangements may be tax-advantaged and flexible, but they can also lead to coverage loss and increased burden on the consumer. Continue Reading
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21 Oct 2020
How Do Medicaid Programs Cover Pediatric Curative, Hospice Care?
States’ Medicaid programs have a wide variety of strategies around covering pediatric care for terminally ill children. Continue Reading
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20 Oct 2020
Average ACA Exchange Premiums Drop for Third Year Running
Although average ACA exchange premiums dropped from plan year 2020 to plan year 2021, they were still higher than in plan year 2017. Continue Reading
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12 Oct 2020
Public Charge Announcement May Have Impacted Childhood Insurance
Although the public charge rule has not yet gone into effect, it may have already impacted children’s health insurance coverage. Continue Reading
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08 Oct 2020
COVID-19 Medicaid Enrollment Is Not Tied to Unemployment Rates
Medicaid enrollment is influenced by a number of state-specific factors and policies, but so far the evidence does not tie it to unemployment. Continue Reading
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06 Oct 2020
How to Improve Children’s Health Insurance Coverage Nationally
Researchers proffer three strategies to improve children’s health insurance coverage and reduce childhood uninsurance. Continue Reading
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05 Oct 2020
Medicaid Expansion Produces Mixed Results on Health Disparities
Medicaid expansion has seen some successes and some setbacks in its efforts against inequality in healthcare coverage, quality of care, and patient outcomes. Continue Reading
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30 Sep 2020
Cost, Health Literacy Cause for Concern Ahead of Open Enrollment
With open enrollment 2021 around the corner, Medicare beneficiaries are confused about their health plan options and struggle financially to meet their healthcare needs. Continue Reading
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29 Sep 2020
Big Premium Drop, More Medicare Advantage Benefits Slated for 2021
Medicare Advantage benefits will likely include more social determinants of health support for enrollees with chronic diseases and increased telehealth benefits. Continue Reading
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24 Sep 2020
COVID-19 Has Negative Impact on Stalling ACA Marketplaces
The Affordable Care Act marketplaces had already stopped seeing significant improvements in insurance gains and affordability, healthcare prices and health outcomes in 2016. Continue Reading
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24 Sep 2020
Medicare Beneficiaries Require More Financial, Coverage Support
The coronavirus pandemic has forced Medicare beneficiaries’ financial struggles into the spotlight, causing researchers to call for more long-term solutions. Continue Reading
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09 Sep 2020
Tobacco Surcharge Hinders Coverage Access for Low-Income Seniors
If the tobacco surcharge was based on ACA enrollee premiums after subsidies, the impact might better protect tobacco users financially while still incentivizing tobacco cessation. Continue Reading
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08 Sep 2020
GA’s Affordable Care Act Exchange Model Moves to Public Comment
Georgia’s new Affordable Care Act exchange model would rely on private vendors entirely for enrollment platforms, instead of HealthCare.gov, and pursues reinsurance. Continue Reading
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04 Sep 2020
How COVID-19 Policies May Affect Medicare Advantage Star Ratings
Policymakers are taking various approaches to minimize negative impacts on Medicare Advantage Star Ratings stemming from the coronavirus. Continue Reading
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03 Sep 2020
How States Handled Medicaid LTSS Coverage, Benefits for COVID-19
Many states expanded Medicaid long-term services and supports coverage and benefits due to the coronavirus pandemic and these changes could have long-ranging impacts. Continue Reading
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24 Aug 2020
Louisiana Will Issue New Medicaid Managed Care RFP, Ends Protest
The new request for proposal will focus on contracting with Medicaid managed care organizations that will help improve the state’s health rankings, the department indicated. Continue Reading
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24 Aug 2020
ACA Special Enrollment Members Have Higher Healthcare Spending
Special enrollment members spend approximately 34 percent more than those who join ACA marketplace plans through open enrollment, indicating possible adverse selection. Continue Reading
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19 Aug 2020
Many Working-Age Americans Face Unstable Coverage, Medical Debt
The authors found that Americans who had unstable coverage due to being underinsured were often in employer-sponsored health plans with high deductibles. Continue Reading
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17 Aug 2020
NY Announces Record Low Individual, Small Group 2021 Premium Rates
New Yorkers will save over $221 million on the individual market and more than $565 million on the small business market with the 2021 premium rates. Continue Reading
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11 Aug 2020
Cigna Embroiled in Lawsuit Over Wellness Program Risk Adjustment
The lawsuit claims that Cigna used its 360 wellness program to raise its Medicare Advantage risk adjustment scores fraudulently, but Cigna stands by its conduct. Continue Reading
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10 Aug 2020
Navigating Medigap Plans: How Payers Can Lead the Way
Payers can play a key role in helping consumers understand their Medigap benefits and policy options through greater benefit and price transparency. Continue Reading
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07 Aug 2020
Consumer Assistance Remains Key to Medicaid, ACA Enrollment Process
Nearly one-fifth of consumers sought consumer assistance when shopping, applying for, or seeking to renew their health insurance coverage or Medicaid enrollment. Continue Reading
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06 Aug 2020
COVID-19 Waivers Improved Medicare Advantage Telehealth Access
More than nine in 10 seniors who took advantage of the improved Medicare and Medicare Advantage telehealth access plan reported a positive experience. Continue Reading
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05 Aug 2020
MO Passes Medicaid Expansion, Second State to Expand Amid COVID-19
Missouri’s Medicaid expansion amendment passed amid COVID-19 has survived two lawsuits and must go into effect by July 1, 2021. Continue Reading
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29 Jul 2020
CMS Transferred $10.8B in Risk Adjustment Payments, Charges in 2019
The risk adjustment payments and charges successfully distributed the costs across participating health payers, the agency said. Continue Reading
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21 Jul 2020
Lawsuit Against UHC Stresses Overpayment Recovery in Employer Plans
The lawsuit questions a practice known as cross-plan offsetting or bulk payment recovery that affects employer plans. Continue Reading
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13 Jul 2020
Dual-Eligible ERSD Patients Yield High Costs for Payers
Data reveals social and cost differences between dual-eligible patients with ESRD and patients with ESRD who are not dual-eligible that payers will need to account for in 2021. Continue Reading
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10 Jul 2020
How to Help Debt-Laden Grads Get Affordable Healthcare Coverage
Burdened with student loans and faced with a challenging job market, recent graduates could get affordable healthcare coverage through ACA tax subsidies tied to student loan payments. Continue Reading
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09 Jul 2020
Medicare Advantage Plans Increase, Improve Quality Over FFS Plans
Medicare Advantage plans kept their expenses low, diversified their benefits, and demonstrated better health outcomes than fee-for-service Medicare. Continue Reading
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08 Jul 2020
Medigap Plans G, N Saw High Enrollment Growth from 2015 to 2018
Medigap enrollment growth was stable across most plans for the past couple of years, but plan G saw a surge in enrollment of 39 percent in one year. Continue Reading
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07 Jul 2020
NC Starts Medicaid Transformation Program, Sidesteps Expansion
North Carolina’s Medicaid transformation program could face even more challenges amid coronavirus. Continue Reading
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06 Jul 2020
Collaboration, Patient Education Key to Increasing Medicaid Coverage
Many individuals experiencing coronavirus-related job loss do not know they are eligible for Medicaid. But provider collaboration and patient education can ensure these patients receive proper coverage. Continue Reading
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01 Jul 2020
Most Furloughed Workers Still Covered by Employer-Sponsored Plan
Coverage options for furloughed workers and laid off individuals who do not have an employer-sponsored plan illuminate the instability of healthcare tied to employment. Continue Reading
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11 Jun 2020
Medicaid Expansion Impacts Contraception Access, Women’s Health
Researchers found that Medicaid expansion influenced women’s health, increasing women’s likelihood to receive long-acting reversible contraception. Continue Reading
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09 Jun 2020
Total Medicaid Expansion May Cut Uninsurance, Uncompensated Care
Researchers analyzed the potential effects of total Medicaid expansion and found that it could lead to 28% lower uninsurance and less uncompensated care. Continue Reading
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04 Jun 2020
Prior Authorizations Discriminate Against HIV Patients in the South
Prior authorizations requirements create unnecessary barriers for HIV patients living in the south and trying to access treatment. Continue Reading
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01 Jun 2020
COVID-19 Impacts on Risk Pool, Costs Stir Rate Setting Uncertainty
Coronavirus presents challenges for the 2021 rate setting process as risk pool and healthcare cost impacts remain unclear. Continue Reading
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29 May 2020
Unemployment Impacts Eligibility in Medicaid Expansion States
In Medicaid expansion states, 83 percent of workers would be eligible for assistance if unemployment compensation was excluded from eligibility calculations. Continue Reading
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28 May 2020
Longer Postpartum Medicaid Coverage Prevents Maternal Uninsurance
Extending postpartum Medicaid coverage for new mothers can not only prevent maternal uninsurance, but could also improve care by lessening financial barriers. Continue Reading
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20 May 2020
Special Enrollment Period Trends on State ACA Marketplaces
States with special enrollment periods are boosting ACA plan marketing and may focus on populations that were unaware of coverage requirements or eligibility. Continue Reading
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18 May 2020
Medicaid Spending, Enrollment Exceed Projections Due To COVID-19
Some states project higher Medicaid spending and enrollment continuing into 2021, as a result of the crisis. Continue Reading
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18 May 2020
Most Payers Cover Member Costs for COVID-19 Testing, Treatment
A majority of health payers are fully covering COVID-19 testing and treatment for their members, according to a new report from Insights by Xtelligent Healthcare Media. Continue Reading
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13 May 2020
27M Americans Could Lose Their Employer-Sponsored Health Plans
When unemployment insurance fizzles out around January 2021, 1.9 million who lost employer-sponsored health plans in nonexpansion states could be left uninsured. Continue Reading
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13 May 2020
Over 6M Seniors May Face COVID-19 Treatment Out-Of-Pocket Costs
Low-income seniors who do not have supplemental coverage or Medicare Advantage could face out-of-pocket healthcare spending. Continue Reading
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05 May 2020
Medicaid Expansion States May See Lower Uninsurance Amid COVID-19
At 20 percent unemployment, over 50 percent of those who lose employer-sponsored health plan covering in a Medicaid expansion state may enroll in Medicaid. Continue Reading