Milliman identifies six key questions arising from the Trump/ACA executive order

Milliman has published six questions for consideration by healthcare stakeholders about the Trump administration’s recent executive order, which gives a sweeping command to the leaders of the new administration to unwind certain aspects of the Patient Protection and Affordable Care Act (ACA)—especially those components deemed “burdensome.” It remains unclear how the Trump administration will implement this authority, especially because of the interconnected nature of the ACA, but given Milliman’s comprehension of the law, several key questions arise.

“Milliman has been working with clients across the healthcare system to implement reform since before the Affordable Care Act was signed into law, and we stand ready to assist clients in another round of reform,” said Lorraine Mayne, Milliman Health Practice Director. “The executive order signed on Friday is the first step in a new healthcare reform journey. Based on our understanding of the regulatory authority held by various federal and state entities, we have highlighted several complex questions. We’ve drawn a particular focus on what this may mean for the ACA individual health insurance market, Medicaid, and small employers. Changes for large employers are likely less significant while pharmas and others might not see any immediate differences.”

Strategic questions facing healthcare stakeholders include:

1. Will “hardship” undermine the individual mandate? The executive branch does not have the power to undo statutes—that requires an act of Congress—but the administration could defang the individual mandate via expansion of the hardship exception. It’s unclear if individuals would need to apply for such hardship, if proof of hardship might become part of tax forms (e.g., simply a checkbox), or if the administration could simply opt not to enforce the requirement. Some repeal and replace proposals have called for enrollment penalties similar to those in the Medicare Part B program as an alternative to a mandate—after all, any stable risk pool needs to ensure healthy people have an incentive to enroll. But until any alternative measure is installed, a weakening of the individual mandate may result in lower enrollment by healthy people and a sicker, higher-cost risk pool.

2. Are transitional plans here to stay? Thirty-three states allowed insurers to provide “transitional plans” where insureds have been able to keep their pre-ACA health coverage. The option began with the initial 2014 open enrollment and remains available through the end of 2017. Because pre-ACA coverage was subject to underwriting and risk-based rating, many insureds could maintain lower rates in the transitional coverage while those with less favorable terms migrated to ACA markets. As a result, these transitional plans generally have lower risk and the plans sold through the ACA marketplace have higher risk than if the pools were combined. Insurers anticipated that the expiration of the transitional plans had the potential to introduce new, healthier members to the risk pool and lead to lower rate increases. If transitional plans are extended indefinitely, it could deny ACA plans that relief.

3. What impact could the executive order have on selling insurance across state lines? President Trump argued repeatedly in favor of selling health insurance across state lines during the presidential campaign. And, in fact, the executive order includes a provision calling on agencies to “encourage the development of a free and open market in interstate commerce for the offering of healthcare services and health insurance.” However, it is not clear how this executive order can actually do that; statutory change is probably required. McCarran-Ferguson remains in place, which gives insurance regulatory authority to the states, and thus would seemingly prohibit interstate sales. Practically speaking, it’s unclear why a state would cede authority to allow for a plan from another state to sell insurance in its market or how interstate regulation would actually work.

4. Will the executive order fast-track pending 1115 waivers? The federal government now may be willing to grant more flexibility to state Medicaid programs requested through pending Section 1115 waivers. As of today, there are 11 new Medicaid 1115 waiver applications pending with the federal government. The executive order may encourage the federal Department of Health and Human Services (HHS) to quickly approve these waivers and empower states to make changes. The approval of the 1115 waivers would lead to a number of Medicaid transformation projects for the requesting states, which include, but are not limited to, healthy rewards accounts, work requirements, and integrated mental health programs.

5. Could the employer market be at the center of the action? Over the years, employers have repeatedly expressed concern about the extra burdens placed upon them by the ACA. These concerns related to higher taxes and fees (e.g., the insurer fee passed on to them in the form of higher premiums, the Cadillac tax, and the employer mandate penalties). Employers have also taken issue with increased administrative reporting requirements. Small-group employers have faced even greater changes than the large-group market, with limited plan design choices and restrictive premium structures. Many employers would applaud a loosening of restrictions. It could start with a reduction in paperwork. An easing of reporting requirements for employer groups could signal a relaxation on other requirements.

6. Will essential health benefits be affected? The ACA created the notion of minimum essential health benefit (EHB) categories. Through regulation, HHS allowed states some flexibility in the definition and implementation of EHBs. One such measure was allowing individual states to select a “benchmark plan” to use as a comparative standard. This would allow states to cover the required categories while at the same time recognizing their own mandated benefits. If EHB regulations are relaxed, some modifications to these minimums may occur. The requirement to provide what are sometimes viewed as controversial benefits such as contraception coverage could potentially be modified by an executive order, or when and if the ACA is modified or replaced. Also linked to this issue is the calculation of the actuarial value of the benefits after cost sharing is applied. This process is dictated by law and regulation and will need to be carefully watched as reconsideration of ACA proceeds.

Transition from RAPS to EDS data decreases Medicare Advantage risk scores

Milliman consultants Deana Bell, David Koenig, and Charlie Mills performed a study of how the transition from Risk Adjustment Processing System (RAPS) data to Encounter Data System (EDS) data is affecting payment year (PY) 2016 risk scores and revenue for Medicare Advantage organizations (MAOs). Fifteen MAOs participated in the study, reflecting a cross section of small- and medium-sized organizations and representing over 900,000 members in 154 plans. The consultants offer perspective in their article “Impact of the transition from RAPS to EDS on Medicare Advantage risk scores.”

Overall, the study found that the median percentage difference between PY 2016 risk scores based on RAPS and the EDS-based risk scores is 4.0%. The percentage difference is larger for special needs plans (SNPs) and smaller for general enrollment plans as shown in Figure 1. The prior year’s diagnoses make up a larger component of SNP members’ risk scores, compared to general enrollment plans, so the risk score impact for SNP plans is larger.

[The authors] have not attempted to quantify what portion of the difference between RAPS and EDS is due to incompleteness of the EDS submissions, issues with CMS’s return files (revised MAO-004 files), changes to filtering logic, and the effect of claims coding errors.

As an illustration, the potential Part C PY 2016 revenue using the median difference of -4% between RAPS and EDS results in a reduction of approximately $40 per member per year, assuming approximately $800 in Part C risk-adjusted revenue and a 1.0 RAPS-only risk score. To the extent that this -4% gap persists in future years, the revenue impact will grow because the EDS-based risk score will make up an increasing portion of the final risk score (e.g., with the 25% EDS weight in PY 2017, the per member reduction would be about $100 per year).

This article is the second in a series of articles on the transition to EDS. For more information about the EDS and RAPS data used in MA risk scores, read “Medicare Advantage and the Encounter Data Processing System: Be prepared.”

Repeal, replace, or reform: Key policy discussions affecting the individual health insurance market

How might the Patient Protection and Affordable Care Act (ACA) be affected by the incoming Trump administration? The new administration and the Republican Party are considering a number of policy ideas regarding ACA’s repeal, replacement, and reform. In this article, Milliman’s Scott Weltz, Fritz Busch, and Nick Krienke highlight key policy discussions to monitor that will have a significant impact on individual health insurers.

This is the first in a series of papers Milliman will publish as the country contemplates another round of healthcare reform. We have also compiled a reading list of relevant papers from our ongoing analysis of the ACA. To view that library, click here.

Increases in self-insured employers and stop-loss coverage

Under a self-insured group health plan an employer shoulders the financial risk for providing healthcare benefits to its employees. Stop-loss insurance can help an employer mitigate the risk associated with high-cost or catastrophic health claims.

While large employers have customarily self-insured, small and midsized employers have increasingly weighed the benefits of self-insurance since the passing of the Patient Protection and Affordable Care Act (ACA), spurring growth in the stop-loss market. In this article, Milliman’s Mehb Khoja discusses the ACA’s impact on self-insurance and on stop-loss coverage.

Here is an excerpt from the article:

The stop-loss market is believed to be a roughly $15 billion industry, up from $8 billion to $10 billion pre-ACA. Its growth is related to the increased prevalence of self-funding along with the changes from ACA which increased premiums, plan enrollment, or both for stop-loss insurance carriers….

… ACA has considerably increased the need for and expanded employer interest in stop-loss coverage due to several factors:

• Removal of annual and lifetime maximums (prior to ACA, a cap on annual expenses on an employer-sponsored plan was common and allowed stop-loss insurance carriers to limit their exposure).
• Removal of pre-existing condition exclusions (prior to ACA, employers could temporarily exclude high risk members).
• The individual mandate and extending dependent coverage to age 26 have all increased membership in employer-sponsored plans.
• Expanded taxes on fully insured health plans.

A tale of two national health plans

The United Kingdom’s National Health Service (NHS) and the United States’ Medicaid program both provide publicly funded medical services to a broad population. The general goal of both is to find a balance of quality and efficiency that promotes access to appropriate and financially sustainable medical care. This article written by Milliman consultant Jennifer Gerstorff and Northampton General Hospital’s Chris Pallot explains the history of both programs. The authors also compare and contrast how the programs are funded, how providers are contracted, and how innovations are changing each system.

Regulatory roundup

More healthcare-related regulatory news for plan sponsors, including links to detailed information.

Technical guidance for self-insured health plans on federal external review process
The U.S. Department of Health and Human Services issued “Technical Guidance – Standards for Self-Insured Non-Federal Governmental Health Plans and Health Insurance Issuers Offering Group and Individual Coverage.” This release replaces the technical guidance issued June 22, 2011, with standards adopted in the final regulation at 76 FR 37208 that further define requirements under Public Health Service Act (PHS Act) section 2719(b)(1).

For more information, click here.

Agencies issue ACA FAQs, Part 37
The U.S. Departments of Treasury, Labor (DoL), and Health and Human Services released frequently asked questions (FAQs) Part 37 regarding Patient Protection and Affordable Care Act (ACA) implementation. The FAQs highlight: health reimbursement arrangements (HRAs); integration of HRAs with group health plans sponsored by the employer of a spouse of an employee; Code Section 162(m)(6); and more.

To read the FAQs, click here.

DoL issues FY 2016 MHPAEA enforcement fact sheet
The Employee Benefits Security Administration (EBSA) enforces the law governing 2.2 million private employment-based group health plans, which cover 130.8 million participants and beneficiaries. EBSA relies on its 460 investigators to review plans for compliance with ERISA, including the Mental Health Parity and Addiction Equity Act (MHPAEA). EBSA released its first annual MHPAEA enforcement fact sheet, summarizing its enforcement activity in fiscal year (FY) 2015.

To read the fact sheet, click here.