The introduction of the Patient Protection and Affordable Care Act (ACA) brought about many legislative changes intended to improve the health of people in the United States. One such change was the introduction of mandatory coverage with no cost sharing for services determined to be “preventive.” Some examples of the services included on the U.S. Preventive Services Task Force (USPSTF)’s A and B Recommendation list are blood pressure screening for adults, depression screening for adolescents and adults, intimate partner violence screening for women of reproductive age, and skin cancer behavioral counseling.
The USPSTF regularly updates its recommendations and the ACA preventive services list has been modified many times since the introduction of the ACA in 2014. In this paper, Milliman’s Barbara Collier and Michelle Klein examine the evolution of preventive services. They also discuss how these services have been impacted by the COVID-19 pandemic.
One innovation that is driving enrollment growth for some Medicare Advantage organizations (MAOs) are preferred provider organization (PPO) plans with a $0 member premium. PPO plans have steadily increased their Medicare Advantage-Part D (MAPD) market share in large part because of these $0 premium plans.
According to one Milliman analysis, the percentage growth of $0 PPO plans is outpacing the growth of total plans in the market by three to five times in each of the past four years. This growth should encourage MAOs to consider the impact these plans are having on their markets because MAPD beneficiaries are drawn to them.
To learn more, read this paper by Milliman’s Matthew Timm and Michelle Klein.
Medicare Plan Finder, provided by the Centers for Medicare and Medicaid Services (CMS), summarizes plan information to allow beneficiaries to quickly compare plan options on a computer or mobile device. CMS recently overhauled Medicare Plan Finder, retaining much of the tool’s valuable and highly accessible information while aiming to improve the transparency and the overall user experience.
In this paper, Milliman actuaries Michelle Klein and Matt Kranovich discuss in more detail several key changes to Medicare Plan Finder—and potential unintended consequences—and offer suggestions as to how those changes could potentially affect Medicare Advantage organizations.
Many issuers faced financial challenges in the individual market in the first few years of the Patient Protection and Affordable Care Act (ACA). The continually changing landscape made it difficult to keep up even after significant rate increases, and issuers repeatedly reported medical loss ratios (MLRs) well above sustainable targets.
As experience emerges for plan year 2018, the tides are changing. A number of issuers filed rate decreases across the marketplace for plan year 2019 and new market entrants are appearing once again, a sign of a more stable market with potential for profitability. MLRs are projected to approach, and potentially to drop below, the 80% threshold for the individual market, on average. As the average MLR continues to decrease, the portion of ACA issuers below the MLR threshold continues to increase.
As MLRs decrease, individual ACA issuers need to start thinking about something that has been mostly irrelevant for them until now—MLR rebates. Although MLR rebate requirements have applied in several markets since 2011, the individual ACA market is unique in that high MLRs have prevented rebates from entering the equation for the majority of issuers since the ACA’s inception.
MLR rebates were introduced in the ACA market with the goals of stabilizing the market and providing customer protection by returning money back to policyholders when an issuer’s MLR reflects high profitability, administrative inefficiencies, or low claim levels not otherwise reflected in premium.
To learn more about MLR considerations for the 2018 reporting year and how to plan for 2019 and beyond, read this paper by Milliman’s Esther Blount, Michelle Klein, and Alison Fasching.
The Centers for Medicare and Medicaid Services (CMS) is adding a new prescription drug category classification system to the 2018 risk adjustment model. Starting in 2018, a condition will be identified through a Hierarchical Condition Category with associated medical diagnosis codes, a prescribed medication, or both—each one affecting the final risk member score differently. This paper by Milliman consultants approximates the likely CMS mapping based on the publicly available information to date.
While legislation to repeal and replace the Patient Protection and Affordable Care Act (ACA) has halted for now, the future of American healthcare remains in flux. In this article, Milliman’s Kim Hiemenz and Michelle Klein discuss how the uncertainty surrounding healthcare may lead to pent-up demand among many Americans.