Archives for May 17, 2023

Trial For Universal Flu Vaccine Based On mRNA Tech Begins Enrolling Volunteers

May 17, 2023 By Jay Baldauf

Trial for universal flu vaccine based on mRNA tech begins enrolling volunteers | The Hill Researchers for a universal flu vaccine based on mRNA technology are beginning to enroll volunteers in an early-stage clinical trial.

The National Institute of Allergy and Infectious Diseases Vaccine Research Center has started to enroll volunteers at the Duke University for its Phase 1 trial of the mRNA-based vaccine, which uses the same technology as the COVID-19 vaccines. The study will have 50 “healthy volunteers” ages 18 to 49 enrolled in the trial who will receive check ups up to one year after their vaccination.

The trial will divide 30 of the participants into three groups of 10 people. Each group will be vaccinated with a different dosage — 10, 25 or 50 micrograms — of the experimental vaccine. After researchers review the data to determine an “optimum dosage,” 10 more participants will receive the vaccine, according to the National Institutes of Health (NIH).

The trial will also have a group of participants who receive a seasonal flu vaccine that is already available on the market to compare the two vaccines.

The NIH press release noted that scientific experts predict which strains of the flu will be most prevalent in the country every year to determine which strains of the flu should be included in the vaccine. A universal flu vaccine would cover all the different kinds of strains of the influenza virus, as opposed to the seasonal flu vaccines on the market now.

“A universal influenza vaccine would be a major public health achievement and could eliminate the need for both annual development of seasonal influenza vaccines, as well as the need for patients to get a flu shot each year,” acting National Institute of Allergy and Infectious Diseases Director Hugh Auchincloss said in a statement.

“Moreover, some strains of influenza virus have significant pandemic potential,” he added. “A universal flu vaccine could serve as an important line of defense against the spread of a future flu pandemic.”

Filed Under: ACA, Doctors, Drugs, Employer Benefits, General Health, Reform, vaccinations Tagged With: based on, begins, Covid19, Duke University, Enrolling, mRNA, NIH, strains, tech, trial, universal flu, vaccine, volunteers

Sorry, The Government’s Not Paying For Your Therapy App

May 17, 2023 By Jay Baldauf

Sorry, the government's not paying for your therapy app - POLITICO

New treatments for chronic conditions like opioid addiction, ADHD and insomnia are here and they’re on your smartphone — not in a pill bottle.

But the government won’t pay for them, even as tech entrepreneurs insist to Congress and the Biden administration that their digital therapeutics are the next big thing.

Though the Food and Drug Administration has cleared dozens of these software-based medicines — which include apps and even video games — the Centers for Medicare and Medicaid Services can’t reimburse providers, in part because Congress hasn’t approved new billing codes that describe the therapy. Because private insurers often take their cues from the government, the companies behind these new ideas are struggling to gain traction.

Now there’s a bipartisan push to change that, but it comes as many of the firms are in a race to survive. Their plight underscores the quandary facing regulators who must balance the need for new treatments with the expense, especially when there’s limited evidence the treatments work and health care costs are spiraling.

Rep. Mike Thompson (D-Calif.) said it’s crucial to let the experiment in digital therapy proceed. “Providing alternative ways to access care is essential in the increasingly modern times in which we live,” said Thompson, who with Kevin Hern (R-Okla.) is leading the effort in the House. Jeanne Shaheen (D-N.H.) and Shelley Moore Capito (R-W.Va.) have a Senate companion bill.

Shaheen said it’s lamentable that “prescription digital therapeutics can help treat a range of diseases, including substance use disorders and mental health challenges, but many who need this treatment currently lack access.”

Capito said that the status quo is “preventing more insurers from reimbursing for the devices and more patients from being able to efficiently access the care and support they deserve.” She sees the technology as a way to better reach patients with conditions like substance use disorder in rural and other hard-to-reach areas.

Their effort comes too late for Pear Therapeutics. As recently as January, the Boston-based firm seemed to be on the cutting edge of health care as it touted interest from leading providers and state governments in its products melding smartphones with addiction therapy.

It all fell apart last month when Pear said it was filing for bankruptcy and selling its assets: online apps that the FDA has cleared to help people addicted to opioids or other drugs.

“Pear filing for bankruptcy was a direct consequence of Congress’ failure to pass legislation,” said Kevin Brennan, a former Pear lobbyist and onetime aide to Connecticut Rep. Rosa DeLauro, the ranking Democrat on the Appropriations Committee.

If Congress doesn’t act, “patients are going to be denied the next generation of innovative care. And it’s going to be particularly problematic for people in underserved communities,” Brennan added.

Others in the industry are making similar arguments.

“I think it’s really important to recognize how far the U.S. is, frankly, falling behind other countries in terms of these products,” said Will Robinson, head of policy at Big Health, which makes insomnia and anxiety therapeutics. Robinson noted that Germany and France have accelerated reimbursement for digital therapeutics.

A CMS spokesperson whom POLITICO granted anonymity to discuss its reviews of digital therapeutics said that it had considered Pear’s products and determined that they did not fit into the Medicare benefit category for “durable medical equipment, prosthetics, orthotics and supplies” and that the agency had denied coverage for that reason.

Even if it could cover the software, there’s no guarantee it would.

The spokesperson said that CMS could consider whether the apps fit into a different category. If the agency determined that they did, it would still need to find that they were “reasonable and necessary” for Medicare beneficiaries before paying for them.

Cost may also be an impediment to government reimbursement for Pear’s apps, since they add about $300 to a typical 12-week treatment protocol for opioid use disorder, according to one analysis. Pear didn’t respond to requests for comment.

While there is some evidence the protocol is cost-effective, it may not convince insurers.

Critics say the companies behind these innovative treatments may have taken a flawed approach to building an entirely new category of medicine.

“As a digital therapeutics company, you have to go to the FDA, go to the insurers, then you actually have to go and get people to use it to get revenue,” said Keith Figlioli of the investment firm LRV Health Ventures. “That is so much friction to get a company off the ground.”

Video games, breathing techniques and more

Winning FDA authorization and proving a product is cost effective are two different things.

Some say they want to see more data.

“We shouldn’t begin to change health systems and payment based on evidence that doesn’t yet exist,” said John Torous, director of the digital psychiatry division at Beth Israel Deaconess Medical Center in Boston. “I don’t think we’ve seen anything present that level of robust evidence yet.”

But others argue that insurers could benefit if these novel therapies prove to be money-savers.

In contrast to manufactured goods, such as pills, software can be relatively cheap to scale once it’s built.

The field of digital therapeutics aims to harness the utility of the smartphone to boost the effectiveness of traditional cognitive behavioral therapy: coping skills to combat illnesses.

The category is ill-defined, but it’s thought that the FDA has authorized three dozen digital therapeutics.

Akili Interactive makes EndeavorRX, a video game that helps ADHD patients learn to focus, multitask and ignore distractions.

Then there’s AppliedVR’s virtual reality chronic pain treatment EaseVRx, which teaches breathing techniques, among other things, to alleviate back aches.

Besides its addiction apps, Pear Therapeutics made an insomnia product, Somryst, which offers lessons to help people train their brain to rest. It markets it as a “long-term fix” to replace the “Band-Aid” that is sleeping pills.

There’s good cause to encourage this innovation, the companies say, given the limits of existing drug therapies. Mental illness and substance use disorder are ripe targets.

After a drop in 2019 and 2020, the number of suicides nearly returned in 2021 to the 48,344 of 2018, the most in American history (though the rate still lags the Great Depression).

Meanwhile, fatal drug overdoses are also at peak levels and rising. According to the CDC’s most recent statistics, they hit 107,622 in 2021, up 15 percent from 2000.

In announcing the agency’s clearance, FDA official Christopher M. Loftus touted EaseVRx as “a treatment option for pain reduction that does not include opioid pain medications,” which are at the root of America’s overdose epidemic.

Proponents of these novel therapies argue that they not only could be more effective than traditional ones, but also could expand the availability of care given their ease of use — if only insurers would pay for them.

“There was a belief that if you get FDA clearance, reimbursement will follow,” said Jenna Carl, chief medical officer at Big Health.

Carl’s company has long been skeptical of this approach and instead focused on building up robust data proving its interventions work.

That strategy has borne dividends. Scotland’s National Health Service provides both of the company’s apps for free. In the U.S., Big Health has inked deals with CVS Health to make its products available to employers and plan sponsors via its pharmacy benefit manager Caremark.

Wheels of bureaucracy

Even as the FDA has authorized digital therapeutic products, the lack of a definition of what one is has held up CMS.

The agency doesn’t have a benefit category for digital therapeutics or software that’s a medical device and Congress has to approve new reimbursement categories.

“This is just another example of the law is not quite catching up with where innovation is,” said Rachel Goodman, a partner at law firm Foley and Lardner.

The bicameral, bipartisan Access to Prescription Digital Therapeutics Act would define them as FDA-cleared or approved devices, products, internet applications or other tech that “primarily uses software.”

Shaheen told POLITICO she’s hopeful about her legislation’s prospects and believes it will prove a money-saver.

In the meantime, the companies are coordinating their efforts.

Led by the Consumer Technology Association, industry groups have developed proposed standards aimed at eliminating confusion and boosting adoption by giving more structure to evidence generation.

Proponents hope that getting devices into lawmakers’ hands will help. Jennifer Mathieu, senior vice president of professional and government affairs at the Academy of Managed Care Pharmacy, said her group plans to host demo days for staffers, representatives and senators.

Some companies are essentially giving their products away, said Vaile Wright, a psychologist and senior director of health care innovation at the American Psychological Association.

Others are trying workarounds. AppliedVR got FDA authorization for its low-back pain program RelieVRx as a software and medical device combo — a CMS reimbursement category.

This spring, CMS approved coding so Medicare can reimburse for it.

AppliedVR has also had success contracting with the Veterans Affairs Department.

Others, like Pear, do the painstaking work of contracting with individual Medicaid programs.

For Pear, at least, that wasn’t enough.

“It’s the real problem of health care,” said René Quashie, vice president of digital health at the Consumer Technology Association. “If you develop an innovative solution, how is it going to be adopted by clinicians and how is it going to be covered and paid for? I don’t think digital therapeutics are any different than a lot of other emerging health tech areas.”

Filed Under: ACA, Chronic Conditions, Doctors, Drugs, Employer Benefits, Federal Government, General Health, Mental Health, Reform Tagged With: ADHD, app, Biden administration, chronic conditions, congress, FDA, Government, Insomnia, not aying, opioid addiction, Sorry, therapy

Medicare Spending Could Increase $2 To $5 Billion If Coverage Expands For Lecanemab

May 17, 2023 By Jay Baldauf

The anti-dementia medication lecanemab, and its ancillary costs, could add $2 to $5 billion in annual Medicare spending if the Centers for Medicare and Medicaid Services revises its coverage decision, according to a research letter in JAMA Internal Medicine.

Currently, the medication is covered only for patients who are enrolled in clinical trials.

Medicare fee-for-service spending was $37 billion in 2019 for drugs such as lecanemab that are administered in outpatient settings. In addition to higher Medicare spending, lecanemab’s medication and ancillary out-of-pocket costs for patients lacking supplemental coverage could reach $6,600 per year, which is approximately one fifth of the median income of a U.S. Medicare beneficiary, data showed.

Medicare annual spending on lecanemab’s medication costs alone would place it among the most expensive Part B medications delivered in outpatient facilities, authors said.

WHAT’S THE IMPACT

Lecanemab is currently available as a treatment for mild cognitive impairment and mild dementia under the Food and Drug Administration’s accelerated approval program.

The FDA is expected to grant lecanemab traditional approval later this year, prompting Medicare to reconsider its coverage restrictions and potentially enabling widespread use. Clinical trials have shown that the drug has modest clinical benefit.

Moreover, because of its risk of brain swelling and brain bleeding, also known as amyloid-related imaging abnormalities, or ARIA, the treatment requires frequent monitoring via neurology visits and MRI scans.

The researchers performed a cost analysis using data from the nationally representative 2018 Health and Retirement study (HRS), incorporating both the direct drug costs as well as the indirect ancillary costs for associated health services such as MRIs, neurology visits and other related care.

Limitations to the study include use of plaque rates derived from population studies rather than from HRS participants’ scans, possible misclassification of some cases of dementia prevalence and stage, and responses from participants with cognitive impairment which may not be reliable, although proxies can respond on their behalf.

THE LARGER TREND

According to Optum, there’s a high unmet need for treatments for Alzheimer’s disease, since it’s a leading cause of illness and death among the elderly. Existing treatment options have been ineffective.

In June 2021, the FDA approved Aduhelm (aducanumab), the first amyloid beta-directed antibody, via the accelerated approval pathway based on reductions in amyloid beta plaques. Subsequently, a CMS National Coverage Determination limited Medicare coverage for Aduhelm and other beta-amyloid targeted therapies to patients enrolled in clinical trials because of unknown clinical benefit.

Lecanemab would be the second drug in the class with FDA approval through the accelerated approval pathway that was followed to approve Aduhelm, based on the surrogate of reductions in beta-amyloid plaques.

In January, CMS released a proposed National Coverage Determination decision memorandum that said the NCD would cover FDA-approved monoclonal antibodies that target amyloid for the treatment of Alzheimer’s disease through coverage with evidence development, meaning for Medicare recipients enrolled in qualifying clinical trials.

Filed Under: ACA, Doctors, Drugs, Employer Benefits, Federal Government, General Health, Medi-Cal, Medicare, Reform Tagged With: $2 to $5 billion, Anti-dementia, CMS, coverage, expands, FDA, increase, JAMA, Lecanemab, Medicare, Medication, Spending

More Companies Try To Lure Workers With Benefits

May 17, 2023 By Jay Baldauf

More companies try to lure workers with benefits

Over a year of rapid wage growth has U.S. companies turning to enhanced benefits to attract and retain workers.

Mentions of employee benefits in job postings on ZipRecruiter soared to the highest rates on record, according to an analysis by the jobs site. A greater share of positions offered benefits like health insurance, paid time off and paid parental leave than in prior years.

One in four jobs now offer retirement benefits, and a growing number are offering student loan repayment and tuition assistance.

“Customers tell ZipRecruiter that they are trying to end out-of-cycle wage increases and cap the size of regular increases to keep costs under control,” said Julia Pollak, chief economist at the jobs website. Against a backdrop of low unemployment and high employee turnover, “many are therefore expanding their benefits offerings.”

Despite some recent cooling in the labor market, many companies are still struggling to fill positions and limit attrition given the enduring mismatch between the supply and demand for workers.

While businesses have been raising wages quite aggressively to do that, it’s unclear how much pricing power firms will have in the months ahead if the economy continues to lose momentum.

Government data also point to a recent increase in benefit offerings. The employment cost index, a broad measure of labor costs, accelerated in the first three months of the year in part due to a pickup in benefits. Benefit costs at companies in the three months ended in March rose 1.1% from the prior quarter, an acceleration from the prior period.

GETTING CREATIVE

Wells Fargo & Co. economist Shannon Seery said she’s been hearing in client conversations that firms are “trying to get creative” to avoid hiking wages at the pace they have been.

Even with labor demand slowing, there’s still a shortage of workers, and “providing better benefits may be a solution firms explore,” she said.

Pollak specifically flagged the challenges of recruiting and retaining talent for in-person roles in hospitality, manufacturing, and tourism ahead of the summer season.

Cooling wage pressures would certainly be welcomed by Fed officials, particularly Chair Jerome Powell, who has voiced concerns about their inflationary impact. Benefits, however, still come at a cost for firms — even if it’s smaller than wages.

While the Fed is likely more focused on wages, especially in the near-term, “the benefits angle does have weight and is important — particularly if we see that get sticky even as wages starts to decline,” Seery said.

Filed Under: ACA, Doctors, Drugs, Employer Benefits, General Health, Reform, retirement Tagged With: Benefits, lure workers, more companies, rapid wage growth, Retirement, student loan repayment, try, ziprecruiter

As COVID-19 Recedes, Payers Face Changed Coverage Landscape

May 17, 2023 By Jay Baldauf

Coronavirus Will Change the World Permanently. Here's How. - POLITICO

There will never be a return to a pre-pandemic normal in terms of what health insurers, self-insured employers and other payers must cover, but they will in some ways be less burdened as COVID-19 recedes, according to Jeff Levin-Scherz, M.D., the population health leader for health and benefits in North America at Willis Towers Watson.

He told Fierce Healthcare that telehealth won’t have the same reach as it did during the pandemic because individuals using the technology will have to interact with a provider in the same state. In addition, the mental health landscape has changed radically, with the prevalence of major symptoms of anxiety or depression tripling since 2019, according to WTW.

Levin-Scherz noted that the telehealth tracking company Fair Health says half of the telehealth interactions going on presently in the country involve mental health or substance use disorders.

“I think there are a couple of reasons for that,” said Levin-Scherz. “One is there’s an enormous shortage of mental health providers. Another is that the needs have just skyrocketed. Also, in many instances, people with mental health issues would prefer not to see somebody in person. There are good reasons why we’re seeing mental health delivered via virtual care.”

One coverage mandate that Levin-Scherz said he’s glad will stay in place allows providers to prescribe opioid use disorder medications such as suboxone until November 2024 for individuals already utilizing telemedicine for that purpose and until November of this year for those who aren’t.

“That, at least for the moment, is not changing,” said Levin-Scherz.

Employers and health plans do not have to cover COVID-19 home tests, which is in keeping with payers not having to pay for any over-the-counter tests or medications.

“If people go get a lab test, they pay for it,” said Levin-Scherz. “If people get a home pregnancy test, it is not covered by insurance. And so, the tests are going to be more like a pregnancy test. You don’t expect your insurance to cover it. The cost of home COVID test in the U.K. is between $1 and $2 whereas here it’s $12. When these over-the-counter tests are no longer covered, we’ll probably see the cost go down.”

COVID-19 vaccinations must still be covered without charge by employer-sponsored health insurance, said Levin-Scherz. But most employers outside of healthcare have already discontinued the vaccine mandates.

That’s because vaccination a year or more ago provides little protection against bringing COVID-19 to the workplace now.

“It also takes a lot of work to track it,” Levin-Scherz said. “Most employers will remove their COVID vaccine mandates, and I think that that’s probably a good idea.”

Employers will no longer be required to waive cost sharing on COVID-19 medications such as Paxlovid. The federal government continues to supply the medication now, so employer-sponsored health insurance is only responsible for administration fees, although the employer plans will also have to start paying for the drug itself when the federal supply runs out, according to WTW.

Many employers made improvements in their offices to mitigate the spread of COVID-19 and other respiratory illnesses. For instance, they improved airflow, and they may have to make even more improvements. Last Friday, the Centers for Disease Control and Prevention upgraded guidelines on airflow, saying that air ventilation should produce five air changes an hour.

And, though the agency has encouraged better airflow in the past, this is the first time it’s ever set a goal.

“I think that this is a really good first step,” said Levin-Scherz. “It turns out that clean indoor air doesn’t just prevent COVID transmission, but influenza transmission and also prevents RSV transmission. Also, there’s evidence that people actually are more productive and more able to get their job done when there are more air exchanges and the air is cleaner.”

Filed Under: ACA, Covid19, Doctors, Drugs, Employer Benefits, General Health, Reform Tagged With: CDC, changed landscape, coverage, Covid19, face, Health Insurers, pandemic, Payers, recedes, telehealth, WTW

Million Dollar Claims Increasing Among Employer Plans

May 17, 2023 By Jay Baldauf

Multi-million dollar claims continue to rise | BenefitsPRO

Million dollar claims per million covered employees rose 15% in the past year and 45% over the past four years, according to a new report from Sun Life. And one-fifth of employers had at least one member with more than $1 million in claims from 2018 through 2021.

For self-funded employers, average cost is a good starting point to plan for risk management because it’s reflective of the costs that will likely be seen for a stop-loss claim related to a condition, the report found. But an employer could see a wide range of costs given the comorbidities that might exist, or the complications that could occur.

Stop-loss is a form of excess risk coverage that provides protection for the employer against a high claim on any one individual.

Even conditions with a low average cost, such as behavioral health and orthopedic issues, can reach over $1 million. For instance, in 2022, orthopedics had an average cost of $90,000, but one severe case uncovered in the data reached more than $4.5 million.

WHAT’S THE IMPACT

Among other insights, the report also found that 71% of all stop-loss claims came from the top 10 conditions unearthed by the data: malignant neoplasm, leukemia, lymphoma, multiple myeloma, cardiovascular disease, orthopedics, newborn and infant care, respiratory, sepsis, neurological, gastrointestinal, and urinary conditions.

While cancer continues to be the largest driver of high-cost claims, cardiovascular disease rose one spot to the number two claim condition in 2022, with $142.4 million in reimbursements over about 2,300 members. In the top spot once more was malignant neoplasm,with $324.8 million in reimbursements.

Rounding out the top three is leukemia, lymphoma and multiple myeloma. Combined with malignant neoplasm, these two cancer categories made up 29% of total claim reimbursements over the past four years, including both medical and drug spend. More than a third of total claim reimbursements can be attributed to the top three conditions.

COVID-19, which appeared on the list for the first time in 2020, fell from number eight in 2021 to number 11 last year, though authors noted it continues to impact other medical conditions.

About 11% of employers experienced a birth-related stop-loss claim in the four-year benefit period from 2018 through 2021, data showed. Newborn/infant care ranks at number five this year, consistent with its previous ranking in the top 5 last year, and has one of the highest average costs at almost $328,000.

Looking at drugs, 11 of the top 20 high-cost injectable drugs are related to the treatment of cancer. Rylaze, the cancer drug with the highest average cost(over $808,000), is new to the top 20 injectable drugs in 2022.

THE LARGER TREND

Employers of all sizes are looking to bolster their health benefit options in 2023 with an eye toward improving recruitment and retention, and will focus on affordability and access, according to a July Mercer survey.

More than two-thirds of the 700 respondents said they are looking to enhance their health and benefit offerings this year. In all, 61% of participating U.S. employers are conducting surveys on employee benefit preferences.

Meanwhile, average costs for U.S. employers that pay for their employees’ healthcare will increase 6.5% to more than $13,800 per employee in 2023, largely due to economic inflation pressures, professional services firm Aon said in August.

This projection is more than double the 3% increase to healthcare budgets that employers experienced from 2021 to 2022. But it’s significantly below the 9.1% inflation figure reported through the Consumer Price Index.

On average, the budgeted healthcare costs for clients are $13,020 per employee in 2022. The analysis uses the firm’s Health Value Initiative database, which captures information for nearly 700 U.S. employers representing about 5.6 million employees.

Filed Under: ACA, Doctors, Drugs, Employer Benefits, General Health, hospital, Reform Tagged With: cancer, cardiovascular disease, Claims, Covid19, employer plans, health benefit options, increasing, million dollar, recruitment, retention, Self Funded, Sun Life

Medicaid Unwinding And The Impact On Group And Individual Health Insurance Markets

May 17, 2023 By Jay Baldauf

The Families First Coronavirus Response Act (FFCRA), signed into law in March 2020, created the first major lifeline for Americans during the onset of the COVID-19 pandemic. It particularly addressed the immediate needs of working Americans who had suddenly lost their paychecks and/or their jobs – and their subsequent eligibilities for health insurance. Now that the pandemic has reached its end (although COVID-19 remains a health issue), some of the changes created by FFCRA are expiring – especially for those covered by federal and state Medicaid programs.

Under the FFCRA, states were enticed to expand their Medicaid programs, to ensure continuous enrollment of Medicaid enrollees throughout the COVID-19 National Emergency. Throughout the pandemic, Medicaid beneficiaries have remained enrolled in the program regardless of changes in income or status.

Medicaid is a federally facilitated, state-administered, jointly funded health care program for low-income American families, adults, children, pregnant women, elderly adults, and people with disabilities. While each state’s Medicaid program varies, Medicaid generally provides zero- or low-cost coverage to beneficiaries based on their household income.

In both California and Nevada (and most other states), residents are eligible for Medicaid if they have household incomes of up to 138% of the Federal Poverty Level (FPL). Although ineligible for Medicaid, earners with incomes between 138-400% of FPL are eligible for subsidies called Premium Tax Credits (PTCs), to help them pay the cost of Individual coverage purchased on a state exchange (such as Covered California, Nevada Health Link, etc.).

California’s Medicaid program is called “Medi-Cal,” and it covers nearly one-third of the state’s population. California’s Medi-Cal program increased its enrollment by 16% during the pandemic.

Nevada’s program is called “Nevada Medicaid,” and it also covers roughly one-third of its state population. Nevada Medicaid increased its enrollment by 40% during the pandemic.

Because of the impacts of the pandemic, many people became newly eligible for Medicaid. Due to the “continuous enrollment provision” and other COVID factors, enrollment in the program boomed. Between March 2020 and December 2022, Medicaid experienced a nationwide enrollment increase of 21.1 million Americans, bringing the total number of enrollees to approximately 92.3 million.

The Consolidated Appropriations Act of 2023 declared an official end to Medicaid’s “continuous enrollment provision,” and assigned it a sunset date of March 31, 2023. Beginning April 1, 2023, states could begin to “unwind” their more than three-year COVID protocol and resume Medicaid eligibility determinations – and subsequent disenrollments. The Kaiser Family Foundation reports estimates 5-14 million Americans will have coverage disrupted or eliminated entirely because of Medicaid “unwinding.”

California began its reevaluation of Medi-Cal beneficiaries’ eligibilities in April 2023. Redeterminations are being processed monthly, beginning with people who enrolled in Medi-Cal in the month of June (of any year). June enrollees will have from the beginning of April through the end of June (approx. three calendar months) to recertify. Those who no longer qualify for coverage will be disenrolled from Medi-Cal effective July 1, 2023. California will continue these recertifications on an ongoing, monthly basis until May 2024.

California law requires the state to enroll all Medicaid disenrollees in the lowest-cost silver-tier Individual & Family Plan (IFP) available to that person on Covered California – or the individual’s same managed care plan (if it is available). To qualify, the applicant must also qualify for PTC subsidies to help pay for some, or all, of the silver plan’s premium. Furthermore, enrollees can elect any IFP coverage available to them within Covered California – including bronze, silver, gold, and platinum tier plans.

Disenrollment from Medicaid also triggers a qualifying event that establishes a Special Enrollment Period (SEP). Employees who waived job-based coverage because of ongoing Medicaid enrollment can utilize the SEP to enroll in their group health plans outside of Open Enrollment.

Federal law establishes a 60-day timeframe for SEPs, beginning on the day of the qualifying event. Those who find themselves ineligible for Medicaid (and subsequently disenrolled) with access to alternate group coverage – including for a spouse’s or parent’s plan – will be impacted.

Nevada Medicaid resumed normal operations on April 1, 2023. Nevada Medicaid enrollees will receive a renewal notice prior to the end of their certification sometime over the next 12 months. Like California, recertification will also occur according to the Medicaid enrollee’s renewal month. They will be processed on an ongoing, monthly basis – beginning with June enrollees. For example, a person with a renewal month in June will receive a renewal notice in April. Clients found ineligible in Nevada will lose their coverage effective June 1, 2023. SEPs will also be available for Nevadans who lose eligibility for Medicaid during the recertification process, to enroll in either an IFP or group health plan within 60 days of the coverage loss.

Those who do not respond to attempts for recertification will be disenrolled but may be eligible to enroll again – if eligibility is proven later, a Medicaid process called “churning.” The industry forecasts minorities and non-English speaking residents will be impacted the most by churning, because of address changes and/or the inability to understand the recertification procedure.

Any person covered by Medi-Cal/Medicaid should anticipate recertification and respond to notices in a timely manner. When switching from Medi-Cal/Medicaid to IFP or group insurance, consumers should be cognizant of provider networks, premiums, and cost-sharing within the health plan.

Also note that each state administers its own Medicaid program, so each state’s approach to Medicaid unwinding and recertification will be at least somewhat different; with some variances between states more drastic than others.

Group insurance brokers should educate their clients on these Medicaid unwinding principles, so they can anticipate a potential increase in enrollment and support requests for their group health plans. Furthermore, employers and their employees should be reminded that an offer of “affordable” coverage from an employer (of any size) disqualifies that employee – and potentially the employee’s entire family – from PTC eligibility on a state exchange.

An offer of coverage is considered “affordable” for the employee if the employee’s contribution for the lowest-cost, self-only premium (for a plan that provides minimum value) does not exceed 9.12% of the employee’s pay in 2023. Family coverage is considered affordable if the employee’s contribution for the entire family’s premium, based on the lowest-cost plan, does not exceed 9.12% of household income – which comes from ACA’s “Family Glitch” fix in 2022.

Filed Under: ACA, Covid19, Doctors, Drugs, Employer Benefits, General Health, Medi-Cal, Medicare, Reform Tagged With: Covid19, Expand, FFCRA, FPL, group, health insurance, impact, individual, KFF, markets, Medicaid, PTCs, unwinding