Marketplace Coverage of Substance Use Disorder Treatments Varies Considerably, Report Finds

The ACA’s inclusion of substance use treatment as an essential health benefit expanded its availability “considerably,” but an Urban Institute report finds that coverage and cost-sharing requirements vary significantly across plans. The report examined Marketplace coverage in six cites (Albuquerque, Chicago, Kansas City, Los Angeles, Manchester, and Memphis) and found that Marketplace plans generally have fewer coverage restrictions for medically assisted treatments (MATs) for alcohol dependency compared to MATs for opioid dependency: MATs for opioid dependency are more frequently excluded from coverage and MATs for alcohol dependency tend to be placed in lower cost-sharing tiers than their opioid treatment counterparts. However, the cost-sharing tier in which each drug is placed varies considerably and each tier’s cost-sharing requirements—which can be substantial—further vary significantly across cities and by plan within cities (except in Los Angeles, because California’s benefit design is standardized). Despite MATs being in lower-cost tiers, the sometimes substantial cost-sharing requirements combined with other restrictions, such as preauthorization, can hinder access to treatment. The report also found that outpatient substance use treatments are less restricted than inpatient treatments, though “considerable variation” exists between and within the study cities.

11.1 Million Consumers Had Coverage at End of March

Approximately 11.1 million consumers effectuated enrollment on as of March 31, 2016, an increase of nearly 1 million from the same time last year. The percentage of individuals who have paid their premiums and maintained their coverage since open enrollment’s conclusion (87%) falls within range of what Marketplace issuers anticipated. CMS projects effectuated enrollment will be 10 million by the end of 2016 as consumers find other coverage or experience changes in life circumstances.

Nearly 500 Insurers Will Receive $7.8 billion in Reinsurance Payments for 2015

CMS will issue $7.8 billion in reinsurance payments to 497 insurers for the 2015 benefit year as part of the risk adjustment program instituted under the ACA to mitigate adverse selection and stabilize premiums. CMS also reported a strong correlation between paid claims, risk adjustment, and reinsurance transfers. Issuers with high paid claims amounts were more likely to have high risk scores and receive risk adjustment payments. CMS states that the correlation confirms the risk adjustment program is working as intended. For example, in the individual market, issuers with the lowest claims costs, on average, were assessed a risk adjustment charge of approximately 12% of total collected premiums, while issuers with the highest claims costs received a risk adjustment payment of approximately 11% of total collected premiums.

Connecticut: CO-OP HealthyCT Placed Under Immediate Order of Supervision, 40,000 Impacted

State Insurance Department Commissioner Katharine Wade announced that the Department has prohibited CO-OP HealthyCT from issuing new policies or renewing existing ones as of July 5, requiring its 40,000 policyholders to seek new coverage once their HealthyCT coverage expires. Coverage in individual plans will expire at the end of December 2016, while group plan members who renewed coverage on July 1, 2016 will maintain coverage through June 30, 2017; group plans up for renewal August 1, 2016 and beyond will not be able to renew their coverage. Commissioner Wade cited contributors to HealthyCT’s financial instability, including a federally mandated $13.4 million payment that HealthyCT must make to CMS as part of the ACA’s risk adjustment program and anticipated risk corridor payments that were not received.

Minnesota: Blue Cross to Withdraw From Individual Market, 103,000 to Lose Coverage

Blue Cross Blue Shield (BCBS) of Minnesota announced it will stop selling policies on Minnesota's individual market (both on and off the Marketplace) starting in 2017, requiring 103,000 individuals to select a new health plan for 2017. Approximately 20,000 of impacted consumers bought policies on MNSure, the State-based Marketplace. BCBS reported a loss of $265 million in 2015 and projected a $500 million loss in the individual market over the next three years. BCBS's subsidiary, Blue Plus, which currently covers 13,000 individual market consumers, will continue to offer HMO options on the individual market.