Changes from 2015 to 2016... Rules, Premiums, Plans, Exchanges, Etc.

[somarco]

I would be surprised if any carrier made money, or even broke even, until this program has been running for at least 3 full years.

From a loss ratio perspective the carriers have one full year including IBNR + about 4 months in 2015. It will be mid 2017 before they can really get a handle on how to price this monster.

 

[kgmom219]

Has any carrier been profitable in the ACA exchange?

No.

HCSC paid for more transplants in Jan 2014 than the previous 24 months combined. That's where a lot of the massive $500 million loss is from.

Then the 2015 rates were due with 4 months of claims history.

They are starting to get a picture on rates, but I think 2017 will be more telling. (Its also when small group will be cheaper than Indy again)

 

[Ann H]

In AZ small group is already priced like Indy, and for 2016 small group is getting much smaller rate increases than IFP, while also keeping better benefits & large PPO networks.

On the loss ratio question - - a large carrier for Arizona business told us that they priced the product for expected claims losses, knowing full well that there would be pent-up demand, guarantee issue, people getting services rendered then cancelling their plans, and overutilization from those who paid very little for their share of the premium or CSR benefits. However, even going in with that knowledge, they still were shocked at the level of claims in 2014, and shocked that the level of claims really hasn't diminished much in 2015. Adding in the loss of expected reimbursement from the 3R's, the underwriting losses in IFP were staggering.

Interestingly enough, that same carrier is paying MLR rebates to its small group market. Which is why small group is now priced at or lower than IFP. Add in the group insurance tax deductions and pre-tax benefits, and the net premium is almost always lower than IFP. Now that IFP is headed to HMO / ACO, that makes group PPO plans even more attractive.

 

[AllenChicago]

9.3.15

Here we go with yet another new rule that will increase the number of claims and the administrative overhead of health insurance companies. This time, it's a rule that mandates approval of sex-change related medical procedures.

Government Proposes Protecting Transgender People in Health Care System - NBC News

Every time HHS invokes a new health insurer rule I wonder if it will be the one that "breaks the camel's back" to cause:

1. Another Health Insurer to leave the market.
and
2. Any health insurer(s) to cut agent commissions to compensate.

 

[somarco]

Medicare pays for sex change operations. Grandma can become grandpa.

Ban lifted on Medicare coverage for sex change surgery - The Washington Post

The Obama administration on Friday ended a 33-year ban on Medicare coverage for gender reassignment surgery — a major victory for transgender rights and a decision that is likely to put pressure on more insurers to provide coverage for such services.

The ruling by a Department of Health and Human Services board was in response to a lawsuit filed last year on behalf of Denee Mallon, 74, a transgender woman and army veteran from Albuquerque.

 

[RayNY]

Does anyone have the text of the rule? The NBC link just goes to a page with 100+ listed.

The article implies that gender reassignment surgery is still not covered, only procedures "related" to it.

So, you'd have to pay for breast implants on your own, but if you develop breast cancer, that would be covered now.

"Jocelyn Samuels, head of the HHS office of civil rights, said the rule does not require insurers to pay for someone to receive sex-change treatment."

"He [Jamison Green] explained, for example, that some transgender men have had trouble getting coverage for mammograms or hysterectomies when they developed fibroids or even cancer. "

 

[Ann H]

"He [Jamison Green] explained, for example, that some transgender men have had trouble getting coverage for mammograms or hysterectomies when they developed fibroids or even cancer. "

I find that hard to believe! Breast cancer in men is rare, but very deadly. When breast cancer is found in a man, transgender or not, there is never any trouble with the eligible expense list. Eligible expenses include testing, surgery or treatment for men and women. After all, men have some breast tissue whether they are transgender or not. The reason breast cancer is so deadly in men is because there is very little breast tissue, so the tumor can grow to other parts quickly.

Granted, there may be a problem with complications of an excluded surgery. But cancer in a body part? Cancer treatment would be an eligible expense whether the person is transgender or not.

 

[somarco]

Carriers typically follow the lead of Medicare. If Medicare approves something the carriers do likewise.

 

[Medigap Bill]

The carriers may not be making money. However, their stock has gone up from this time last year. All of them...Aetna, UHC, Humana. Even with the craziness in the market over the last several months they are still way up.

It makes about as much sense to me as ACA.

10 Best Managed-Healthcare Stocks for 2015 - TheStreet Ratings

 

[somarco]

Carriers are diversified. They can lose money on the health side and still be profitable.