The success of certain areas in the health insurance industry--namely, the individual insurance exchange, Medicaid, Medicare and dual eligibles--depends on payers' ability to better understand the overall consumer population, according to a new IDC report that was emailed to FierceHealthPayer.
Listed below are two main areas of concern for payers in 2015, according to IDC, along with their implications for the industry.
Individual exchange
Toward the end of 2014, the Department of Health and Human Services (HHS) predicted that overall enrollment for this current enrollment period would exceed lower-than-normal expectations.
While this bodes well for both payers and consumers, as it means more people have health insurance, payers will not receive their complete risk-adjusted payments until the middle of 2015. The larger issue is that payers submitted their premium rates several months ago--meaning, payers are issuing insurance products without the necessary risk-related data for their population segments, IDC noted.
The risk corridor payments, which were designed to stabilize premiums during the Affordable Care Act's first few years, may be in jeopardy. In the newly signed federal omnibus legislation, the federal government is prohibited from contributing to the risk pool. This can negatively affect payer revenue, and it's possible this situation will impact payer participation in the 2016 open enrollment period.
Dual eligibles
Dual eligibles--those consumers who qualify for both Medicare and Medicaid--typically have low incomes as well as specific health needs. As such, they pose a bit of a challenge to payers. Their health status is further complicated by a lack of access to transportation and providers, according to IDC.
Recognizing the need to improve this population, 12 states are teaming with the Centers for Medicare & Medicaid Services (CMS) to establish three-year dual-eligible demonstration programs with the hopes of improving the health needs of the Medicare-Medicaid dual-eligible population, FierceHealthPayer previously reported.
Congress and other industry groups also hope to change the Medicare STARS rating system to include risk adjustments for the aforementioned factors. While this change would help better serve dual eligibles, payers are still waiting to see just how the risk adjustment model will be determined.
For more:
- here's the report abstract