The new plan -- Align powered by Sanford Health Plan – covers Medicare Advantage enrollees in South Dakota, North Dakota and western Minnesota.
Sanford Health Plan announced Monday that it has launched a Medicare Advantage health insurance plan for beneficiaries in three states.
Enrollment runs from October 15 – December 7, 2021, and coverage starts on January 1, 2022.
Described by the Sioux Falls, South Dakota-based payer as an "all-in-one bundled health insurance option,Align powered by Sanford Health combines Medicare Part A and Part B "with more tailored, comprehensive health benefits and prescription drug coverage."
"What makes our offering stand out from other options on the market is that seniors will be able to join a Medicare Advantage plan that is backed by a network of Sanford Health providers working together to deliver personalized care," said John Snyder, president of Sanford Health Plan.
"As a health plan that is part of Sanford Health's comprehensive system of care, we provide members with innovative services and supplemental benefits to improve health and manage chronic conditions," Snyder said.
The plan -- offered in North Dakota, South Dakota, and western Minnesota – is touted by Sanford as meeting the comprehensive needs of beneficiaries while remaining affordable and, in some cases, offer $0 premiums and copays.
The plan will include personal health "navigators" who can help members schedule appointments, set up transportation, arrange for a trusted partner to attend appointments alongside members, and coordinate follow-up care.
Other benefits include: PPO plans; In-network and out-of-network benefits; access to an integrated network of local Sanford Health providers; visitor and travel benefits; virtual care; pharmacy; dental; vision; hearing; OTC allowance; gym memberships; and meals.
The rule lays out how payers and providers will resolve billing disputes under the No Surprises Act.
The Centers for Medicare & Medicaid Services on Thursday released its interim final rule on surprise medical billing, and payers and providers gave the long-awaited provisions decidedly different receptions.
In short: Hospitals Hate it. Payers are delighted.
The key point of contention in the final rule – which take effect on January 1, 2022 -- is the independent dispute resolution process for some out-of-network billing, which presumes that the payer's out-of-network reimbursement is the starting point for negotiations.
The disputing stakeholders will have a 30-day "open negotiation" to determine a payment. If they're still at loggerheads, they can open the dispute resolution process, which is conducted by a jointly select a "certified independent dispute resolution entity" that's been authorized by CMS.
CMS says the dispute resolution process – mandated by the No Surprises Act -- creates a process "that will take patients out of the middle of payment disputes, provides a transparent process to settle out-of-network rates between providers and payers, and outlines requirements for healthcare cost estimates for uninsured (or self-pay) individuals."
CMS Administrator Chiquita Brooks-LaSure said the final rule requires "healthcare providers and healthcare facilities to provide uninsured patients with clear, understandable estimates of the charges they can expect for their scheduled healthcare services."
Stacey Hughes, executive vice president of the American Hospital Association, called the rule "a windfall for insurers."
"The rule unfairly favors insurers to the detriment of hospitals and physicians who actually care for patients," Hughes said in prepared remarks. "These consumer protections need to be implemented in the right way, and this misses the mark."
Federation of American Hospitals President and CEO Chip Kahn called the final rule "a total miscue" that goes against the intent of Congress when it passed the law.
"It inserts a government standard pricing scheme arbitrarily favoring insurers," Kahn said. "For two years, hospitals and other stakeholders stood shoulder to shoulder with lawmakers to develop legislation that would protect patients from surprise medical bills and last December, Congress passed a bill with a fair and balanced payment dispute resolution process. This regulation discards all of that hard work, misreads Congressional intent, and essentially puts a thumb on the scale benefiting insurers against providers and will over time reduce patient access."
Matt Eyles, president and CEO of America's Health Insurance Plans, said the final rule "signals a strong commitment to consumer affordability and lower healthcare spending through an independent dispute resolution process that should encourage more providers to join health plan networks."
"We are particularly encouraged to see the rules conform to the intent of the No Surprises Act and direct that arbitration awards must begin with a presumption that the appropriate out-of-network reimbursement is the qualified payment amount," Eyles said.
"This is the right approach to encourage hospitals, health care providers, and health insurance providers to work together and negotiate in good faith. It will also ensure that arbitration does not result in unnecessary premium increases for businesses and hardworking American families."
Justine Handelman, senior vice president of policy and representation for the Blue Cross Blue Shield Association, called the IFR "a win for patients and a step toward building a more affordable and equitable healthcare system.
"We commend the administration for protecting patients and using an independent resolution process that focuses on affordability. This was Congress’ intent, and we will continue to work with Congress and the administration to create a more transparent, affordable and equitable health system," Handelman said.
Docs hate it too
The IFR is also getting panned by the American Medical Association, which called it "a surprise gift to the insurance industry."
Like the hospital associations, the AMA says the IFR "ignores congressional intent and flies in the face of the Biden Administration's stated concerns about consolidation in the health care marketplace."
"It disregards the insurance industry's role in creating the problem of surprise billing at the expense of independent physician practices whose ability to negotiate provider network contracts continues to erode,” said AMA President Gerald A. Harmon, M.D.
"Congress appreciated the negative consequences of national price setting for healthcare services and spent considerable time and effort developing a robust independent dispute resolution process to maintain market balance and preserve access to care, which the Administration apparently ignored,” Harmon said.
"It also is apparent that the Administration failed to appreciate the importance of creating an accessible and impartial dispute resolution processes as a backstop against even greater insurer abuses," he said.
Thursday's final rule is the third in a series of implementations of the No Surprises Act put forward by the Departments of Health and Human Services, Labor, Treasury and the Office of Personnel Managment.
The letter notes that 20% of rural Americans experience mental illness, and that rural America is disproportionally adversely affected by the opioid epidemic.
Twenty advocacy groups have called upon the Centers for Medicare & Medicaid Services to extend and make permanent billing for tele-behavioral health outpatient service after the COVID-19 Public Health Emergency expires.
In a letter to CMS Administrator Chiquita Brooks-LaSure, the stakeholders lauded CMS's efforts to bolster telehealth in its CY 2022 Medicare Physician Fee Schedule, which extends through the end of 2023 some of the temporary telehealth regulations that were imposed at the start of the pandemic.
"Given the enormity of the challenge ahead of us, we must leverage our entire rural safety net to address these surging behavioral health needs," the letter said. "We strongly believe that CMS should ensure critical access hospitals, rural health clinics, federally qualified health centers, and other providers are all equipped to fully leverage telehealth and that they are able to bill for clinically equivalent services the same way they would an in-person service."
The letter signers include the American Physciatric Association, Gundersen Health System, the National Association for Rural Mental Health, and the National Rural Health Association.
Among the provisions of the CY2020 fee schedule, it would allow for RHCs and FQHCs to bill and get paid for tele-behavioral mental health visits, including audio-only visits, the same as in-person
"We agree that telehealth payment should be addressed for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs), and also believe outpatient behavioral therapy services offered by Critical Access Hospitals (CAHs) are a key component of a comprehensive rural behavioral health strategy," the letter stated. "Without action to ensure these hospitals can bill tele-behavioral health as they do in-person services, access to CAH-provided outpatient will be lost for thousands of Americans in rural areas."
The letter notes that 20% of rural Americans experience mental illness, and that rural America is disproportionally adversely affected by the opioid epidemic. In addition, suicide rates are 40% higher in rural areas than in large urban areas (and are increasing at a faster rate).
"This is only made worse by the fact that there is a severe shortage of mental health professionals in rural areas. Over 80% of rural counties do not have a psychiatrist, compared to 27% of counties in metropolitan areas," the letter said, adding that the challenges "are particularly acute for Medicare beneficiaries."
"Approximately 33% of widowers become depressed – and while elderly adults represent only 13% of the population, they represent approximately 20% of all suicide deaths. At the same time, approximately 68% of elderly adults have little awareness about how to recognize and be treated for depression."
"These are exactly the issues that Congress intended CAHs to address when designating them providers of essential services in rural communities," they wrote. "As you know COVID has only exacerbated these challenges."
The executive order, set to expire on September 30, relaxes regulations on telehealth, including waivers on privacy and security protection laws.
California Gov. Gavin Newsom this week signed an executive order extending relaxed telehealth security and privacy provisions through the remainder of the COVID-19 emergency.
The original executive order was issued in April 2020 and was set to expire on September 30. The new order extends the order through the end of the public health emergency, or until the original order is rescinded or modified.
Newsom said that the extension was needed because "surges in COVID-19 cases in some regions have caused increased wait times for healthcare services, and seasonal influenza is likely to increase further the usage of healthcare facilities across the state."
California has recorded more than 4.7 million COVID cases, and nearly 69,000 COVID-related deaths. Nationally, the virus has claimed 687,000 lives, according to the Centers for Disease Control and Prevention.
However, CDC data also show that California has the nation's lowest level of "community transmission," which measures the number of cases and the number of positive tests in the past week per 100,000 population.
The extended provisions of the prior order will continue to allow providers to conduct routine and non-emergency medical appointments through telehealth without the risk of being penalized.
"I find that strict compliance with various statutes, regulations, and certain local ordinances specified or referenced herein would prevent, hinder, or delay appropriate actions to prevent and mitigate the effects of the COVID-19 pandemic," Newsom said in the order.
Newsom's order said the executive order "is necessary to continue to facilitate the use of telehealth services, where appropriate, to minimize the threat of COVID-19 to Californians and healthcare workers alike, to expedite access to healthcare services, and to reduce strain on the healthcare delivery system."
A CMS audit found that Sacramento-based InnovAge was out of compliance in several areas.
The federal government has suspended the InnovAge California PACE program from enrolling new members after a May audit determined that the Sacramento-based Medicare provider repeatedly failed to provide its enrollees with medically necessary equipment and services.
"CMS has determined that the seriousness of these deficiencies requires the suspension of any new enrollments of Medicare beneficiaries into InnovAge Sacramento," John A. Scott, director, Medicaid Parts C and D Oversight and Enforcement Group, said in a September 17 letter to Innovage California PACE COO Maureen Hewitt.
"The enrollment sanction will remain in effect until CMS is satisfied that InnovAge Sacramento has corrected the causes of the violations and the violations are not likely to recur," Scott said. "This enrollment suspension will apply to the enrollment of all Medicare beneficiaries regardless of their Medicaid eligibility status."
The CMS audit found that InnovAge was out of compliance in several areas, including: a failure to ensure participants received necessary services from certain specialists; a failure to coordinate care, review specialists' diagnoses, and provide services recommended by specialists; unwarranted delays in care delivery; and a failure to provide specialists services, including ophthalmology, optometry, dermatology, and nephrology.
The audit noted that even though InnovAge Sacramento was not contracted for these services, the provider "is still responsible for furnishing all services covered under the PACE benefit, which includes all Medicare-covered items and services, all Medicaid-covered items and services, and all other services determined necessary by the IDT to improve and maintain the participant’s overall health status."
InnovAge issued a statement acknowledging the audit and said it was "focused on working closely with CMS to expeditiously address and resolve the points they've identified."
"As a healthcare provider in a highly regulated industry, InnovAge has established protocols to cooperate with and fully support regulatory measures," the company said. "Our primary concern is always the health and safety of our participants in every market we serve."
The hurdles to broadening tele-behavioral health services for Medicaid enrollees come as the nation "confronts the psychological and emotional impact of COVID-19," OIG said.
The COVID-19 pandemic has prompted an increased reliance among states for virtual delivery of behavioral healthcare services for their Medicaid populations, particularly in rural and underserved areas and at-risk communities.
However, a new federal audit, based on interviews with Medicaid directors and other stakeholders in the 37 states that offer tele-behavioral health services, has identified multiple challenges that are hamstringing expansion and adoption efforts.
"Most states reported multiple challenges with using telehealth," said the audit, compiled by the Department of Health and Human Services' Office of the Inspector General, "including a lack of training for providers and enrollees, limited internet connectivity for providers and enrollees, difficulties with providers' protecting the privacy and security of enrollees' personal information, and the cost of telehealth infrastructure and interoperability issues for providers."
"Some states also reported other challenges, including a lack of licensing reciprocity and difficulties with providers obtaining informed consent from enrollees," the audit said. "These challenges limit states' ability to use telehealth to meet the behavioral health needs of Medicaid enrollees.
The hurdles to broadening tele-behavioral health services for Medicaid enrollees come as the nation "confronts the psychological and emotional impact of COVID-19," OIG said.
The auditors noted that the federal Centers for Medicare & Medicaid Service "has an important role to play in facilitating the exchange of information among states to improve the use of telehealth for behavioral health services."
"We recommend that CMS share information to help states address the challenges they face with using telehealth," OIG said.
"This information could include examples from states that describe how they have responded to these challenges. It could also include best practices from states and information about working with other state and federal partners. Further, CMS could collect information from states detailing their experiences and lessons learned in response to the COVID-19 pandemic that address these challenges."
Blacks, Hispanics lost nearly twice as many quality adjusted life years as Whites.
The COVID-19 pandemic that has claimed more than 660,000 lives in the U.S. has also cut aggregate life expectancy here by more than 9 million years, according to a study published Monday in Annals of Internal Medicine.
The study authors said their findings suggest that the mortality burden of COVID-19 is more substantial than previously thought.
"Beyond excess deaths alone, the COVID-19 pandemic imposed a greater life expectancy burden on persons aged 25 to 64 years, including those with average or above-average life expectancies, and a disproportionate burden on Black and Hispanic communities," study lead author Julian Reif, PhD, and colleagues concluded.
With data from the Health and Retirement Study, Panel Study of Income Dynamics, and CDC and CMS data, University of Illinois and University of Southern California researchers used their Future Adult Model and Future Elderly Model to create a microsimulation that measured years of life lost (YLLs) and quality adjusted life years (QALYs) lost from the COVID-19 pandemic, by age, sex, race/ethnicity, and comorbidity.
The researchers measured YLLs and QALYs lost per 10,000 persons and included demographic information, along with obesity, smoking behavior, and other risk factors. They found that the COVID-19 pandemic resulted in 9.08 million years of excess lost life through March 2021, with 4.67 million years lost by those aged 25 to 64 years.
The greatest toll was on Blacks and Hispanics, who lost more than twice as many QALYs per capita as Whites. The toll was especially high among Black and Hispanic men age 65 or older. The researchers estimate that 38% of excess deaths in the first year of the pandemic would have otherwise had average or above-average life expectancies for their subgroup.
"Measuring the mortality burden of the COVID-19 pandemic is about more than excess deaths," the researchers said. "Focusing solely on excess deaths from the COVID-19 pandemic can underestimate its effect on young and middle-aged adults who have a longer life expectancy than older, sicker adults."
"Understanding disproportionate mortality rates by race/ethnicity is also important. Calculating years of life lost (YLLs) and QALY by demographics and risk factors may provide greater perspective into the true mortality burden of the pandemic," the researchers said.
Writing a corresponding editorial, Ashish K. Jha, MD, MPH, dean of the Brown University School of Public Health -- who was not involved in the research -- said the study may be lowballing the grim numbers because it analyzes deaths only through the middle of March 2021.
"In the months since, more than 120 000 Americans have died of COVID-19, and it is likely that the burden of disease has shifted to a younger population as older Americans have generally embraced vaccination," Jha wrote. "Furthermore, measuring mortality yields an incomplete picture of the pandemic's effect. Those who survive COVID-19 often face a long road to recovery and may endure chronic symptoms and disability."
When a Medicare Advantage plan fails for three straight years to meet the 85% threshold, CMS must suspend them from accepting new enrollees for the next contract year.
Four Medicare Advantage plans affiliated with UnitedHealthcare and Anthem, Inc. have been barred from enrolling new members until 2023 after failing to meet the 85% medical loss ratio threshold for paying benefits, the Centers for Medicare & Medicaid Services says.
The medical loss ratio, mandated by the Social Security Act, is applicable to all Medicare Advantage plans. When an MA plan fails for three straight years to meet that 85% threshold, CMS must suspend them from accepting new enrollees for the next contract year.
The UHC plans affected by the suspensions are: UHC of the Midwest (MLR in 2020 of 84.5%), with a footprint in Missouri, Kansas, Nebraska, Iowa; UHC of New Mexico (MLR 84.9%); and UHC of Arkansas (MLR 79.8%). The enrollment suspensions affected about 80,000 of UHC's 7.5 million Medicare Advantage enrollees, the Minnetonka, Minnesota-based payer confirmed.
In a statement to the media, UHC said it "spends at least 85% of the premiums we take in on care for the people we serve."
"In a few markets, we were not able to do that because so many of our members deferred going to get care due to COVID-19. As a result, we can’t enroll any new members in a few local plans until 2023 when we expect care patterns to be at more normal levels," the payer said.
Existing members will not be affected by the suspension, UHC said, adding that it would "continue to offer alternative plan options for people who want to choose a new UnitedHealthcare plan in these select markets."
Also suspended was Indianapolis-based Anthem, Inc.'s MMM Healthcare, purchased as part of MMM Holdings LLC, in June from InovaCare. MMM Healthcare is Puerto Rico's largest MA plan, with more than 260,000 enrollees. CMS said the plan had a MLR of 77% in 2020.
In a statement to the media, Anthem stressed that the suspension "does not impact any of MMM Healthcare's other Medicare Advantage plans nor any other Anthem-affiliated health plan."
"Anthem will continue to invest in our health plans to ensure our members have access to high-quality healthcare services. We will also work with MMM Healthcare and CMS to address the agency’s concerns," Anthem said.
If the plans can document that they have achieved a medical loss ratio of at least 85% in 2021, they will be allowed to resume enrollments effective January 1, 2023.
Both payers may appeal the suspensions, but neither indicated that it would.
The two health systems say they hope to have a definitive agreement finalized by year's end, and to close the deal in early 2022, pending regulatory approval.
Nonprofits Intermountain Healthcare and SCL Health announced Thursday that they have signed a letter of intent to merge and create a 33-hospital health system serving six states.
Under the deal, the consolidated health system will keep the Intermountain Healthcare brand. SCL Health's seven Catholic hospitals and one secular hospital will keep their names and continue to operate under existing religious guidelines.
Salt Lake City-based Intermountain operates 25 secular hospitals, 225 clinics, employs 42,000 people, and includes a medical group, SelectHealth insurance company, and other services in Utah, Idaho, and Nevada.
The consolidated health system would employ more than 58,000 people, with 386 clinics in Utah, Idaho, Nevada, Colorado, Montana, and Kansas, and would provide health insurance to about 1 million people.
Intermountain and SCL Health say they now provide services in adjacent regions with no geographic overlap.
"American healthcare needs to accelerate the evolution toward population health and value, and this merger will swiftly advance that cause across a broader geography," said Marc Harrison, MD, president and CEO of Intermountain. "We'll bring together the best practices of both organizations to do even more to enhance clinical excellence, transform the patient experience, and support healthy lives."
Lydia Jumonville, president and CEO of SCL Health, said the two health systems are negotiating the merger "from positions of strength."
"We are two individually strong health systems that are seeking to increase care quality, accessibility, and affordability. We will advance our missions and better serve the entire region together," she said.
The consolidated system will be headquartered in Salt Lake City, with a regional office in Broomfield. Harrison will be president and CEO of the merged organization. Jumonville will keep her job during a two-year transition and become a member of a new combined board.
"The ability to access care virtually has gained momentum and become a valued option for employees," says Mercer.
One-fifth of 14,000 employees from 13 nations surveyed in a poll conducted by Mercer consultants used telehealth for the first time during the COVID-19 pandemic and 72% of them say they intend to keep using it.
The 2021 Mercer Health on Demand survey, released this week, also detected a big bump in employee interest in other digital health options, including apps to find providers and virtual reality tools for self-care.
Compared to the 2019 Health on Demand survey, a greater percentage of employees in the 2021 survey found digital solutions to be highly or extremely valuable," Mercer wrote. "The ability to access care virtually has gained momentum and become a valued option for employees. Survey results reinforce that employers need to plan for a future in which most healthcare journeys include virtual visits and digital healthcare supports."
The survey also found that:
The pandemic has had a material impact on the mental, financial, and physical health of employees, with more than half of U.S. employees feeling some level of stress in the last year. Nearly one-fourth say they experienced mental health issues such as depression or anxiety, a fifth are financially worse off, and nearly a fifth feel less physically healthy or fit.
However, 53% of employees feel their employer has provided good support during the pandemic – and, compared to those who have received little support, they are less likely to have experienced the pandemic’s impact as mostly or entirely negative.
45% of employees who feel they have received good support from their employers during the pandemic say they are less likely to leave their company as a result.
"There is nothing more important to the health of a business than the health of its people and the communities in which that business operates," Mercer CEO and President Martine Ferland said.
"COVID-19 challenged our global healthcare system, but the ability of employers to have a positive impact on employee health and resiliency is one of the most important findings from our 2021 Health on Demand survey," he said.
"The research is clear – employers that place health and humanity at the center of business transformation will build a more energized and adaptable workforce that is better able to persevere through periods of crisis."
