In light of the recent failure of the Republican healthcare reform proposal, payers are in a particularly awkward position of uncertainty. As the June deadline quickly approaches in which payers must submit rate suggestions and initial plan designs, many are left in confusion. Currently, there is little clarity as to the funding for cost-sharing subsidies and reinsurance payments because of the demise of the American Health Care Act (AHCA).

Healthcare Payers

The fate of healthcare payers is uncertain as many are unsure of what to expect from upcoming legislation.

Let’s review the latest news affecting healthcare payers to see if we can get a better picture of what is on the horizon as we push on through 2017.

Proposed California Legislation Promotes Single-Payer Healthcare Reform

Also resulting from the failure of the recently proposed and rejected federal legislation is the reemergence of discussion surrounding the introduction of legislation to create single-payer healthcare plans that would provide universal coverage to all. Health Payer Intelligence reported last week about the recently introduced legislation, SB 562, or the “Healthy California Act”. The article explains: “Should the law pass, the state would consolidate existing federal funds such as payments for Medicare, Medicaid, and tax revenues to support universal health insurance eligibility for all state residents.”

“Californians, as individuals, employers, and taxpayers have experienced a rise in the cost of health care and health care coverage in recent years, including rising premiums, deductibles, and copays, as well as restricted provider networks and high out-of-network charges. While the federal Patient Protection and Affordable Care Act (PPACA) brought many improvements in health care and health care coverage, it still leaves many Californians without coverage or with inadequate coverage.” – as stated in the proposed California legislation HB 562

Could a Nationwide Single-Payer System be the Future for the United States?

As reported by the Wall Street Journal, the failure of the American Health Care Act (AHCA) has left payers in a state of uncertainty as to reinsurance payments and cost-sharing subsidies. Still, the June deadline for payers to submit initial plan designs and rate suggestions fast approaches. The Washington Post reports that the Democratic party sees the failure of the proposed legislation as the prime opportunity for the advancement of the long-held objective by many Democratic leaders for a single-payer, government-sponsored healthcare system, such as those in Canada and Great Britain. Bernie Sanders, who has long-time been an advocate for a single-payer healthcare system, weighed in on the issues on CNN‘s “State of the Union”. According to Sanders: “Ideally, where we should be going is to join the rest of the industrialized world and guarantee health care to all people as a right. That’s why I’m going to introduce a Medicare-for-all, single-payer program.”

Will More Payers Pull Out of Affordable Care Act Exchanges?

Considering the uncertainty with the rate increases and funding for subsidies, many payers are considering pulling out of the exchanges altogether, as many have already done. Molina’s Healthcare chief executive of Long Beach, Calif., J. Mario Molina, told the Wall Street Journal that his company is considering pulling out of the exchanges due to the double-digit rate increases expected in 2018.  According to Molina: “There are still some big unknowns, including how and if subsidies will help low-income Americans pay their deductibles.”

CMS’s Insurance Marketplace Stabilization Rule Under Review

What will healthcare payer plans look like in 2018? No one is quite sure. In order to give payers more clarity on the outlook for the marketplace in 2018, Centers for Medicare and Medicaid Services (CMS) submitted a final rule that is designed to stabilize the health insurance marketplace to the Office of Management and Budget (OMB), as reported by Modern Healthcare. The Trump administration hopes to finalize the rule as soon as possible according to the article, and the OMB has 90 days to review the rule, and send it back to CMS for final publication. With the pressing deadline of June for payers to submit their plans and rates for 2018 and decide whether they will even offer plans on the ACA exchanges next year, it is anticipated the rule will be sent back much sooner than the 90-day time frame. At The SSI Group, we help payers with our managed gateway for claims processing, Claimsnet. We will continue to watch the trending news that affects payers in the healthcare marketplace, and report on the developments of this final ruling and other relevant payer news on our blog.

SSI Claimsnet functions as an extension to your EDI/IT department to ensure claims are complete, accurate and standardized appropriately for your system. Request a demo today to see how Claimsnet can help your payer business thrive.