HealthCheck, Spring 2024
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Spring 2024
VOL 15 | NO 1 |
KleverThe Health Practice Council’s (HPC) Behavioral Health Task Force, formed last year, is looking at a variety of issues for 2024. Topics the group is exploring include the current state of behavioral health coverage, challenges to access, and how behavioral health interacts with other HPC priority areas. Academy Health Vice President Barb Klever offered insight into the new task force’s formation, activities, and goals.
Interested in volunteering? The task force is looking for volunteers—if interested, contact Academy Senior Health Policy Analyst Matthew Williams.
What is behavioral health?
Behavioral health is a wide, encompassing term that includes both mental health and substance abuse disorders. CMS [the Centers for Medicare & Medicaid Services] defines it as including the emotions and behaviors that affect your overall well-being. Behavioral health care can be provided by specially trained providers, such as psychologists, psychiatrists, mental health counselors, and clinical social workers. It can also be incorporated into primary care.
What was the motivation for forming the task force?
The HPC formed the task force in part due to the growing recognition of the prevalence of behavioral health problems and the challenges of meeting behavioral health care needs.
According to SAMHSA [the Substance Abuse and Mental Health Services Administration, part of the U.S. Department of Health and Human Services]—which leads public health efforts to advance the nation’s behavioral health—nearly a quarter of adults in 2019 (61.2 million people) either had a mental illness or a substance abuse disorder. The prevalence of behavioral health problems likely increased further during and after the COVID-19 pandemic.
A behavioral health breakout session was held at Envision Tomorrow, the Academy’s Annual Meeting, in November. During the session, officials from SAMHSA and GAO [the U.S. Government Accountability Office] discussed federal work and initiatives, and a representative from the Senate Finance Committee also talked about legislative proposals on behavioral health.
What expertise do actuaries have on behavioral health issues?
As with other types of health benefits, actuaries are part of multidisciplinary teams working to develop plan benefits. Actuaries also project costs and utilization of behavioral health services, and use that information to develop premiums. In addition, actuaries have the skills to help assess the effects of behavioral health services on other, wider medical spending.
What types of issues is the task force exploring?
The task force is still in the initial phases of its work and is exploring potential projects. Topics that are being considered for future work include: current coverage of behavioral health care, mental health parity, behavioral work force shortages, integration of behavioral health and physical health care, and behavioral health payment models.
How does behavioral health interact with the HPC’s priority areas?
Behavioral health intersects with many other parts of the health care system and nearly all of the HPC’s key priorities, which were outlined in the January/February issue of Contingencies. For instance, behavioral health disorders can be exacerbated by other public health challenges, such as the COVID-19 pandemic and climate change. In addition, as with physical health care, behavioral health can face equity challenges in terms of differential access and unmet needs. Behavioral health is a coverage component in all types of insurance, including the individual market, employer group market, Medicaid, and Medicare. Ideally, financing behavioral services can make use of payment models that make care affordable to consumers, provide sufficient income to providers, and improve health care outcomes.
NEW—April Webinar to Examine Medicaid Issues
LercheJoin the Academy for next month’s health webinar, Continuous Medicaid Unwinding: What’s Next for the Health Care Markets in 2024? During this webinar, presenters will discuss where we are a year after the COVID-19 public health emergency expired, the unwinding of the continuous coverage requirements, and the projected effects on health coverage for the Medicaid population. They will also share considerations for addressing the unwinding in Medicaid managed care capitation rate-setting. Speakers will be Jennifer Tolbert, director of state health reform, and deputy director, program on Medicaid & uninsured with KFF; and Colby Schaeffer, a member of the Academy’s Medicaid Committee. Academy Board Member Julia Lerche will moderate. The webinar is set for April 2—register today.
Academy Health Outlook Featured in Contingencies
Be sure to read “Your Membership in Action,” from the January/February Contingencies, which profiles Academy vice presidents’ outlook for the new year.
In “Bringing a unique understanding of complex issues during a pivotal election year,” Health Vice President Barb Klever highlights the Health Practice Council’s 2024 plans, from familiar issues and challenges to a national election that will heighten the public’s focus on certain aspects of traditional public policy issues. “The Academy’s key health priorities reflect the value of our actuarial perspective regardless of the landscape,” Klever wrote, highlighting such topics as health equity issues, behavioral health, and deeper looks at health insurance benefit design. Read Klever’s full report in the issue.
Academy to Present Health Update at NAIC
The Health Practice Council (HPC) will present an update on its activity to NAIC’s Health Actuarial (B) Task Force (HATF) as part of the NAIC Spring National Meeting, being held in Phoenix in mid-March. Priorities discussed will include health equity and behavioral health, and heightened awareness in this election year around the financial sustainability of the commercial and government markets—especially in Medicaid and Medicare Advantage.
The HPC also looks forward to continuing discussions with HATF and regulators on long-term care issues, and will discuss its ongoing work with the Health Risk-Based Capital (E) Working Group on the H2-Underwriting Review Project and the H3-Health Care Receivables Project.
Academy ‘Hill Visits’ Coming in April
Academy health, casualty, and risk management & financial reporting volunteers will hold “Hill Visits”—meetings with federal lawmakers and policymakers—April 18–19 in the nation’s capital. Health practice area visits will include meetings with federal lawmakers and committee staff, agencies, and departments. Look for more details coming soon.
Your Input Wanted—May 1 Deadline for Cross-Practice ASOP No. 12
The Actuarial Standards Board approved an exposure draft of a proposed revision of Actuarial Standard of Practice (ASOP) No. 12, Risk Classification (for All Practice Areas), which applies to actuaries with respect to designing, developing, selecting, modifying, reviewing, evaluating, or opining on any elements of a risk classification framework in connection with financial or personal security systems.
Originally adopted in 1989 and last updated in 2005, ASOP No. 12 was developed as the need for more formal guidance on risk classification increased as the selection process became more complex and more subject to public scrutiny. Comments are due by May 1—to weigh in, see the exposure draft.
The 2023 edition of The Record—the Academy’s annual report to its membership and the public—covers everything from public policy and professionalism resources to stakeholder engagement and membership growth and value-driven resources.
Health issues including long-term care financing; health equity; short-term, limited-duration plans; and premium drivers; and the Academy’s successful Health Equity Symposium held shortly after Envision Tomorrow, the Academy’s Annual Meeting, which drew a wide range of health industry stakeholders.
Be sure to check out this lively volume—2023 was a jampacked, whirlwind year, and The Record distills 12 months of activity into just a few easily scannable pages.
Year-in-Review Public Policy Alert Covers Health Issues
A year-in-review Academy alert offers highlights of 2023 state and federal legislative and regulatory health actions affecting the U.S. actuarial profession and the Academy’s effort to fulfill its role to educate and support our stakeholders on these critical issues.
It includes President Biden’s executive order aimed at boosting long-term care, the Centers for Medicare & Medicaid Services’ unveiling of the 2024 Actuarial Value (AV) Calculator Methodology, and North Carolina Gov. Roy Cooper signing legislation expanding Medicaid availability. Read the Academy alert.
Health Public Policy News in Brief
- The Individual and Small Group Markets Committee and the Active Benefits Committee submitted comments to the Department of Labor’s Employee Benefits Security Administration, responding to a proposed rule on the definition of “employer” in Association Health Plans.
- The Health Care Delivery Committee, Individual and Small Group Markets Committee, and Active Benefits Committee sent a letter to the U.S. Senate Committee on Health, Education, Labor, and Pensions (HELP) in response to the committee’s request for information on access to gene therapies for patients with an ultra-rare disease.
- Health Equity Committee co-chairpersons Annette James and Rebecca Sheppard, and member Yi-Ling Lin, gave an overview of the committee’s work on equity considerations related to benefit design to AHIP’s Health Equity Workgroup.
- The Individual and Small Group Markets Committee submitted comments to CMS regarding the proposed rule for the 2025 Notice of Benefit and Payment Parameters (NBPP).
The Actuarial Foundation (TAF) is celebrating its 30th anniversary this year and invites you to play a starring role in commemorating this milestone. Visit actuarialfoundation.org/30th-anniversary/ to learn how you can start celebrating with the foundation today.
Prefer to watch your news? Check out this “Highlights From HealthCheck” video for a quick recap of what you need to know.
Academy Board Member Annette James provided highlights of the Academy’s work on diversity, equity & inclusion issues in health benefits, artificial intelligence, and other areas in an InsuranceNewsNet article.
CNN and Best’s News & Research Service (subscriber-only) cited the Academy’s issue brief on drivers of 2024 health insurance premium changes.
Legislative/Regulatory Activity
Federal
The Federal Trade Commission (FTC) and the Department of Health and Human Services (HHS) are soliciting feedback on how group purchasing organizations and drug wholesalers influence the availability of generic drug shortages. On Feb. 14, the FTC and HHS released a joint request for information asking how group purchasing organizations and drug wholesalers affect drug shortages. The agencies are seeking information on how market concentration and various contracting terms have impacted the generic drug supply, as well as small and rural medical practitioners.
CMS released the Interoperability and prior authorization final rule on Jan. 17. The new rule requires Medicare Advantage organizations, Medicaid, and other government-sponsored health programs to respond to prior authorization requests faster and include specific reasons for denying requests. This final rule focuses on efforts to improve prior authorization processes through policies and technology, to help ensure that patients remain at the center of their own care.
The House passed HR 5378 on December 11, legislation focused on health care cost disclosures by health care providers and insurers. The bill, introduced by Rep. Cathy McMorris Rodgers of Washington, seeks to require hospital, clinical laboratories, imagining service providers, and ambulatory surgical centers that participate in Medicare to publish prices and related information, including the discounted cash price and negotiated charges, on an annual basis. The bill also directs PBMs to report semiannually on the number and types of claims for covered drugs, including whether the drugs were brand-name or generic drugs and associated costs. It also establishes requirements for certain payment methodologies under Medicare, Medicaid, and extends several public health programs.
The House Oversight and Accountability Committee advanced HR 6283, sponsored by Rep. Mariannette Miller-Meeks of Iowa, prohibiting spread pricing by PBMs. It also restricts PBMs from steering patients to pharmacies it owns and allows the Office of Personnel Management to collect penalties for noncompliance.
The House Energy and Commerce Committee passed several PBM-related bills on Dec. 6. HR 2880, introduced by Reps. Buddy Carter of Georgia and Lisa Blunt Rochester of Delaware, prohibits PBMs that participate in Medicare Part D from linking service fees to a drug’s list price. Another PBM bill (HR 5385), from Reps. Greg Landsman of Ohio and Diana Harshbarger of Tennessee, creates reporting requirements for PBMs under Medicare Part D beginning in 2026. And a third (HR 6545) combines three previous measures into one that extends incentive payments for participation in Medicare alternative payment models through 2026; extends for a year higher Medicare physician payments in certain localities based on a physician’s cost of labor in that area; and updates the Medicare physician fee schedule, including a provision to increase overall payment rates in 2024.
The House passed HR 485, sponsored by House Energy and Commerce Chair Cathy McMorris Rodgers of Washington, which bars the use of quality-adjusted life years, or QALYs, and similar measures in federal health care programs. The bill would apply to payment determinations and coverage in Medicaid, the Children’s Health Insurance Program (CHIP), managed care organizations, Medicare Advantage, and Medicare Part D.
HHS revised a Trump administration-era rule permitting the removal of funds from health-care facilities taking action against workers who cite religious or moral objections to providing care. The rule, announced Jan. 11, maintains provisions of the earlier rule with some revisions based on HHS’ desire to avoid redundant or confusing language.
State
California received federal approval to reinstate a tax on managed health care organizations that is expected to generate $19.4 billion over three years. Those dollars will be used to increase funding for Medicaid services. CMS approved a waiver of broad-based and uniformity requirements related to the state’s managed care organization (MCO) tax, which applies retroactively to April 1, 2023, and applies until Dec. 31, 2026, according to the state Department of Health Care Services.
CMS approved a proposal from New Mexico for community-based mobile crisis intervention teams to provide Medicaid crisis services on Feb. 6. New Mexico is the 15th state to expand access to community-based mental health and substance use crisis care through the American Rescue Plan. The state is now able to provide Medicaid services through mobile crisis teams by connecting eligible individuals in crisis to a behavioral health provider around the clock.
New York Gov. Kathy Hochul signed A 1707/S 599 into law in December—companion bills that require manufacturers of certain prescription drugs to notify the Department of Financial Services of any proposed wholesale increase costs for prescription drugs. The legislation increases the transparency requirements concerning prescription drug costs.
Hochul also gave her approval to A 345/S 2330, a measure that increases transparency in the long-term care insurance premium rate increase approval process. It requires the state Department of Financial Services to notify policyholders when an insurer files a rate increase application and allows for public comment on such requests.
Illinois Gov. J.B. Pritzker signed SB 1559 into law in December, creating an insulin urgent-need program and requiring health insurers to charge no more than $35 for a 30-day supply of the drug. It also mandates the state Department of Insurance to offer a discount program allowing participants to purchase insulin at a discounted, post-rebate price.
New Jersey Gov. Phil Murphy signed A 4049/S 3495 in January, which provides for presumptive eligibility for home and community-based services, nursing home services, and programs of all-inclusive care for the elderly (PACE) under Medicaid.
The District of Columbia City Council enacted B25-0419 without the signature of Mayor Muriel Bowser on Feb. 5. The legislation provides for continuous coverage for any child, from birth to age six, under Medicaid, CHIP, or the Immigrant Children’s Program, regardless of any increase in family income.
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