CO-OP explains why it thinks ACA risk-adjustment is nuts

Minuteman Health says many of the program rules have nothing to do with health risk

Minuteman Health says the U.S. Department of Health and Human Services needs to improve how it handles patients with no health records. (Image: iStock) Minuteman Health says the U.S. Department of Health and Human Services needs to improve how it handles patients with no health records. (Image: iStock)

Minuteman Health, one of the new nonprofit, member-owned CO-OP carriers, may have to pay an amount equal to about 40 percent of its enrollees' 2015 premiums into New Hampshire's Affordable Care Act risk-adjustment program.

The ACA Consumer Operated and Oriented Plan carrier may also have to pay an amount equal to 39 percent of its Massachusetts premiums into the state-run, Massachusetts-based version of the ACA risk-adjustment program.

In New Hampshire, the CO-OP may account for 90 percent of all 2015 risk-adjustment program payments, even though it had only a 19 percent share of the state's individual exchange market.

Julie Myers, regulatory counsel at the Boston-based CO-OP has put those statistics in a comment on U.S. Department of Health and Human Services' to adjust the ACA risk-adjustment program.

Related: Maryland ACA CO-OP to seek shift to for-profit status

From the perspective of a small, new health insurer, the way the U.S. Department of Health and Human Services is running the Affordable Care Act risk-adjustment program is "wildly ineffective," Myers writes. "Such Minuteman's cost-saving, narrow-network business model, are plainly not what Congress intended."

Managers of the CO-OPs, which tapped an ACA startup loan program that was supposed to help increase the level of competition in the commercial health insurance market, have been trying to get HHS to change the way three big ACA risk management programs, including the risk-adjustment program, for months. Some other smaller, newer carriers have also joined the effort.

Related: Small health plans: ACA program may kill us

Myers gives a particularly blunt, detailed rundown of Minuteman Health's concerns about the program in the new comment letter, which was posted on a federal government regulatory comment management site.

The risk-adjustment program is supposed to help ACA exchange plan issuers operate without use of medical underwriting. The program takes cash from issuers that end up with enrollees with low risk scores and sends the cash to issuers with enrollees with high risk scores.

One obvious problem has been program managers' delays in building enrollee prescription drug user records into the health scoring system, even though the prescription records are actually more accurate than physician health records, Myers says.

Another challenge is that the program punishes issuers that do a good job of attracting previously uninsured people, and people who lacked good access to the health care system, Myers says.

"The risk adjustment methodology presumes these enrollees will not utilize health care services and will cost insurers little to no money," Myers writes. "In reality, enrollees with no [health risk scores] nevertheless utilize health care services."

A third challenge is that the risk adjustment formula is designed in such a way that it always treats the cost-conscious enrollees who choose low-premium, bare-bones bronze plans as low-risk, Myers says.

"Insurance companies are always out money on bronze products," Myers says. Managers' "own data shows that, in 2014, there was no scenario under which an insurer would receive risk-adjustment transfer payments for a bronze plan."

The fixes program managers have proposed are vague, Myers says.

Myers says managers could easily fix that problem by using the existing claim data associated with various risk score levels to adjust the scoring system. 

Related:

Failing ACA nonprofit CO-OPs add to ‘death spiral’ fears

New Jersey’s CO-OP to suspend operations in December

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