A company that helps health insurers measure exactly how risky their enrollees are says major medical insurers may have to start sending health evaluation workers to some enrollees’ homes.
PopHealthCare, a company that has been selling enrollee analysis services to Medicare and Medicaid plan issuers, is now marketing its services to the insurers that write individual major medical coverage. The company argues in a new commentary that the best way to make enrollee risk assessments more accurate is to conduct in-home enrollee assessments.
The Patient Protection and Affordable Care Act of 2010 (PPACA) requires insurers that sell PPACA-compliant individual and small-group major medical coverage, inside or outside the PPACA public exchange system, to participate in a permanent risk-adjustment program, to reduce the possibility that some insurers will do better than others simply because they find ways to avoid covering people with health problems.
Individual and small-group issuers are supposed to use the Hierarchical Condition Categories (HCC) system to assign as many enrollees as possible an HCC code; translate the HCC code into a risk score; and use risk scores to calculate how risky the enrollees in a plan are.
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Plans with relatively low risk scores are supposed to send cash to plans with relatively high risk scores. Analysts at Standard & Poor’s recently suggested that some health insurers had problems with accurately estimating risk-adjustment transfer amounts and will be getting or paying much more than they had expected.