The Blue Cross and Blue Shield Association is heading into a big risk-adjustment policy meeting with a new batch of data, which shows that individual health plan enrollees cost a lot more than they used to.
The Center for Consumer Information & Insurance Oversight (CCIIO) proposed last week that it should assume that public health insurance exchange plan enrollees look more like enrollees in employer group health plans than like Medicaid plan enrollees when it’s running the risk-adjustment program.
The Blues and other insurers are arguing that Patient Protection and Affordable Care Act (PPACA) exchange plan enrollees look much more like sickly Medicaid plan enrollees than like group health plan enrollees.
The Blues have used member company data for 4.7 million non-group enrollees ages 21 through 64 and 25 million group plan enrollees in that age group to make their case.
In a new document drawn from that data, the Blues contend that the medical costs associated with new individual market enrollees were, on average, 19 percent higher than the costs for group plan enrollees in 2014, and 22 percent higher in 2015.
The “new-rule” individual health enrollees are 24 percent more likely to have high blood pressure than the “old-rule” enrollees, 32 percent more likely to have coronary artery disease, 34 percent more likely to have depression, and 48 percent more likely to have diabetes, according to the Blues. The Blues say the new-rule enrollees are also much more likely to have HIV and hepatitis C than other commercial plan enrollees.
In the first three quarters of 2015, group plan enrollees filed claims for 18,596 medical professional services per 1,000 enrollees on an annualized basis.
Old-rule individual health enrollees filed 16,174 professional services claims per 1,000 enrollees per year, and new-rule individual health enrollees filed 20,453, according to the Blues.
The Blues have not compared the new-rule enrollees with Medicaid plan enrollees, and they have not compared the new-rule enrollees with enrollees in the old risk pools that once covered people who could not qualify to buy commercial major medical coverage in states that let health insurers use medical underwriting.
PPACA imposed tough underwriting restrictions and benefit plan design rules on the individual health market starting Jan. 1, 2014. Before the PPACA underwriting rules took effect, most states let carriers use pre-sales underwriting programs and post-sale limits on coverage to control how much they spent on new individual health enrollees’ pre-existing conditions, such as diabetes or HIV.
Actuaries knew before the PPACA underwriting and plan benefits rules took effect that the new-rule enrollees would be sicker than the old-rule enrollees. No one was sure how much sicker.
The Society of Actuaries (SOA) predicted in an analysis released in March 2013 that non-group per-enrollee health costs might increase 29 percent if no states took PPACA Medicaid expansion money, and 31.5 percent if all states took Medicaid expansion money.
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