Safeguarding Financial Stability of Provider Risk-Bearing Organizations
Erin Taylor and Michael Bailit, Bailit Health
JoAnn Volk, Georgetown University Center on Health Insurance Reforms
An increasingly common feature of health care payment models is the transfer of financial risk from payers to providers for health care services delivered to a defined population of patients. In these “value-based payment” models, providers accept financial responsibility (i.e., liability for financial losses) should spending for most, or all, services for an attributed patient population exceed targeted levels. This financial liability is often shared with payers, and maximum risk exposure is typically capped. This issue brief explores options for states as they consider oversight of risk-bearing organizations , with a focus on states that have elected to act to protect against provider insolvency.
At the end of the public health emergency (PHE), people currently enrolled in Medicaid and the Children’s Health Insurance Program are at risk of losing their coverage unless state Medicaid/CHIP agencies take steps to update enrollee mailing addresses and other contact information. This expert perspective examines the information technology system, policy, and operational strategies states can consider to update key enrollee contact information to ensure eligible enrollees are able to keep or transition to new affordable health coverage at the end of the PHE.
On October 7, the U.S. Departments of Health and Human Services (HHS), Treasury, and Labor (DOL) and the Office of Personnel Management (OPM) published a third rule implementing the No Surprises Act (NSA), the comprehensive federal law banning balance bills in emergency and certain non-emergency settings beginning January 1, 2022. This third rule, an interim final rule, provides details on the independent dispute resolution process (IDR), good faith estimates for enrollees on the cost of services, the dispute resolution process for uninsured patients, and external review. This expert perspective summarizes the provisions of the IFR and notes particular implications for state regulators.