With the Patient Protection and Affordable Care Act’s (ACA’s) ninth open enrollment period (OEP) set to launch in less than a month, the ACA Marketplaces are seeing record enrollment numbers with more generous subsidies, new carrier competition, and a relatively stable rating environment. At the same time, there is uncertainty with the trajectory of the COVID-19 pandemic and medical costs trending upward as the economy recovers, albeit at an uneven pace. These trends have made for a challenging rate review process in the 47 states plus the District of Columbia (D.C.) that conduct their own ACA rate reviews of carrier-proposed rates using federal review standards. State announcements of 2022 rates have trickled out at a slower pace than in prior years, and it is likely that many states will not publish their approved rates until the beginning of open enrollment. As always, state rate results vary widely and, even within states, there often are substantial variations among carriers and across different regions in geographically diverse states. With these caveats, this expert perspective highlights some observations about the factors that are impacting rate changes this year and the kind of variations that exist among states.
Specialty Tier Pharmacy Benefit Designs in Commercial Insurance Policies: Issues and Considerations
Georgetown Health Policy Institute, Center on Health Insurance Reforms – Sally McCarty and David Cusano
As health care costs rise, one of the chief determinants of the rate of increase has been the cost of prescription drugs. Over time, additional tiers have been included in pharmacy benefit designs and, as they were added, cost sharing in the new, higher tiers has increased. With the enactment of the Affordable Care Act (ACA), which eliminated underwriting and imposed the federal minimum loss ratio (MLR), a limit on administrative and other non-healthcare spending, health insurers have looked to pharmacy benefit designs as one of the few remaining mechanisms for controlling costs. As a result, tiered pharmacy benefit designs with as many as five or six tiers are emerging. These tiered pharmacy benefit designs could significantly affect the affordability of prescription drug therapies for those who need them most, and could also potentially violate the anti-discrimination policies of the ACA. This issue brief, prepared by the Georgetown Health Policy Institute’s Center on Health Insurance Reforms, examines these issues and explores several regulatory approaches for how best to address them.