Aetna has joined other major health insurers in sounding a warning about the Affordable Care Act's public insurance exchanges.
The nation's
third-largest insurer said Monday that it has been struggling with
customers who sign up for coverage outside the ACA's annual enrollment
window and then use a lot of care. This dumps claims on the insurer
without providing enough premium revenue to counter those costs.
The
ACA provides an annual enrollment window that gives people several
weeks starting every fall in which they can buy coverage for the next
year. The law established that window to prevent people from waiting
until they become sick to buy insurance. But insurers say it has become
too easy for customers to sign up outside of this window.
Customers
are allowed to buy coverage outside that time frame if they lose a job,
get divorced or have a child, among other reasons. Insurers want the
federal government, which processes coverage applications in 38 states,
to take a closer look at whether people actually qualify for these
special enrollment periods when they apply for coverage.
Both
Aetna and UnitedHealth Group Inc. said the exchange customers they get
outside the annual enrollment window use more health care than those who
sign up within it. This includes some cases where it appears that a
customer bought coverage, used it and then dropped it.
"Insurance
systems tend to get stressed when people can buy coverage when they
know they need it and then drop it when they know they don't," Chief
Financial Officer Shawn Guertin told The Associated Press.
The Centers for Medicare and
Medicaid Services recently outlined several changes it said it was
making to help shore up exchange enrollment windows.
Aetna
is a big player in the ACA's state-based exchanges. It has enrolled
about 750,000 people and is selling coverage in 15 states this year. It
lost more than $100 million last year on its exchange business, which
makes up a small part of its overall enrollment.
"We
continue to have serious concerns about the sustainability of the
public exchanges," Aetna Chairman and CEO Mark Bertolini said Monday.
Blue
Cross-Blue Shield insurer Anthem Inc. also is paying close attention to
how the government deals with special enrollment periods as it judges
how sustainable the exchange business will be in the future, CEO Joseph
Swedish said recently.
UnitedHealth Group has said it will decide this year whether to participate in the public exchanges in 2017.
Aetna leaders, who have publicly
supported the exchanges in the past, say they are still committed and
not ready yet to make that kind of call.
"It would be premature frankly to declare victory or defeat at this stage in the process," Guertin said.
Federal
officials announced last month that they would end several narrow
special enrollment windows that focused on consumers like non-citizens
with incomes below the federal poverty level who experienced processing
delays.
Customers will still
be able to use special enrollment periods to shop for coverage if they
lose their insurance for more common reasons like a move, a marriage or
divorce or the loss of a job.
But
the government plans to clarify guidelines on those remaining windows
so customers understand them better. That includes clarifying that an
enrollment period cannot be used for a temporary move, and people who do
not provide accurate information on their insurance application could
be penalized.
HealthCare.gov
CEO Kevin Counihan said in a Jan. 19 blog post that special enrollment
periods will not be available for "the vast majority of consumers."
HealthCare.Gov operates public insurance exchanges in 38 states.
"For
example, special enrollment periods are not allowed for people who
choose to remain uninsured and then decide they need health insurance
when they get sick," he wrote.
Insurers
are also making adjustments. Aetna has left exchanges in markets like
Kansas where it incurred high costs. It also has raised rates and done
other things to shore up a business that only contributes about 5
percent of its total enrollment.
Guertin said the company hopes its exchange business will move closer to breaking even next year.
By: Tom Murphy (AP).
Review:
Emerging Market Formulations & Research Unit, Flagship Records.
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