Identifies Areas of Compliance and Opportunities to Continue Health Care Payment Transformation

Early in March, Insurance Commissioner Trinidad Navarro and Cristine Vogel, the Director of the Department’s Office of Value-Based Health Care Delivery, issued the Annual Review of Carrier Progress Towards Meeting Affordability Standards. Vogel leads the Department’s efforts relating to value-based care, primary care, pharmacy benefit managers, and other health-policy initiatives, including grant programs. After establishing affordability standards in 2021 and 2022, the Office collected data from insurance carriers concerning their projected compliance with the affordability standards for 2023, the first year of affordability standard implementation.

“The statutory charge of the Office is to “reduce health-care costs by increasing the availability of high quality, cost-efficient health insurance products with stable, predictable, and affordable rates,” said Commissioner Navarro. “I am pleased that overall, carriers project compliance with the affordability standards set by the Office.”

The 2023 projections show that carriers will increase their investment in primary care spending to seven percent of their total medical spend ($40 million) and will hit the mandated 8.5 percent of total spend toward primary care programs that have engaged in care transformation activities. This results in an $8 million increase from 2022. Additionally, carriers were required to limit price growth for hospital and other non-professional services increases to 5.5 percent. All carriers project compliance for each of the three required service categories – inpatient hospital, outpatient hospital, and other medical. A key finding of the Report is that the Office estimates these limits saved Delawareans $2 million to $12 million in 2023, depending on the price increases hospitals would have otherwise negotiated with carriers.

Critical to successful implementation of value-based care delivery programs, are carriers non-fee-for-service (FFS) reimbursement to primary care providers. Compliance with the affordability standards for does not require carriers increase payment equally across all providers, and therefore, the increased investment will generally lean toward larger practices already engaged in care transformation activities. Projections for 2023 show that on a per member per month (PMPM) basis, primary care investment has increased from $11 PMPM in 2022 to $29 PMPM in 2023 for those practices engaged in value-based care programs.

“Helping to bend the health care curve towards more affordable care is critically important in these times of ever-increasing hospital and medication prices,” said Commissioner Navarro. “The data in the 2023 Report make it clear to me that we can keep making progress toward higher-quality care at a lower cost.”

“Delaware continues to make progress in its innovative efforts to address care quality and cost,” said Director Vogel. However, she stressed that there is room for progress. Key challenges include the fact that the fully-insured portion of total health care spending is relatively small, carriers with low membership appear reluctant to design value-based programs, provider practices with low attributed members appear reluctant to invest in value-based infrastructure, and there is a lack of multi-payer program alignment (e.g., care delivery, payment, etc.).

Vogel also pointed out what she considers to be a critical challenge, namely that the Department regulates a small portion of the health insurance industry. “We regulate the fully-insured segment, which comprises only 10 percent of the total health insurance market and is therefore too small to drive change alone.” Vogel further commented, “we remain committed and engaged to collaborate with the industry to find ways to continue this great progress toward value-based care”.

An additional hurdle may come from a new strategy under consideration by carriers, namely, to separate hospital and physician fees for self-insureds from fully insureds. If this strategy were to be implemented, Vogel opined that the hospital price growth cap of CPI+1 would apply to only fully insured and not self-insured, as hospitals would not be held to the price growth cap for self-insured rates. Carriers and providers would need to re-think their care delivery approaches, since bifurcating the market will likely add administrative burdens and market inefficiencies.

Vogel continues to search for policy solutions. At the March 13th meeting of the Delaware Primary Reform Collaborative, she suggested that Delaware could consider ways to include additional payer types (e.g., Medicaid, self-funded) to increase the size of the market and result in more impactful results for value-based care programs. She is also seeking creative solutions for carriers with low membership counts to be able to offer non-FFS programs, opportunities to provide certain care transformation activities in a more “centralized” manner (for smaller practices) and expanding her Office’s ability to require financial amounts within categories of non-FFS activities. The Office is working on a supplemental report which will further explore these challenges and opportunities.

Medicaid renewals began April 1;  

Members should verify contact information with DHSS, watch for renewal information 

The Delaware Department of Health and Social Services (DHSS) has resumed the standard eligibility renewal process for Medicaid and CHIP recipients as of April 1, 2023, as required by federal law. Annual renewals were not required from March 2020 to March 2023 during the federal Public Health Emergency designation. Federal legislation, signed into law on December 29, 2022, set a specific date to resume renewals, regardless of when the Public Health Emergency ends.  

As of January 2023, approximately 315,000 Delawareans were enrolled in Medicaid. With annual renewals underway, DHSS estimates 40,000 to 50,000 Delaware residents who were receiving continuous coverage due to the Public Health Emergency may no longer qualify for Medicaid or CHIP, also known as the Delaware Healthy Children Program, and may be disenrolled. 

Between April 2023 and April 2024, DHSS is reviewing every member’s eligibility and, where approved by state or federal rules, using available data sources to automatically renew members. If DHSS cannot auto-renew a person’s coverage using available and approved data sources, the member will receive a pre-populated renewal letter by mail. Delaware Medicaid and its Managed Care Organization partners are also using texts, email, and social media when available to enhance outreach efforts.  

A member can complete their renewal through a variety of ways: online through Delaware ASSIST, by phone, by mail, by fax, or at any Division of Social Services (DSS) office locations. Individuals who need assistance filling out their renewal can call the Division of Social Services Customer Service Unit at 1-866-843-7212. 

“Over the past three years, the state’s public assistance programs have been a crucial safety net for so many Delawareans,” said Molly Magarik, Secretary of the Delaware Department of Health and Social Services (DHSS). “As we are undertaking the monumental task of restarting eligibility renewals again, our goal is to ensure Medicaid members who continue to be eligible stay enrolled and that those who are determined to no longer be eligible get connected to affordable coverage.”  

The most important thing Medicaid and CHIP members can do is to update their mailing address, email and phone numbers with DMMA and sign up for electronic notifications. Contact the Change Report Center at (302) 571-4900, Option 2 or send changes via fax to (302) 571-4901. Changes and notification preferences can also be made at ASSIST Self Service https://assist.dhss.delaware.gov/. Individuals can find out more information about the renewal process at de.gov/medicaidrenewals. 

“There are many Delaware residents who qualified for Medicaid coverage for the first time during the Public Health Emergency who have never had to complete an annual renewal before,” said Steven Costantino, Director of Health Care Reform for DHSS. “This is why it is critical that we have the most accurate information available for each member, and that individuals on Medicaid watch out for communication and take the necessary steps to renew. We do not want anyone who is eligible for Medicaid to be disenrolled.”   

Health care providers and others who provide services to members can help by reminding their Medicaid members to look for and complete their Medicaid renewals this year and to encourage them to start exploring other coverage options if they believe they will no longer qualify for their current coverage. 

Special Enrollment Period Authorized for Health Insurance Marketplace  

To help individuals who are no longer eligible for Medicaid coverage, the federal government has authorized a Special Enrollment Period for the Health Insurance Marketplace. Individuals who lose their coverage through Medicaid and CHIP any time between March 31, 2023, and July 31, 2024, will be eligible for a marketplace special enrollment period. After a person is determined eligible for the marketplace, they will have 60 days to choose a plan, and their coverage will start the first day of the month after the plan is selected. 

Many enrollees can find plans on the Health Insurance Marketplace that cost less than $10 a month. Plans cover services like prescription drugs, doctor visits, urgent care, hospital visits, and more. 

Delawareans who no longer qualify for Medicaid should ensure that they do not experience a gap in health insurance coverage, but choosing the right private health insurance plan can seem daunting. Trinidad Navarro, the Commissioner of the Delaware Department of Insurance, suggests that a good first step would be to visit ChooseHealthDE.com to locate a local, federally registered/approved Navigator for assistance in enrolling in the Federally Facilitated Marketplace.   

In Delaware, assistance enrolling in the Health Insurance Marketplace is available from certified Health Insurance Marketplace Navigator teams at Westside Family Healthcare and Quality Insights. To be connected to a trained Navigator, call:  

• Westside Family Healthcare: New Castle County: 302-472-8655, Kent or Sussex counties: 302-678-2205 
• Quality Insights: 1-844-238-1189 

Some individuals who are found to be ineligible for Medicaid may be eligible for or already enrolled in Medicare. If that’s the case, the Department’s Delaware Medicare Assistance Bureau (DMAB) (302-674-7364) is ready to help with locating supplemental Medicare and Prescription coverage.   

“Our DMAB team is friendly, knowledgeable and approachable, and they are always there to help older Delawareans get the best possible coverage to supplement their Medicare plans,” said Commissioner Navarro. 

Be Aware of Potential Insurance Scams 

Additionally, Commissioner Navarro pointed out that buyers should beware of offerings that say they are “plans” that are actually not health insurance. 

“As a general rule, if an offer seems too good to be true — it probably is,” Commissioner Navarro said. “Please be careful when searching for insurance on the Internet as you may accidently access a website that looks like it is advertising health insurance when it actually is not.”   

For example, buyers may receive aggressive advertising from discount plans or discount cards offering discounts on health care for a monthly fee. Another example is so called “health sharing” plans, which allow buyers to join a group or association that will take a participant’s monthly payments, put them in a savings account or trust with other participants’ money, and then help pay some of the participant’s health care costs, as needed. Neither of these “plans” are health insurance plans, and participants do not have the same protections as they would under major medical health insurance. 

It has also been reported that scammers may be calling or texting individuals that receive Medicaid asking for money to help with the Medicaid renewal process. Scammers might pretend to be from a real organization or a government agency. They can use phone, text or email to try to steal money or something of value from you. If someone contacts you and requests money for help with your Medicaid renewal they are not a representative of DHSS. DHSS will never ask you for money or for your credit card information. 

The Delaware Department of Justice also reminds residents to be extra diligent about telephone scams by: 

• Never agreeing to pay any fine or other money over the phone, including by purchasing a money order or gift card at a store and providing the number to someone over the phone or by email. Government agencies do not take payments this way.  
• Not answering calls from unknown numbers or unfamiliar persons. Scams can be “spoofed” to appear to be coming from a local number, even though the call is originating from out of state or overseas. 
• Hanging up on aggressive callers, particularly those who threaten arrest. 

Consumers who believe they may have been scammed may call the Consumer Protection Unit’s toll-free Consumer Hotline at (800) 220-5424, or e-mail consumer.protection@delaware.gov. Consumers can also report scammers’ phone numbers to the National Do Not Call Registry and file complaints at www.donotcall.gov.   

For more information about the Medicaid renewal process, visit de.gov/medicaidrenewals. 

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Delaware Health and Social Services is committed to improving the quality of the lives of Delaware’s citizens by promoting health and well-being, fostering self-sufficiency, and protecting vulnerable populations.

NEW CASTLE (Jan. 27, 2023) – With more choice in plans than ever before, enhanced federal subsidies, and Delaware’s reinsurance program keeping the cost of monthly premiums relatively steady, enrollment on Delaware’s Health Insurance Marketplace for 2023 again set an all-time high, increasing 8% over the open enrollment total for 2022.

During Delaware’s 10th open enrollment period, which began on Nov. 1, 2022, and ended Jan. 15, 2023, a total of 34,742 Delawareans enrolled for health insurance on HealthCare.gov. During the previous year, sign-ups during the open enrollment period totaled 32,113. For those who enrolled by Dec. 15, 2022, and paid their first premium, coverage began Jan. 1, 2023. For those who enrolled by Jan. 15, 2023, and paid their first premium, coverage will begin Feb. 1, 2023.

“All Delaware families need access to affordable, quality health care,” said Governor John Carney. “This year, we celebrated the 10th year of open enrollment on Delaware’s Health Insurance Marketplace with more plans to choose from, helping to make coverage even more affordable. With record-breaking enrollment numbers, we know Delawareans are prioritizing their health. Thank you to all the community navigators and health advocates who helped us reach this milestone.”

“Marketplace plans play a crucial role in improving access to high-quality and affordable health care,” said Department of Health and Social Services Secretary Molly Magarik. “I am thrilled to see a record number of Delawareans taking advantage of the many affordable options offered through Delaware’s Health Insurance Marketplace, and we are grateful to the community navigators and application counselors who worked hard during open enrollment to help individuals and families find the plan that was right for them.”

This year, Delawareans were able to choose from three insurers, compared to only one last year, and a total of 30 plans, the highest total in the 10 years of the marketplace. Insurance Commissioner Trinidad Navarro announced in June 2022 that two new insurers – AmeriHealth Caritas (four plans) and Aetna CVS Health (nine plans) – would join Highmark Blue Cross Blue Shield Delaware (17 plan options) in offering coverage on the marketplace for 2023.

All plans offer essential health benefits such as coverage of pre-existing conditions, outpatient care, emergency services, hospitalization, prescription drugs, mental health and substance use disorder services, lab services, pediatric services, birth control and breastfeeding coverage, and COVID-19 vaccines, including the updated bivalent booster. In addition, coverage cannot be terminated due to a change in health status, including diagnosis or treatment of COVID-19.

“Judging from the final enrollment numbers, it is clear that Delaware consumers appreciate being able to choose from a variety of plans at prices that are affordable,” said Insurance Commissioner Trinidad Navarro. “Affordable, high quality health care is critical to Delaware consumers, and market stability and increased competition are key to helping provide consumer-friendly health insurance options in Delaware.”

The overall stability of Delaware’s Health Insurance Marketplace reflects continued federal approval of Delaware’s reinsurance program. The program has lowered health insurance premiums for plans sold in the individual insurance market by partially reimbursing insurers for high-cost health care claims through a fund that uses a mix of federal funding and assessments collected by the Delaware Department of Insurance from health insurance carriers. Because the insurers’ claims costs are lower, the insurers can reduce the cost of premiums or limit increases.

In 2021, the Biden administration made expanding access to health insurance and affordability a priority through the American Rescue Plan Act, which increased tax credits and expanded subsidies into the middle class. This year, the passage of the Inflation Reduction Act continued those enhanced benefits through 2025. For instance, a family of four (both parents in their 40s) making $50,000 are eligible for a credit of roughly $16,000, compared with $14,300 previously.

“Over a decade ago, when crafting the Affordable Care Act, we had one goal in mind: to make affordable, quality health care available to all Americans – and the marketplaces were vital to reaching that goal,” said U.S. Senator Tom Carper. “Now, we are seeing enrollment numbers go up year after year, and more Delawareans are able to get preventative screenings at no cost and get access to health care services previously not afforded to them. I thank the hard-working navigators for their work enrolling uninsured Delawareans in plans that work best for their families, and I look forward to continuing our work to drive down health care costs for all Americans.”

“Over the past decade, the Affordable Care Act has made affordable, quality health care coverage a reality for millions of Americans,” said U.S. Senator Chris Coons. “I’m proud to have worked with President Biden and my colleagues to strengthen the ACA in the American Rescue Plan and Inflation Reduction Act, further driving down costs for families, and am excited to see record numbers of Delawareans benefitting from this landmark legislation this year.”

“Ensuring that Delawareans have accessible, affordable, high-quality health care is critical to the health and well-being of communities across the First State,” said U.S. Rep. Lisa Blunt Rochester. “I am encouraged to see that this year a record number of Delawareans signed up for health care coverage through Delaware’s marketplace. This would not have been possible without the hard work of DHSS, Insurance Commissioner Navarro, and Community Navigators such as Westside Family Healthcare and Quality Insights that were on the ground guiding Delawareans and providing the resources they needed to find plans that fit them and their families best. I am grateful to be a partner in keeping Delaware healthy and remain as committed as ever in advocating for more affordable, accessible, high-quality health care for Delawareans in the 118th Congress.”

Delawareans who need help enrolling in coverage have access to free in-person assistance from federally funded and trained specialists at Westside Family Healthcare (statewide) and Quality

Insights, Inc., (New Castle and Sussex counties) and by certified application counselors at Henrietta Johnson Medical Center in Wilmington and La Red Health Center in Georgetown. Westside and Quality Insights each received increased federal funding for navigators to help people enroll for coverage.

“As a Federally Qualified Health Center, Westside understands how health insurance coverage reduces barriers to routine care and can save lives” said Lolita Lopez, President & CEO of Westside Family Healthcare. “Westside has provided enrollment assistance in the Health Insurance Marketplace since 2013, and we are thrilled with the record-breaking results during this open enrollment period. We commend the work of our state partners to reduce premium costs making coverage on the Delaware Health Insurance Marketplace more affordable than ever before.”

“We are very pleased to see a continued increase in those taking advantage of the affordable coverage offered through the Marketplace,” said Shanen Wright, Program Director of Quality Insights’ Navigator program. “And although 2023 open enrollment has concluded, we are available year-around to help Delaware residents learn more about their coverage options for 2024, or to enroll this year for those who become newly eligible through a qualifying event. We encourage anyone in need of information or assistance to reach out at qualityinsights.org/navigator or 1-844-238-1189.”

With the end of open enrollment on the health insurance marketplace, Delawareans can enroll for coverage if they experience a life event that qualifies them for a special enrollment period. Among the many qualifying life events are birth or adoption of a child, a permanent move, loss of other coverage through a job, and marriage or divorce. Visit HealthCare.gov/screener to see if you qualify.

In addition to the health insurance marketplace, some Delawareans might be eligible for coverage through Delaware’s Medicaid program, which is open year-round. To be screened for eligibility or to apply for Medicaid benefits, go to Delaware ASSIST.

Experienced healthcare management strategist hired after lengthy national search

Insurance Commissioner Trinidad Navarro welcomed Cristine Vogel to the Delaware Department of Insurance as its Director of Value-Based Health Care Delivery this week after a lengthy national search to fill the role. As the inaugural Director, Vogel will lead efforts that relate to value-based care, primary care, pharmaceuticals and pharmacy benefit managers, affordability, and other health-policy initiatives including grant programs.

“It is more important than ever before to ensure the accessibility and affordability of healthcare and prescriptions,” said Commissioner Navarro. “Hospital prices, the cost of medications, and low-quality services all raise the price of consumer care and insurance coverage. With Cristine’s expertise on board, we can keep making progress toward higher-quality care at a lower cost.”

Director Vogel has been involved with healthcare management for over 25 years, with experience in hospitals and medical practices, state government, insurance, and consulting. Leading the Office of Value-Based Health Care Delivery, Vogel will establish, implement, and monitor Affordability Standards such as those to increase primary care investment, and manage the reporting of carrier investments in health care. This will include assessing commercial reimbursement rates for primary and chronic care services, the role of price and utilization in healthcare spending, and prescription drug spending as a driver of total cost of care.

“Delaware is taking on innovative efforts to address care quality and cost, and I’m proud to work with Commissioner Navarro to make these projects a success,” said Director Vogel.

Vogel most recently served as the Director of Population Health Initiatives for Nuvance Health System in Connecticut, where she developed solutions to improve clinical outcomes, increase quality of care, and control healthcare costs through implementing a nurse care management program, a clinical pharmacy program, and through integrating behavioral health within primary care practices. Her experience in healthcare reform also includes leading the State of Connecticut’s Office of Healthcare Access and evaluating Certificates of Need. The position, funded by the department, was made necessary by several legislative mandates related to healthcare affordability and pharmacy benefits.