$12.3 Million in Health Insurance Rebates for Individuals and Small Businesses

Highmark plan participants and groups to receive checks

Insurance Commissioner Trinidad Navarro announced today that Highmark Blue Cross Blue Shield Delaware will issue rebates totaling over $12.3 million to some Delawareans. Residents who purchase insurance on the Delaware Health Insurance Marketplace, those who purchase Highmark Delaware plans outside of the marketplace, and Highmark small group policyholders may receive rebates as a result of the Medical Loss Ratio (MLR) calculation.

MLR measures an insurer’s spending on medical expenses to confirm that at least 80 percent of premiums are being used for policyholders’ healthcare and prescription needs. It is an accountability measure included in the Affordable Care Act (ACA) that holds insurers to a strict standard and requires refunds if the threshold is not met. Insurers are not permitted to retain funds above this value for any reason, including to lower premiums for future years, as the policyholders effected may change. MLR is calculated on a three-year average – 2018, 2019, and 2020 were used in this assessment.

“Requiring insurers to meet the MLR ratio is one of the most critical tools the ACA gave us to protect consumers. These guardrails ensure residents and small businesses get the care they pay for, or get their money back – and they’re more important now than ever before,” explained Commissioner Navarro, who pointed to policyholders’ decreased and delayed use of healthcare throughout the pandemic as something likely to necessitate future rebates. “With decreased utilization of health services in 2020 and 2021 factoring into MLR for the next four years, and expected increases of utilization factoring into rates for 2022, this is yet another reminder that COVID will impact all aspects of healthcare, including insurance, for much of the foreseeable future.”

20,857 individual policyholders will receive rebates totaling over $8.4 million, with the average rebate being $405. This will be the second time in state history that rebates will be distributed to the participants of the individual market, with more than $12.6 million being sent to over 19,000 residents last year.

Highmark small groups, often small businesses, will receive nearly $3.9 million in cumulative return. 2,573 groups will receive an average rebate of $1,514, with 20 groups receiving rebates over $10,000. Employers can consider using these dollars to enhance benefits, reduce premiums for employees in future policy years, or provide refunds directly to group health plan participants.

Communications will be sent to policyholders in September and checks for both individual policyholders and small groups will be sent the week of September 15. Not every policyholder will receive a rebate. Those in the individual market with rebate questions can contact Highmark at 800-544-6679. Small group employers with rebate questions can contact their insurance producer, or Highmark at 800-241-5704.


Highmark Increases 2022 Affordable Care Act Marketplace Premiums

Expanded federal subsidies keep consumer costs low; SEP sees success

After two consecutive years of rate decreases, Highmark Blue Cross Blue Shield of Delaware, who offers the state’s Affordable Care Act (ACA) health plans, will increase base rates an average of 3% for the 2022 plan year. The announcement comes after extensive, in-depth independent actuarial reviews and a public comment period on the insurer’s initial proposal of a 4% increase. While insurers are increasing rates across the country, federal subsidies from the Biden-Harris Administration have cut consumer costs by 40% and will continue to be applied in the 2022 plan year. Residents are still expected to see savings despite the modest increase in the base rate.

The 2022 rate announcement comes after the end of the Biden-Harris Administration’s Special Enrollment Period (SEP), which gave residents the ability to enroll in 2021 ACA plans between February 15 and August 15. More than 5,377 Delawareans signed up for coverage during the SEP. Taking into account the 5% participation increase seen in last fall’s open enrollment, an estimated 30,000 Delawareans are now covered by 2021 plans. 23% of new and returning Delaware participants are enrolled in a plan costing $10 or less per month due to the American Rescue Plan.

“Stability in the individual health insurance market is so critical as we continue to battle COVID-19 and healthcare shortages. Rates remain more than 15% lower than they were just a few years ago, and with the American Rescue Plan, they’re more affordable than ever before,” said Insurance Commissioner Trinidad Navarro. “Coupled with the safety net of the SEP, the past year has been positive for insurance access.”

Delaware SEP enrollment February 15 through July 31 was more than double the same period last year, which saw higher-than-usual circumstantial enrollment due to COVID, and is nearly triple the typical enrollment for this time of year. Final numbers are expected in the coming weeks. The SEP’s success has led to proposals at the federal level for permanent open enrollment expansion as well as monthly enrollment opportunities.

Expansion of access and increased affordability remains a priority at the federal level, as American Rescue Plan funds increased tax credits and expanded subsidies farther into the middle class. Premium assistance will continue through 2022, and majority of Delaware marketplace enrollees will be eligible for these discounts that can reduce their monthly premiums.

Nationally, insurers are requesting premium increases as policy use is expected to rise with more residents scheduling postponed elective procedures and visits. The rise of prescription costs continues to be a factor in premium planning.

All ACA plans offer essential health benefits, including coverage of pre-existing conditions, prescriptions, emergency services and hospitalization, mental and behavioral health coverage, outpatient care and telehealth, lab services, and more. ACA rates do not vary based on vaccination or COVID-19 status.

Highmark Blue Cross Blue Shield Delaware is the sole health insurer offering plans on Delaware’s Health Insurance Marketplace for 2022, offering 12 plans for individuals and families. Two dental insurers – Delta Dental of Delaware, Inc. and Dominion Dental Services, Inc. – offer stand-alone dental plans on the marketplace.

Open enrollment for the Marketplace takes place between November 1 and December 15 each year. However, residents may qualify to enroll or change plans based on special circumstances, such as a loss of qualifying health coverage, change of income, becoming a parent, and several other qualifying factors. Find out if you qualify for special enrollment.

The rate change does not apply to Medicare, Medicaid, or those with group or individual policies outside of the Marketplace.

More information on the rate review process


Commissioner Trinidad Navarro Announces National Improper Marketing of Health Plans Working Group

National Antifraud Task Force takes on new charges to protect consumers

Delaware Insurance Commissioner Trinidad Navarro, Chair of the National Association of Insurance Commissioners’ (NAIC) Antifraud Task Force, announced today the successful creation of the Improper Marketing of Health Plans Working Group, which aims to tackle some of the nation’s most serious consumer-centered health scam efforts and end the siloed approach to addressing the issue.

“Robocalls, search engine advertisements, mailers, and endless telemarketing efforts aim to steal from those seeking comprehensive health insurance. All across the country we have seen scam artists build out networks of communication that center around selling insurance plans that do not offer residents adequate protection. They are merciless in their efforts, and they trick consumers into thinking they will have the coverage they need for their medical care” said Insurance Commissioner Trinidad Navarro. “There’s no need to sugarcoat it – there is deception occurring, and its being directed towards some of the most vulnerable residents. COVID-19 rightfully increased consumer concerns and led more people to seek out affordable insurance – but this concern has been manipulated by scammers. This Working Group will make headway towards ending these efforts to exploit residents.”

The Working Group is a new approach to address concerning increases in consumers being marketed away from ACA-compliant plans to other products that do not offer comprehensive coverage for things like preexisting conditions or hospital visits. Many improperly marketed health plans claim to be compliant, or advertise under look-a-like naming that deliberately creates confusion, such as “Bidencare,” or “Healthcare.com.”

These products may be inadvertently found by consumers searching for legitimate coverage, or on websites where a fraudulent entity has purchased advertising. Often, a consumers’ inquiry can be turned into a request for a quote without consent, and contact information is sold to third parties. The plans use of lead generators and telemarketing is so pervasive that department investigators must purchase dedicated phones for their investigations due to the intrusive, rapid-fire robocalls and text messages that can mount to more than 40 per day from a single webform completion.

The Working Group has meet informally since March 2020 to create a comprehensive conversation on the issue, combining discussions that previously took place in separate health, market conduct, and fraud committees. State and federal level regulators have attended, discussing the latest bad actors and efforts in their jurisdictions, often finding that those efforts are echoed elsewhere. Movement of scams from state to state after regulators shut them down is one of the key reasons that regulators sought approval of the subcommittee and its charges by NAIC’s Executive and Plenary Committees.

“The formation of this Working Group can help stop scams before they start,” shared Delaware Special Deputy Frank Pyle, who has served decades in law enforcement, fraud investigation, and market conduct, and lends his expertise to the new subgroup as Co-Chair. “With greater communication between regulators, those who aim to exploit consumers should be scared. Running from state to state will not be an option.”

The Working Group’s official charges include:

  • Coordinate with regulators, both on a state and federal level, to provide assistance to and guidance on monitoring the improper marketing of health plans, and coordinate appropriate enforcement actions, as needed, with other NAIC Committees, task forces, and working groups.
  • Review existing NAIC Models and Guidelines, including laws and regulations, that address the use of lead generators for sales of health insurance products and identify models and guidelines that need to be updated or developed to address current marketplace activities.

“The Nebraska Department of Insurance is pleased with the official recognition of this group by the NAIC. When we started this group, our goal was to create open communication between all states and the federal government in order to identify and investigate these bad actors in the improper marketing of health plans. Today, that goal is achieved, but the work is just beginning. We will utilize this group to further investigations and prosecutions of those entities and strengthen our laws so we can protect the insurance buying public from these activities,” shared Martin Swanson, Deputy Director of the Nebraska Department of Insurance and Chair of the Working Group.

Following approval of the Working Group, regulators can now formally join the committee. Ad hoc virtual meetings have consisted of contributors from nearly every state, with meetings regularly engaging 100 to 300 participants. The Working Group’s members have already taken multiple administrative actions against entities and schemes identified by the group to protect consumers. Meetings are regulator-only.

The Working Group is part of the National Antifraud Task Force, which works with insurance regulators across the country, as well as local, state, federal and international law enforcement and antifraud organizations. The Task Force provides guidance and resources for insurance departments across the country and in the U.S. Territories, including tracking and analyzing trends in fraud. Numerous subgroups inform the Task Force’s work, including the Antifraud Education Enhancement Working Group and the Antifraud Technology Working Group.

More information about non-compliant health plans


Mental Health Parity Examinations Find Inequities in Insurer Behavior

More than $1.3M in total fines assessed for coverage discrimination

Insurance Commissioner Trinidad Navarro has announced the completion of additional Mental Health Parity examinations on regulated health insurers in Delaware. These violations resulted in $735,000 in fines and significant insurer corrections to create a less discriminatory environment in the future. Combined with two examinations completed in 2020, Delaware’s largest health insurers have been fined a total of $1,332,000 for not treating mental and behavioral health care equally to other forms of needed care. A high number of violations was expected as these final reports complete the first round of assessments by the department.

“Every person should be able to seek the care they need without undue expense or difficulty, and that remains true whether the person is seeking care for a physical ailment, or a mental one,” said Commissioner Navarro. “The thorough examinations conducted by the Department of Insurance highlight many needed improvements to ensure parity, and we will continue to work to bring these corrections to fruition and to hold insurers accountable.”

Mental Health Parity laws, which exist both at the state and federal levels, aim to eliminate coverage discrimination between policyholders seeking mental illness or substance abuse care and those seeking physical care. A lack of parity can prevent a person from pursuing needed care due to cost or limited access, or otherwise make it more expensive or more time intensive than medical visits. Department examinations are critical to uncovering parity issues as consumers may not be aware if they are experiencing disparate treatment.

“We have been working toward a more just healthcare system over the past decade, and mental health parity has been a key solution to the issues of access and affordability that plague our communities,” Commissioner Navarro shared on an American Health Law Association podcast.

Throughout the examination processes, instances where parity was violated included placing greater limits on the coverage of medicines for an insured during the diagnosis and treatment of mental illness or substance dependency than for covered services provided in the diagnosis and treatment of any other illness or disease covered by the health benefit plan. Insurers imposed Non-Quantitative Treatment Limitations (NQTL) prior authorization requirements more stringently to mental and behavioral health benefits than to medical/surgical benefits and thus created barriers and delays to treatment. Companies excluded mental health-related medications in their cost-saving programs for policyholders, and placed these medications on formulary tiers that resulted in members who take those pharmaceuticals facing higher copays compared to other medications offered in lower tiers.


Advances in Primary Care Reform Made Possible by Legislature

General Assembly sent key bill to the Governor

The Delaware General Assembly passed legislation to increase Delawareans’ access to high quality, affordable health care through a series of reforms that will refocus Delaware’s healthcare system on primary care and improvements in value.

Senate Substitute 1 for Senate Bill 120 requires commercial health insurance companies to make meaningful increases in their primary care investment, limits price increases for hospital and other non-professional services, and compels health insurance companies and health systems to work together to improve healthcare value. By implementing these reforms simultaneously, models show that the increases in primary care investment do not result in unsustainable increases in total cost of care.

“Informed by data and the perspectives of Delaware consumers, physicians, employers, health insurance companies and hospitals, the Delaware Department of Insurance created a road map aimed at ensuring residents have access to high-quality, affordable health care, and that the primary care provider community would be strengthened in the process,” stated Insurance Commissioner Trinidad Navarro. “Through this legislation, the General Assembly has put these plans into action. We look forward to working with those stakeholders and the General Assembly to implement this important legislation that will improve the health and wellbeing of Delawareans while bending the healthcare cost curve.”

The types of reforms included in SS 1 for SB 120 were first contemplated in a report by the Delaware Department of Insurance and its Office of Value-Based Health Care Delivery, which was created by the General Assembly in 2019. Those same agencies would be tasked with implementing the legislation, creating necessary regulations, and enforcing its measures. To inform this work, the Office of Value-Based Healthcare Delivery embarked on an extensive data collection and stakeholder engagement process in 2020, which included data from Delaware health insurers, the Delaware Health Information Network Health Care Claims Database, publicly available sources, and perspectives shared during more than two dozen stakeholder interviews.

Research by the Office of Value-Based Health Care Delivery found that primary care spending in Delaware is low relative to the national average and about half of what is spent in leading states. This low investment in primary care services has likely contributed to declining numbers of primary care providers and poor access to primary care statewide. Increased numbers of primary care providers have been associated with improvements in health and decreases in mortality, as well as lower rates of emergency department visits and hospital admissions. Though many states face similar trends, the research also found primary care access problem in Delaware is particularly acute. The state’s population is among the oldest in the nation, a trend that will continue to grow.

“With one in five Delawareans are over the age of 65 and two in five of our neighbors living in an area with a shortage of primary care doctors, we have to do more to ensure our communities have access to the frontline providers they need to improve the quality of their health and keep them out of the hospital,” said Senate Majority Leader Bryan Townsend, the prime sponsor of SS 1 for SB 102. “Even as costs continue to rise for us all, the current system is simply providing positive results for too few Delawareans,” he said. “After three years of careful study and consideration, I am confident the legislation that Rep. David Bentz and I passed through the General Assembly will result in more primary care providers serving our state and better healthcare outcomes for our neighbors.”

“The primary care industry in Delaware is facing substantial challenges. Physicians are retiring or leaving the state, creating a shortage that means poor access to care for residents. Factor in the low levels of investment and we have an unsustainable system. We need to tackle this crisis head-on immediately,” said Rep. David Bentz, the bill’s lead House sponsor. “SS 1 for SB 120 will modernize and enhance primary care services in Delaware by directing the Health Care Commission to monitor and promote compliance with alternative payment models that promote value-based care. Primary care is critical in our efforts to improve public health outcomes and reduce long-term costs. It is, without question, where we get the best return on investment with our healthcare spend both financially and in-terms of the health of our population. I look forward to Governor Carney signing this bill into law to reverse the losses we’ve seen in recent years.”