Health Plans

The large, regional and national health plans—United Healthcare, Aetna, Humana, CIGNA, HealthNet, Wellpoint and others—are heavily engaged managing their entry into the individual insurance markets established by the ACA exchanges. Each has taken a different approach to jumping in, some very cautious, others more aggressive. They all hope that this new market created for the 30+ million uninsured in the U.S. will yield economically viable incremental business to their plans. But, the higher risk in these exchanges dictates their current efforts to shift more risk to providers.

Many of these organizations operate Medicare Advantage (MA) plans serving Medicare beneficiaries. These plans have grown rapidly over the last decade and currently enroll over 15 million lives, about 30 percent of all beneficiaries. However, as CMS tightens up on the number of plans and the rates it pays, there’s the potential to see enrollments flatten out or decline in certain areas.

Medicaid expansion under the ACA will continue the increase of beneficiaries in managed care plans. Nationwide about three-fourths of all Medicaid beneficiaries are in some form of managed care.

Smaller, independent Provider Sponsored Health Plans (PSHPs) can operate very successfully in the shadow of these larger plans, but will also be affected by the changes here. In addition, many of the evolving ACOs will seek to develop their own MA plans as they independently need to acquire most of the tools the health plans possess—claims processing, data analytics, care coordination, member communication, physician networks, quality metrics.

Valiante – Healthcare Management Solutions provides services to provider-sponsored health plans:

  • Network development and contracting
  • Stars plan implementation and coordination with physicians
  • Medicaid plan development and expansion
  • Provider sponsored health plan development
  • Federal, state and private exchange development