Among for-profit insurers, Bright Health Group’s $1.9 billion charge is the highest owed through the program, according to analysis by Modern Healthcare. The company also reported a peak “risk-adjusted fee” of $3 million for failing to provide complete, timely data to federal regulators, the CMS report said.
A spokesperson wrote in an email that Bright Health’s risk-adjusted payout reflects the size, health, and metal mix of the company’s 2022 membership. The company declined to comment on whether it would be able to make the full risk-adjusted payout.
Bright Health switched to third-party claims processor Evolent Health last January after its internal system failed to record a patient’s health and medical bills. The company closed exchange plans in 15 states last year and is working with the states to settle claims incurred by the company’s nearly 1.1 million former members.
Insurtechs Oscar Health and the defunct Friday Health Plans owe the second and third highest totals through a risk-adjusted program of $1.4 billion and $779.7 million, respectively. State regulators aren’t sure if fledgling insurers can profit from the fees, especially in the case of Friday Health, which the states have placed a stake in. reception area. Friday Health did not respond to a request for an interview.
Oscar Health, which did not respond to a request for an interview, attributed its high risk-adjusted payout to a spike in new member rates caused by the Biden administration’s special enrollment period last year, according to the filing. Securities and Exchange Commission filings that the company filed in May. SEC filings say Oscar worked with federal regulators last year to restrict registrations in its largest market and is expected to pay a smaller amount in 2024 because most All of their subscribers renew. The company faces a class-action lawsuit from shareholders alleging that it failed to disclose the extent of the COVID-19 pandemic’s impact on its payout through its pre-payment risk adjustment program. initial public offering.
Oscar extended his contract with Ciox Health in April for another seven years to perform risk adjustment functions.
If companies are unable to reimburse the full fees, the risk-adjusted amount paid to other carriers in the state will be cut in proportion to the shortfall.
Centene is the largest exchange provider with 3 million members and, among for-profit service providers, is also poised to receive the largest net proceeds through the program of $782.2 million. la. The company did not immediately respond to a request for an interview.
