Insurers are increasingly requiring genetic counseling and prior authorization for complex genetic tests due to high costs and uncertainty around appropriate use; Cigna found positive results from a policy requiring counseling, with genetic counseling sessions increasing by 4.5 times. Insurers face complexities in genetic testing due to rapidly growing tests, use of broad gene panels, and aggressive marketing by testing companies that can lead to overuse.

1. Volume 24, Number 37 October 27, 2014
Published by Atlantic Information Services, Inc., Washington, DC • 800-521-4323 • www.AISHealth.com
An independent publication not affiliated with insurers, vendors, consultants or associations
3 Insurers Increase
Incentives, Transparency in
ACO Models
3 Additional Health Plan
News of the Week
4 Aetna Pilot Seeks to Match
Data to New Breast Cancer
Patients
4 People on the Move
6 Table: Top Behaviors
Employers Are Focusing
On in 2015 for Wellness
7 Health Plan Briefs
Insurers Clamp Down on Genetic Testing
Costs Via Counseling, Prior Authorization
Health insurers are turning to utilization management for complex genetic testing,
with one major insurer, Cigna Corp., releasing an update that shows positive results
from a policy it implemented last September requiring counseling from a board-certi-
fied genetics specialist for people seeking coverage for genetic testing for diseases like
breast and colorectal cancers.
Genetic tests draw eye-popping costs, from a range of $500 to $10,000 per test, ac-
cording to insurers. And since the field is so new, health plans are likely to follow in Cig-
na’s footsteps and take aggressive actions like counseling requirements to make sure the
right people are getting the right tests and for some necessary purpose, stakeholders say.
“In the genetic testing field, we basically have an approach to manage tier-one ge-
netic tests by taking the most commonly done test and the most controversial test, in
terms of misunderstood tests, and requiring genetic counseling,” David Finley, M.D.,
Cigna’s national medical officer for enterprise affordability and policy, tells HPW. “So
the patients get the benefit of not only the counseling but the benefit of spending a lot
of time with a counselor to figure out what is the right test, other than just a kind of a
reflexive response. And that’s working quite well.”
Contents Plans Help Shape 2015 Wellness Programs
As Large Employers Measure More Results
As large employers extend and tweak wellness programs for 2015, health insurers
are finding opportunities to take a greater role by assisting in the measurement of health
promotion and incentive-based plan design outcomes, employee benefit consultants
say. Increasingly, CFOs of major corporations are asking their internal human resource
and benefits departments to show the results of incentive-based wellness programs. But
in the area of building and creating new-style wellness programs, it is the slew of third-
party vendors that rule the roost.
Kayla O’Neal, consultant, health risk solutions at Lockton Benefits Co., tells HPW in
the market at large, a lot of employers are still figuring when they should use incentives
versus penalties. “I think when it comes to anything new and different, there is the slow
but steady dial-up going on about more of the total worker health analysis. How do
we incorporate things like financial well-being, happiness, stress and resilience? Try to
put some metrics around awareness in our wellness program of a broader spectrum of
things that will impact worker health,” she says.
In this new “total health” way of thinking, corporations still look to vendors like Vi-
tality and RedBrick Health to design the programs even if carriers have the background
on the back end in measuring results. “Insurers are in the game but not leading it; they
are not the cutting edge. It is still the third-party vendors that are really building out
true platforms that can manage these programs going to a broader scope. Insurers want
to be there, but vendors still have them beat to the finish line,” O’Neal says.
continued on p. 5
continued
Strategic Business, Financial and Regulatory News of the Health Insurance Industry
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2. 2Health Plan Week October 27, 2014
Since implementing the counseling requirement,
the number of Cigna customers who have received
counseling from a board-certified genetics specialist has
increased by 4.5 times. The insurer did not provide raw
numbers on how many of its members receive genetic
tests or were redirected from doing so as a result of coun-
seling.
Finley says there are a number of genetic tests, but
the ones that are most heavily utilized have tier one codes
in the American Medical Association Current Procedural
Terminology (AMA CPT) manual. “A tier one code is a
code that has a 1:1 correlation between a genetic test and
a CPT code, like the BRCA test [for a gene mutation tied
mostly to female breast and ovarian cancers]. And for
those tests, the number of tests that we are seeing is go-
ing up. The ones that are often ordered where the patient
may not meet the criteria are the ones we put on prior
authorization,” he says. “Other genetic tests like cystic
fibrosis, most of the patients who have that genetic test
are ordered appropriately. It’s been around a long time. It
is well understood, and we don’t put that on prior autho-
rization. The ones that are difficult to understand in terms
of the criteria and the genetics involved in them, we do
put on prior authorization. BRCA and colon cancer are
two of them.”
According to a 2013 report from Booz Allen Ham-
ilton, the number of available genetic tests has grown
markedly, from 1,680 in 20019 to 2,886 in 2012.
Finley is not certain why demand for genetic tests is
going up, and offers that the rise is not all good and not
all bad. “I think that to the extent that these tests are in-
dicated and used according to scientifically based guide-
lines it is a good thing. To the extent that they are being
done for other reasons, it is not a good thing,” he stresses.
The “not good” reasons for testing include overzealous
marketing efforts. “I think that there are some tests out
there, and also some panels out there, that are being ac-
tively marketed by genetic testing companies, where the
doctors are given one side of the story because it is a sales
pitch and the doctors are saying, ‘that makes sense to me,
I will go ahead and order it.’ To the extent that they rely
on a sales pitch and not scientific guidelines it may not be
such a good thing,” Finley says.
Cigna contracts with a network of genetic counselors
that do most of the carrier’s counseling in face-to-face en-
counters with patients at the office of the counselor, much
in the same way the insurer contracts with physicians
and ancillary providers, Finley says. Genetic counselors
are often located in hospitals and tertiary care centers. “In
addition to that, we have made available to our custom-
ers telephonic genetic counseling for those people who
have difficulty finding a genetic counselor with an office
near them, contracted for them through InformedDNA,”
a St. Petersburg, Fla.-based genetics counseling firm, he
adds.
Options like the use of panels containing a series of
tests instead of a test for one gene at a time change very
rapidly in the genetics field. This may make sense in
some cases, but Finley contends there is much opportu-
nity for waste in deploying panels in genetic testing. “The
way I look at it, if there is a patient who needs a genetic
test or a patient who needs two or three, those are the
tests that you should order. Even though it may be more
convenient to order a panel of a dozen tests, where nine
of them are not needed, that is not a good thing.”
Complexities Abound in Genetic Tests
Faced with these complexities, insurers are tap-
ping into the expertise of genetic counselors. Joy Larsen
Haidle, president of the National Society of Genetic
Counselors, tells HPW that a genetic counselor’s job in
the oncology space, for instance, is to look at the family
history of cancer and try and determine the odds that
there is a strong inherited risk factor. They must also
determine of the genetic tests that are available, what’s
the best test for a given family, and who is the best person
in the family to test. “And then we talk about how would
a person use that information to help with their medical
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3. October 27, 2014 Health Plan Week 3
management decisions, so that they can choose what type
of surveillance is best based on the family tree or the gene
test results or what they could do to reduce that cancer
risk,” she says.
Some of the problems that arise without tight over-
sight or proper consultation is that providers sometimes
have a difficult time getting the exact degree of relation of
some of the relatives in place, or they merge both sides of
the family together instead of keeping it one blood line at
a time. “You can’t take cancers on mom’s side and dad’s
side and merge them together to meet criteria,” Haidle
says. “And so having the genetic counselor involved in
that piece helped filter through even further patients that
did not need testing. It also helped reduce duplicate tests
and errors in the tests that were selected.”
Contact Larsen Haidle via Veronica Jackson at vjack-
son@pcipr.com and Rogelio DeLaMar at rogelio.dela-
mar@cigna.com for Finley. "
Insurers Increase Incentives,
Transparency in ACO Models
As accountable care organization models become
more prevalent, health insurers are further exploring in-
novative ways to increase transparency and incentives for
both providers and members.
At the U.S. Chamber of Commerce Annual Health
Care Summit in Washington, D.C., on Oct. 22, executives
from WellPoint, Inc. and CareFirst BlueCross BlueShield
discussed results from their innovations in payment
benefit design, including a redesigned provider payment
model and the use of hospital rankings, reference-based
pricing, wellness incentives and telemedicine.
The newest development is CareFirst’s “copay waiv-
er” program for needed services in 2015. CareFirst has
filed plans with the Maryland Insurance Administration
to waive copays so long as the members are following the
care plans developed by their primary care physician and
working with their nurse care coordinator, Vice President
of Public Policy John O’Brien said. The waiver acts as an
incentive for members who commit to a healthy lifestyle.
CareFirst’s overall payment program also rewards
providers for remaining engaged in each patient’s well-
being. The 4,000 providers involved are assigned to pan-
els of 10 providers, each of which manages a population
of around 3,500 patients. The “rosters” are chosen based
on risk analytics, and presented to the provider panels
that can either accept or refuse them. The providers are
then paid a $250 participation bonus once they create a
care plan for each patient, and can bill the insurer at a
12% premium to their normal fees each time they see the
patient. The panels are also awarded outcome incentives
Web addresses cited in this issue are live links in the PDF version, which is accessible at
HPW’s subscriber-only page at http://aishealth.com/newsletters/healthplanweek.
to encourage the providers to work together and share
best practices.
“We’ve seen a panel champion emerge in each team,
one who’s really going over the numbers and sharing the
best practices within the panel,” O’Brien said. “If you’re
a rock star provider and your panel isn’t achieving the
quality and cost improvements that you had hoped, it’s
your opportunity to rally the troops.”
The outcome incentive is a percentage of the total
amount of fees the provider billed to the insurer in the
previous year. In 2013, of the participating 291 panels, 200
achieved an outcome incentive award, with an average
award of 36%, meaning each provider was paid a 36%
increase on all of the fees they billed to CareFirst in 2012.
“So you take the 12% they get for participating in the
program, add 36% to that, and they’re receiving about a
48% increase in fees for all of their billing to us for all of
their patients from the following year, in addition to the
fees that we’re paying them,” O’Brien said.
Additionally, the panels are awarded an additional
bonus for beating their performance the previous year,
to incentivize them against doing the bare minimum.
CareFirst provides the panels with a nurse care coordina-
tor who acts as a liaison between the patient and physi-
cian, as well as keeping each patient’s care plan updated.
The providers are also given a “suite of analytics tools” to
help track each patient’s progress.
O’Brien said CareFirst has seen a $70 decrease in cost
per patient per month through the program, as well as
a 6% reduction in hospital admissions, 8% reduction in
readmissions and 11% reduction in outpatient facility use.
O’Brien said CareFirst has avoided hundreds of millions
of dollars in costs since the program launch.
Insurers are also increasing cost and quality transpar-
ency for their members. By analyzing and comparing
Additional News of the Week
Coverage of these health plan developments was
included in this week’s issue of Spotlight on Health
Insurers:
• CoOportunity Exits Iowa Medicaid Program
• Colorado Insurers Cancel 22,000 Plans
• Patients Sue United for $2.5B Over Hep C
• PreferredOne to Increase Premiums by 63%
• Kaiser HMO Scores Top Marks in Calif.
• CareSource Names New Leadership
• Sutter North Docs Added to Anthem Network
Links to these additional news stories can be accessed
at www.AISHealth.com/enews/spotlightonhealthinsurers.

4. 4Health Plan Week October 27, 2014
cost and quality, said George Lenko, WellPoint staff vice
president, client solutions, insurers “can start leveraging
those differences in advanced benefit design.” Reference-
based benefits are an area with incredible potential, he
said, citing WellPoint’s success in referring members to
lower-cost radiology sites through its subsidiary, specialty
benefits management group AIM Specialty Health (HPW
8/11/14, p. 8).
According to Lenko, when a physician refers a pa-
tient to an imaging site for a CAT scan or MRI, AIM can
alert the physician if it identifies a lower-cost site of equal
quality. Since physicians or office staff don’t always act on
the information, Lenko said, last year AIM began call-
ing patients directly to give them the lower-cost options.
Since then, AIM has been able to redirect care about 15%
of the time, resulting in lower costs to the insurer and the
beneficiary.
“This is especially important now that so many peo-
ple have high-deductible health plans,” Lenko said. “If
they’re spending their own money, whether it’s an HRA
[health reimbursement arrangement] or an HSA [health
savings account] or frankly just out of pocket, it will mat-
ter to them where they get this imaging.”
CareFirst has also begun assigning specialists in hos-
pitals colors (red, yellow and green) according to how
expensive their services are. O’Brien said the insurer lets
the referring physician know the specialist’s ranking
when they refer the patient, to keep them aware of the
overall cost.
O’Brien said CareFirst is “very interested in how
consumers and providers respond to this advanced trans-
parency.”
Contact O’Brien via Sarah Wolf at mediarelations@
carefirst.com and Lenko via Jill Becher at jill.becher@
wellpoint.com. "
Aetna Pilot Seeks to Match Data
To New Breast Cancer Patients
A new pilot program unveiled by Aetna Inc. on Oct.
20 will for the first time use data analytics to match newly
diagnosed breast cancer patients to survivors of the
disease in an effort to improve care on both clinical and
psychosocial levels. The insurer says 30,000 of its mem-
bers meet the criteria for being in the voluntary CarePal
pilot, which was launched by Aetna Innovation Labs and
initially thought of by a company employee as part of a
brainstorming contest.
“The concept of trying to match individuals with a
clinical issue to other individuals with a similar clinical
issue —that per se is not unique. But the concept of doing
it by using data analytics to help in the matching process
upfront is unique and it is actually something that is be-
ing patented as we speak,” Greg Steinberg, M.D., the
head of clinical innovation at Aetna, tells HPW.
The goal is to ease the strains on breast cancer pa-
tients by having survivors relate their own experiences,
from clinical issues to the personal, like how to manage
family matters while dealing with treatment and its after-
math, he says.
Jess Jacobs, direction of innovation at Aetna, explains
that an Aetna member meeting the pilot criteria will go
to the CarePal web page and sign in. There, the member
will answer a series of questions, most of which cannot
be gathered from claims data alone. “They are various
things that have to do with psychosocial factors, like ask-
ing are you married, do you have kids, how old are the
kids,” she tells HPW.
The point is to try and match the newly diagnosed
breast cancer patient with a survivor based on factors
such as demographics and preferences on what the
“pals” will want to talk about. The member will also give
an email or phone number for a potential pal to connect
with them, and eventually the insurer gets out of the way.
“We let them know we made a match. They can log back
Subscribers who have not yet signed up for Web access — with searchable newsletter archives, Hot Topics, Recent Stories and more —
should click the blue “Login” button at www.AISHealth.com, then follow the “Forgot your password?” link to receive further instructions.
Dan Paquin is senior vice president of govern-
ment products at Blue Cross and Blue Shield of
Louisiana. He’ll oversee the company’s Medicare
Advantage (MA) plan. Paquin most recently was
president of national health plans for WellCare
Health Plans, Inc….Horizon Blue Cross Blue
Shield of New Jersey named Minal Patel, M.D.,
to the newly created position of senior vice presi-
dent and chief strategy officer. Most recently, Patel
served as founder and CEO of Care Management
International, Inc….San Francisco Health Plan
named James Glauber, M.D., chief medical of-
ficer. Most recently, he led utilization management
practices at Kaiser Foundation Health Plan….
The American Academy of Actuaries board of
directors elected Tom Wildsmith president-elect.
Wildsmith, an actuary who serves as senior public
policy manager in Aetna Inc.’s Washington, D.C.,
office, will succeed Mary Miller as president for
the 2015-16 term….Washington, D.C.-based con-
sultant Avalere Health LLC named Lindy Hinman
senior vice president in charge of its health plans
and managed care practice. Most recently, Hinman
was chief operating officer for Colorado’s public
exchange, Connect for Health.
PEOPLE ON THE MOVE

5. October 27, 2014 Health Plan Week 5
in and see the match information and communicate with
each other. From there, it is up to them. We are not watch-
ing interactions or refereeing,” Jacobs adds.
By March, she says Aetna will start to get results on
the effectiveness of the pilot through surveys of partici-
pants and a look at claims data to analyze progress or
outcomes.
Steinberg says breast cancer was chosen for the pilot
over other conditions for two main reasons. “It has to be
a disease that had enough prevalence to matter and give
us a pretty big target audience. And the other was the
subjective anecdotal evidence of the psychosocial aspects
to the disease and its aftermath. It made breast cancer an
ideal candidate for this kind of an approach,” he says.
Using data will help intelligently match people to
other people, Steinberg stresses. “One of the things miss-
ing from our current love affair with technology is the in-
terpersonal. It seemed to us that this particular approach
was to some extent trying to remedy that,” he says.
One condition among many that may be part of an
expanded pilot, if the initial effort proves successful, is
autism, Steinberg adds. That disease is the one that ac-
tually triggered CarePal. As part of an Innovation Idea
Incubation Challenge within Aetna, Daniel Tedesco, a
lawyer working in the company’s procurement depart-
ment, submitted the CarePal idea based on his family’s
experience in managing their autistic child’s experiences.
Contact Steinberg and Jacobs via Ethan Slavin at
slavine@aetna.com. "
Copyright © 2014 by Atlantic Information Services, Inc. All rights reserved.
Please see the box on page 2 for permitted and prohibited uses of Health Plan Week content.
Public Exchange Enrollment Preview:
Insurer Strategies to Sidestep the Pitfalls Ahead
Why are last year’s high-cost carriers positioned to win big in 2015?
Why are re-enrollments likely to be more challenging than bringing in new members?
To what extent is sacrificing margins for members likely to pay off down the road?
Why are few members likely to switch plans this fall? Why might they stop paying their
premiums?
Why will the highest premium increases be experienced by enrollees older than 50?
Why are recent reports of low rate hikes misleading and a potential problem for carriers?
Why is HHS’s auto-reenrollment good news for “web-broker entities” (WBEs) who will seek
to enroll consumers in different plans?
Join Susan Pantely and Paul Houchens of Milliman, and
Mark Waterstraat of Benaissance, for a Nov. 5 Webinar.
Visit www.AISHealth.com/webinars or call 800-521-4323
Wellness Programs Draw Reviews
continued from p. 1
These programs are often formed in conjunction with
third-party vendors that work with employers to try and
figure out whether positive “carrot-based” approaches
work better than punitive “stick” designs to reduce medi-
cal trend by changing unhealthy behavior and avoiding
chronic illnesses.
Overall, large employers are making wellness incen-
tive programs a priority but the growth in companies
doing so has moderated, LuAnn Heinen, a vice president
at the National Business Group on Health and director of
the Institute on Innovation in Workforce Well-being, tells
HPW. “By 2010 there had been a steady increase, so we
don’t see companies backing off incentives but not grow-
ing by leaps and bounds either. The trend is toward a
combination of carrots, positive incentives, and a penalty,
which is almost always for tobacco use,” she says. “But
they want to keep the program positive for participation
in other things, like health assessments, coaching, physi-
cal activity and weight management.”
With wellness an entrenched part of the large-group
benefits segment, employers are trying to keep tabs on
what works and what does not to a greater extent. Just
this past August, a global survey by Buck Consultants
put the dollar stakes in perspective for major employers,
with the biggest takeaway being that higher incentives
produce higher participation rates and lower medical
trend. And incentives focused on completing activi-

6. 6Health Plan Week October 27, 2014
ties are more successful than those centered on lifestyle
changes, Dave Ratcliffe, principal in the health and pro-
ductivity practice for Buck, a Xerox Company, tells HPW.
An example in the survey showed that employ-
ers that offered an average incentive value of $265 for
employees to take a health appraisal realized a 2% or
more decline in medical trend. An employer seeing trend
reduction of less than 2% spent an average of $201 in
incentives. For biometric health screenings, the incentive
amount on average for more successful employers was
$398 compared with $174 for less productive companies
(in terms of cutting medical trend.)
So with all of this money being spent on incentives,
there is more vigor for measuring outcomes, which
puts health carriers in a good spot for that aspect of the
wellness business, Ratcliffe says. The Buck survey, for
instance, found a 6-percentage-point increase in the pro-
portion of employers that rely on health insurers to track
outcomes of health promotion and wellness programs,
from 31% in 2012 to 37% in 2014. Insurers advanced clos-
er to internal program managers (57%) and third-party
Web addresses cited in this issue are live links in the PDF version, which is accessible at
HPW’s subscriber-only page at http://aishealth.com/newsletters/healthplanweek.
vendors (56%), which ranked one and two, respectively,
for 2014.
If an employer wants to gauge the effectiveness
of programs to lower the severity of diabetes in the
workforce, “that is right in the wheelhouse of insurance
companies who know when someone was admitted to a
hospital and are expert in case management and integra-
tion of data and measurement,” he says. “A lot of insur-
ance companies can tell a really good story. Third-party
wellness vendors have to set up all the integration points
that pay claims that can tie success of wellness program
to reduced trend. Employers want to have someone show
them the return, which is hard to do without the data.”
The Buck survey, “Working Well: A Global Survey
of Health Promotion and Workplace Wellness Strate-
gies,” also revealed that 78% of 1,000 companies asked
are strongly behind wellness programs, 43% have created
a brand identity for their effort and 52% offer wellness-
related premium reductions (HPW 8/11/14, p. 8).
Large Groups Search for Right Formula
As for other trends in 2015 wellness programs in the
large-group space, Susan Connolly, U.S. leader of the
total management health practice at Mercer, tells HPW
that increasingly employers are learning that incentives
are good but not sufficient, and must instead be part of
a more comprehensive strategy. “It starts out with the
idea of a culture that supports health, from leadership to
branding and one that offers communication as a sup-
port,” she says. “We are also beginning to see cash as a
more effective way than premium discounts” to incent
better health, like in small amounts in gift cards, Con-
nolly says.
She agrees that validation of wellness efforts is also
a growing trend for 2015, and this can take the form of
not only measuring outcomes but in having programs in
place to actually show physical activity has taken place,
like via a wearable tracking device like Fitbit. “The mea-
surement piece around wellness is still emerging as an
area with only a third of large employers measuring well-
ness,” Connolly says.
Another focus of wellness for this coming year will
be attempts to personalize wellness, letting employees
choose the mode of their incentive (see box, p. 6). “For
one, it might be the extrinsic financial reward, for another
it might be the enjoyment of competition and for others it
might be to choose a corporate donation to charity, really
tying better health with an improved spirit,” she says.
Contact Heinen via Ed Emerman at eemerman@
eaglepr.com, O’Neal through Jeannie Wilcox at jwilcox@
lockton.com, Ed Gadowski for Ratcliffe at edward.gad-
owski@buckconsultants.com and Bruce Lee for Connolly
at bruce.lee@mercer.com. "
Top Behaviors Employers Are Focusing
On in 2015 for Wellness Programs
(Number of Responses=136)
Note: Other responses included nutrition and biometric results.
SOURCE: “2015 National Business Group on Health Plan Design
Survey Report.” www.businessgrouphealth.org.

7. October 27, 2014 Health Plan Week 7
Subscribers who have not yet signed up for Web access — with searchable newsletter archives, Hot Topics, Recent Stories and more —
should click the blue “Login” button at www.AISHealth.com, then follow the “Forgot your password?” link to receive further instructions.
N Sam’s Club, a unit of Wal-Mart Stores, Inc., on
Oct. 23 unveiled a host of new services, includ-
ing a private health insurance exchange for small
business owners with Aetna Inc. called the Aetna
Marketplace for Sam’s Club. The exchange will be
available starting this month. “Aetna Marketplace
for Sam’s Club is the first mass retail-supported
private health care exchange designed to meet the
needs of both the small business owner and their
employees. Sam’s Club business members with two
or more employees in 18 states have exclusive access
to personalized plan tools and resources from Aetna
at SamsClub.com/healthcare,” the retailer said. Visit
http://tinyurl.com/nxv6xn7.
N CMS on Oct. 16 released the certification agree-
ment and privacy and security agreement for quali-
fied health plans to sign before doing business
on federal exchanges for 2015. The agreements
cover items like health plan obligations to protect
personally identifiable information and ensure secure
communication links with CMS. The documents
also contain assurances from CMS that the agency
understands that health plans developed their insur-
ance products based on tax credits and cost-sharing
reductions being part of exchange coverage. In a nod
to pending litigation that could strip subsidies from
federal exchange coverage, CMS said insurers could
have cause to terminate the agreements if this hap-
pens. The full U.S. Court of Appeals for the D.C. Cir-
cuit on Sept. 4 agreed to conduct a second hearing on
the controversial Halbig v. Burwell case, which could
upend health reform law tax subsidies for enrollees
on federal exchanges (HPW 9/8/14, p. 7). Visit http://
tinyurl.com/pkntgy8.
N States that want to establish a Basic Health
Program in 2016 now have guidance from CMS on
the methodology for determining federal funding,
which will equate to 95% of premium and cost-
sharing subsidies that would have been provided
to individuals through public exchange coverage,
the agency said on Oct. 21. The Affordable Care Act
(ACA) allows states to install a Basic Health Program
for individuals earning between 133% and 200%
of the federal poverty limit who are not eligible for
Medicaid, the Children’s Health Insurance Program,
other government programs or employer-sponsored
insurance. Visit http://tinyurl.com/ngvww7d.
N Humana Inc. is actively shopping its urgent care
unit Concentra in a deal that could net the insurer
around $1 billion, according to an Oct. 22 report on
Reuters. The sale, if it occurs, would mark a sharp
turnaround for Humana and Concentra, considering
Humana purchased the health care provider only
four years ago (HPW 3/28/11, p. 8). Reuters said Hu-
mana has hired Goldman, Sachs & Co., Inc. to advise
on the sale. Humana declined to comment to HPW
about the report. Visit http://tinyurl.com/l2a9w4c.
N Reversing course from its July announcement,
BlueCross BlueShield of Western New York on Oct.
23 said it has decided not to exit the state’s Med-
icaid and Health Plus managed care program. “Af-
ter the company’s public announcement, BlueCross
BlueShield of Western New York was approached by
an entity who provides coverage to individuals and
families in government programs. We are actively
engaged in discussions with this entity around a
strategic alliance to support and administer our state
sponsored programs and as such, have provided the
DOH [Department of Health] with a formal suspen-
sion of our previously announced exit plan,” the
insurer said in a statement. The move means the in-
surer’s members do not need to switch health plans.
The Blues plan, which is a division of HealthNow
New York Inc., on July 18 had said it would no longer
offer Medicaid coverage to members in six counties
of the state, affecting 53,000 policyholders effective
Oct. 31 (HPW 7/28/14, p. 7). Visit http://tinyurl.com/
k9cx98w.
N Aetna is discontinuing its Delaware Medicaid
plan at the end of 2014, the insurer said on Oct.
15. Highmark Inc. will take Aetna’s place, joining
UnitedHealth Group in the state program. Aetna has
offered its Delaware Physicians Care Inc. (DPCI) plan
for 10 years. Aetna said it could not reach an agree-
ment on a reimbursement rate with the state after
several months of negotiations. DPCI will continue
service through the remainder of the year and said it
will work with the state to transition its 137,000 Med-
icaid members to another plan. Visit http://tinyurl.
com/la5eotj.
N Cigna Corp. formed an accountable care or-
ganization (ACO) with South Carolina’s Regional
HealthPlus, the insurer said on Oct. 16. The ACO,
effective Oct. 1, will cover Cigna’s 5,000 members
who receive care from Regional’s 100 primary care
HEALTH PLAN BRIEFS

8. 8Health Plan Week October 27, 2014
physicians and specialists. Cigna now has 105 ACOs
in 27 states, covering more than 1.1 million commer-
cial customers and incorporating more than 41,000
doctors. Visit http://tinyurl.com/qffanxy.
N Private exchange builder Connecture Inc. has
filed with the Securities and Exchange Commission
(SEC) for its initial public offering on the Nasdaq
Global Market, according to an Oct. 20 filing with the
SEC. Connecture has not chosen a symbol to trade
under. Visit http://tinyurl.com/mkr722a.
N CMS extended the waiver program for ACOs until
Nov. 2, 2015, the agency said in an Oct. 17 interim
final rule. The regulation made ACOs participating
in CMS’s Shared Savings Program exempt from the
Stark law, which bars kickbacks and physician self-
referrals. The rule was originally set to expire this
November. Visit http://tinyurl.com/px9mtod.
N Cigna is suing Health Diagnostic Laboratory Inc.
(HDL) for $84 million over what it calls “free for-
giving,” in which the lab allegedly waived patient
copays and inflated the insurer’s bills instead,
the Hartford Courant reported on Oct. 17. Two Con-
necticut Cigna subsidiaries, Connecticut General Life
Insurance Co. and Cigna Health and Life Insurance
Co., claim the lab, based in Richmond, Va., attracted
customers with the promise of little or no copay, then
billed the insurers “phantom” rates to make up the
difference. Visit http://tinyurl.com/lbbhpod.
N WellCare Health Plans Inc. and the state of Flori-
da have solidified kick payment rates pertaining to
Medicaid patients undergoing Sovaldi treatments,
according to an Oct. 13 filing with the Securities and
Exchange Commission. The amendment between the
insurer and state sets kick payments for WellCare of
Florida at $34,972 for four-week treatment, $69,943
for eight-week treatment and $104,915 for 12-week
treatment. Kick payments refer to additional pay-
ments beyond the contracted amount because of un-
foreseen circumstances. The amendment is effective
beginning Oct. 1, but providers can submit claims
for dates of service beginning May 1, 2014. WellCare
provides services to eight of Florida’s 11 Medicaid
regions. Visit http://tinyurl.com/pb7b93o.
N California health insurers continue to pour
money into the “No on 45” campaign to defeat the
Proposition 45 ballot measure that would give the
state insurance commissioner the power to reject
“excessive” rate requests, according to an Oct. 20
article in The Los Angeles Times. In a five-day period
from Oct. 15 to 19, insurers donated more than $12
million. Blue Shield of California gave $2.66 million,
WellPoint, Inc. $6 million, Kaiser Permanente $3.73
million and Health Net, Inc. $350,000, according to
the newspaper, citing state data. “The latest contribu-
tions boost the No on 45’s campaign kitty to $55.4
million. Proponents report having raised about $2.5
million,” the Times said. Opponents of the Nov. 4
ballot measure claim that giving the state new rate
authority will harm the economy and add another
layer of bureaucracy to an already over-regulated
health insurance industry. Consumer advocates see
the ballot initiative as filling a gap left by the ACA,
which calls on states to handle rate oversight. But in
states like California with no prior-approval laws,
regulators now can only review proposed premium
changes and not stop them from happening (HPW
9/15/14, p, 1). Visit http://tinyurl.com/o8se7er.
N States are employing sharply different essential
health benefit packages that insurers must cover
if they offer plans in public exchanges, according
to an Oct. 21 report prepared by researchers at the
University of Pennsylvania’s Leonard Davis Institute
and funded by the Robert Wood Johnson Foundation.
The report said that outside of the 10 ACA-mandated
service categories, where members live determines
whether they’ll have coverage for various types of
medical care. “For example, only 25 states require
plans to cover nutrition counseling, and 26 states
require coverage of services to treat autism. Forty-five
states require coverage of chiropractic care, while
only five require coverage for weight loss programs,”
the report said. Visit http://tinyurl.com/kwfw8a5.
N Surveys show mixed results in regard to employ-
ers moving from sponsored health coverage to
private exchanges, an Oct. 17 Health Affairs blog sug-
gests. Brian Klepper of the National Business Coali-
tion on Health (NBCH) reported that findings from
several different surveys that indicate an “aggres-
sive” move to private exchanges contradict NBCH’s
survey of 333 middle-market benefits managers, in
which 55% of respondents said they would never
stop offering employer-sponsored benefits. Visit
http://tinyurl.com/lkz44ym.
HEALTH PLAN BRIEFS (continued)
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