What Health Plans Need to Know About QHPs Now That the ACA Is Here to Stay  — Penstock Group

Penstock president of regulatory solutions Joe Boyle recently wrote an article for MedCity News providing tips for payers looking to expand their footprint in the growing QHP market.

Providing Qualified Health Plans, or QHPs, that meet the requirements of the Affordable Care Act has become an integral part of many health plans’ offerings. Now that numerous calls for repeal and legal challenges brought against the ACA over the years have failed, health plans can finally invest confidently in this line of business.

As healthcare costs continue to rise, Americans need QHPs. With 35 million people enrolled in coverage related to the ACA and rapid growth of enrollments, QHP plans present an incredible growth opportunity for participating health plans. Here’s what health plans need to know to navigate this market successfully.

Regulatory filing is key — and inflexible

QHPs can be lucrative for health plans, but this particular revenue stream comes with unique responsibilities. Regulatory filing for the purpose of maintaining compliance can be a cumbersome burden and tedious task — there are myriad changes each year — but even the simplest of mistakes can result in millions of dollars in lost revenue.

For example, Tufts Health missed a Rhode Island regulatory filing deadline by two minutes — which Tufts attributed to traffic and construction — and it may have caused them to lose a $400 million Medicaid contract. The snafu disqualified Tufts from bidding on Rhode Island’s $7 billion contract for five years. The rejection of Tufts’ appeal cited avoiding setting a precedent that would allow the acceptance of proposals that were submitted late. In other words, if you can’t file on time, you can’t be trusted to offer a health plan in the marketplace.

In addition to high-stakes examples like this with long-term repercussions, the Center for Medicaid and Medicare Services scores and rates health plans based on the quality of their QHPs on an annual basis. Ratings are based on a number of measures using CMS methodology and criteria such as enrollee experience, plan efficiency, affordability and management on a national and health plan-specific basis.

While the health insurance business is highly regulated, investing in offering QHPs comes with an additional level of scrutiny and complexity for which health plans have to be ready. Noncompliance can lead to federal fines, withdrawal from federal and state exchanges for years, or other penalties. Some states will impose thousand-dollar-a-day fines for missing a deadline.

Read the full article on MedCity News.

Share this post

Sign up for Newsletter

Get the latest Penstock news, events and insights, delivered straight to your inbox.
By clicking Sign Up you’re confirming that you agree with our Terms and Conditions.

Related Articles

We’re sharing the secrets behind regulatory success for health plans.

Let’s get started

Ready to mitigate recurring, high-cost claim and regulatory filing errors? 

Payment Accuracy

From training and education to technology and scale, we’ll help your health plan transform into a payment integrity powerhouse.

Regulatory Efficiency

We understand every facet of the regulatory filing process. We’ll take care of your certification, while you focus on what matters most—your members.

We're always innovating.

Our team is continuously inventing and launching new solutions. Subscribe to our newsletter for the latest news & updates from Penstock.