Kaye Pestaina

1 month ago | kff.org | Lindsey Dawson |Kaye Pestaina |Matthew Rae

March 10th, CMS issued a proposed rule that seeks to change how plans sold on and off the Affordable Care Act’s (ACA) Marketplaces (plans for individuals and small businesses), would cover gender affirming care services, which the rule calls “coverage for sex-trait modification1.” The rule proposes, beginning plan year 2026, to prohibit insurers from covering gender affirming care as an essential health benefit (EHB), which could lead insurers to drop coverage or shift costs to individuals...

Mar 19, 2024 | kff.org | Krutika B. Amin |Kaye Pestaina |Cynthia Cox

For privately insured patients, surprise medical bills can arise from either having to pay a high deductible, or from “balance billing.” Typically, health plans negotiate payments to in-network providers. Out-of-network providers may directly bill privately insured patients the difference between the typical in-network health plan payment and the full charge, also known as “balance bills”.

Dec 8, 2023 | kff.org | Nirmita Panchal |Matthew Rae |Kaye Pestaina

A growing number of employer-sponsored health plans use Center of Excellence (COE) programs as a way to provide enrollees with specialized care for selected health services. COE programs designate providers or facilities based on cost and quality of the care they deliver. Providers participating in COE programs often specialize in selected services, and may provide additional case management and other support services for patients.

Nov 2, 2023 | healthsystemtracker.org | Kaye Pestaina

In late 2020, Congress passed and President Trump signed the No Surprises Act establishing new federal protections for consumers from surprise medical bills. The law became effective in 2022. A significant component of the law was to hold consumers harmless for surprise, out-of-network medical bills by creating a process where the medical provider and health plan would negotiate a payment for the service provided or end up in an independent dispute resolution (IDR) process.

Mar 31, 2023 | kff.org | Larry Levitt |Cynthia Cox |Lindsey Dawson |Kaye Pestaina

Note: This post was updated on April 4, 2023, to include additional details and a table showing potentially affected preventive services. On March 30, 2023, a judge in the U.S. District Court in the Northern District of Texas issued a final judgment in a court case challenging the provision of the Affordable Care Act (ACA) that requires most private health plans to cover a range of preventive services without any cost-sharing for their enrollees.