Evensun Health

Evensun has posted updated DIY code for the 2026 proposed risk adjustment factors! Check it out and let us know if there's any bugs. I'm running some of my sample data through it and the ACF could really have an impact on some of the game theory of plan design. https://lnkd.in/eNBT6JPj

Continuing my blog series on risk adjustment, I take a bit of a diversion this week to look at some interesting stuff I'm seeing in the 2025 rate filings: namely, chronic-condition focused plans. Why would a health insurer not charge more for a plan they think will yield $9,000 a year in additional claims expense? The answer, of course (as is the answer to most problems), is risk adjustment. https://lnkd.in/ed6Z64sn

It’s with mixed emotions that I announce that I will be taking my talents from Denver Health Medical Plan, Inc. to Evensun Health as a principal consultant. I look forward to working with Wesley Sanders again but will miss all of the people that have made my time here at Denver Health pleasant. I’ll still be fractional at DHMP over the coming months as their CFO while at the same time getting ramped up with Evensun on all of our EDGE, Risk Adjustment, strategic ACA planning, and ACA operations engagements. I also look forward to adding to the expertise there with my experience in Medicare and Medicaid. So, a cherished farewell to Denver Health but a welcome hello from Evensun. Call me for all of your health plan needs, we have the expertise to fix the problems that ail your plan. My cell is 423-991-6763 or email me at [email protected]. If you’re interested in the CFO job at DHMP please contact Greg McCarthy at [email protected].

Taking a step back from the weeds of the last few days, I've written a blog post giving an overview of ACA risk adjustment: why it exists to begin with, and why the transfer number alone doesn't tell you much. If my last few posts just confused you, this may be a good place to start! What should I look at next? A few areas I'm thinking about digging into are: 1) Impact of Bright/ Friday's exit 2) New entrants 3) Market share trends 4) High Cost Risk Pool 5) Big shifts from 2022 Let me know! https://lnkd.in/ehJGXcJj

Yesterday I shared some initial thoughts on the 2023 risk adjustment transfer report. The headlines tend to focus on the big dollar amounts, but looking at the transfer on a per member, per month basis tells you a lot more. Today, I'm going to explore some of the year over year changes. A few things stood out to me: 1) Florida Blue's transfer is massive, no doubt about it. But it's remarkably consistent year over year - in 2022, their transfer was $110 PMPM, and in 2023, the transfer was $116 PMPM. They have a pretty stable membership block that's fairly high risk. FL Blue is also one of the few carriers in the FFM to offer a platinum plan. A few other carriers show a pretty consistent PMPM transfer: HCSC (BCBS IL,TX, MT, NM, and OK) had around a $100 PMPM transfer both years, Kaiser with about a $45 PMPM payable both years, United with about a $100 PMPM payable both years. 2) Ambetter (Centene) had a fairly sizable shift: in 2022, they received an aggregate transfer of $25 PMPM, whereas in 2023, their transfer was basically $0. Their market share also increased from 13.5% of the entire ACA block to 20% (by far the largest ACA carrier). It makes sense that their transfer would have gotten smaller - with such a large market share, their membership starts to set the standard for what the average risk is. This plays out at the state level, too: in Georgia, their market share declined from almost 50% in 2022 to about 40% in 2023, and their receivable increased from $77 PMPM to $117 PMPM. In Florida, by contrast, their market share increased from 11% to 13%, and their receivable decreased from $27 PMPM to $17 PMPM. As a carrier's market share increases, their receivable / payable is likely to get closer to $0, since a larger market share means their risk is going to be a bigger component in determining the statewide average. 3) I've been a long time Oscar skeptic, but they may finally be hitting their stride. They buck the trend discussed above - their market share decreased in 2023, but their PMPM payable came down from $117 PMPM to $89 PMPM. (Full disclosure: my wife is an employee at Oscar, but she doesn't share anything with me about them and these observations are strictly from the publicly available data below. Neither she nor I have any equity in Oscar... in fact, I shorted them at their IPO but have since closed out that position). I'll share more over the coming days, but does anything stand out to you? Tomorrow I'll look at how Friday and Bright's market exit may have affected the market. If you found this insightful and want to explore your own ACA strategy, Evensun can help. Reach out to me. Fair warning: be prepared for at least an hour or two of free consulting time consisting of me excitedly talking about risk adjustment and ACA strategy! People tell me it's a flawed business model but I can't help myself... https://lnkd.in/g6kmvt4X

If you are a health plan in the ACA market, you know how important and challenging it is to manage your policy-based payments, especially the Advanced Premium Tax Credit (APTC). APTC is a major source of revenue for many plans, but it also comes with significant audit risk and compliance requirements. CMS recently released the audit results for plan years 2018 and 2019, and the findings were surprising: most plans netted additional funds from CMS as a result of the audit, but this won’t be the case for future year audits, which will be downside only. How can you ensure that you are not leaving money on the table or exposing yourself to audit risk? Evensun Health is a proud bronze sponsor of the Health Plan Alliance, and we are offering a webinar on July 17 exclusively for Health Plan Alliance members to share insights and best practices that we gained by reading the 100+ audit reports and from working with health plans of all sizes across the country. You will learn: -Common issues found in the APTC audits and how to avoid them Trends and benchmarks to interpret your audit results and compare your performance with your peers -What health plans can do to minimize audit risk and maximize APTC revenue, both in the short term and the long term -How to provide appropriate oversight to your enrollment and billing vendors and ensure data quality and accuracy -How to take advantage of a free evaluation of your APTC data from Evensun and get actionable recommendations This webinar is designed for health plan executives, managers, and analysts who are responsible for or involved in APTC reconciliation, enrollment, billing, finance, compliance, or audit. Whether you were audited or not, you will benefit from the insights and tips that I will share. Don't miss this opportunity to learn how to optimize your APTC revenue and avoid audit pitfalls. https://lnkd.in/ewUe9uM6

Risk adjustment plays a critical role in the operations and profitability of ACA health plans. Therefore, health plans' ability to accurately capture and recapture HCCs is critical to financial success. HCC recapture rates is one window into the performance of a health plans' risk adjustment performance. This study provides HCC and RxC recapture rates for participating health plans and the study-wide benchmarks at key drill downs such as year, region, and metal tier. Featured Authors: Matt Sauter & Chia Yi Chin #ACA #RiskAdjustment #HCCs #HCC #RecaptureRates #RiskTransfers