Among for-profit insurance companies, Bright Health Group’s $1.9 billion charge represents the highest amount owed through the program, according to the Modern Healthcare analysis. The company also reported the highest “default risk adjustment charge” of $3 million for failing to provide adequate, timely data to federal regulators, the CMS report said.
Bright Health’s risk-adjustment payment reflects the size, health and metal mix of the company’s 2022 membership, a spokesperson wrote in an email. The company declined to comment on whether it would be able to make its risk-adjustment payment in full.
Bright Health switched to third-party claims processor Evolent Health last January after its in-house system failed to record patients’ health status and medical bills. The company closed its exchange plans in 15 states last year and is working with states to pay down the claims incurred by its nearly 1.1 million former members.
Insurtechs Oscar Health and the defunct Friday Health Plans owed the second- and third-highest total amounts through the risk-adjustment program at $1.4 billion and $779.7 million, respectively. State regulators are unsure whether the young insurance companies will be able to make good on the charges, particularly in the case of Friday Health, which states have placed in receivership. Friday Health did not respond to an interview request.
Oscar Health, which did not respond to an interview request, attributed its high risk-adjustment payment to the balloon in new membership driven by the Biden administration’s special enrollment periods last year, according to a Securities and Exchange Commission filing the company submitted in May. Oscar worked with federal regulators last year to limit sign-ups in its largest market and expects to pay a smaller sum in 2024 because most of its enrollees are renewals, for which it already holds claims data, the SEC filing said. The company faces a class-action lawsuit from shareholders alleging it failed to disclose how the COVID-19 pandemic could impact its payment through the risk-adjustment program ahead of its initial public offering.
Oscar extended its contract with Ciox Health in April for another seven years to perform risk-adjustment functions.
If companies are unable to reimburse the full charge, the risk adjustment sum paid to other carriers in the state will be cut in proportion to the shortfall.
Centene is the largest exchange carrier with 3 million members and, among for-profit carriers, is also poised to receive the largest net amount through the program of $782.2 million. The company did not immediately respond to an interview request.