Insurers Score Another Risk Corridor Win; New Guidance On Consumer Assister Training

On August 4, 2017, judgment was awarded for another insurer in a risk corridor case in the Court of Federal Claims, this time for Molina for $52.4 million. Molina’s win means that insurers have now prevailed on the merits in two of the 26 risk corridor cases pending in the Court of Claims while the government has prevailed in three. Judge Thomas Wheeler, who ruled in favor of Molina, was also the author of the Moda decision, the only other risk corridor decision to date in favor of an insurer. Not surprisingly, he followed his earlier decision. Judge Wheeler held that the Affordable Care Act requires the government to make risk corridor payments to insurers that qualify for those payments under the statute’s payment formula, even though Congress did not specifically appropriate funds for this purpose. He also held that the government had entered into an implied contract when if offered to cover Molina’s losses under the risk corridor program if it sold qualified health plans, and Molina had sold QHPs and suffered losses. He further held that the 2015 and 2016 appropriations riders that sought to bar the use of CMS program management funds failed to repeal the government’s obligation, because a statutory obligation cannot be repealed through an appropriations rider unless the rider is clear and unambiguous in its intention to repeal and the 2015 and 2016 riders did not meet this test. Judge Wheeler explicitly rejected the holding of another Court of Claims judge to the...
Source: Health Affairs Blog - Category: Health Management Authors: Tags: Following the ACA Insurance and Coverage Navigators risk corridor payments Source Type: blogs