Aetna Delays And Changes Downcoding Policy
After major pushback from lawmakers and providers, Aetna is easing a controversial “downcoding” policy for inpatient Medicare Advantage (MA) claims. The insurer said the policy’s start date has been delayed to Jan. 1, 2026 and that its severity review would now apply to urgent or emergent inpatient hospital stays that include at least one midnight but fewer than five. As part of the reimbursement approach, Aetna will approve these inpatient stays without a medical necessity review and cover the claim at a rate that aligns with observation services. Stays of five or more midnights will not be subject to a severity review in the updated policy.
Additional articles: https://www.fiercehealthcare.com/payers/american-hospital-association-urges-aetna-rescind-new-inpatient-policy-payment and https://www.modernhealthcare.com/insurance/mh-aetna-medicare-advantage-downcoding-policy/
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#aetna #hospitals #claimsdenials #priorauthorization
https://www.beckerspayer.com/payer/aetna-delays-new-inpatient-reimbursement-policy/
Exchange Subsidy Saga
President Donald Trump’s Domestic Policy Council and senior health officials have been meeting privately on how to address the expiration of the enhanced Exchange premium subsidies and on issues of healthcare affordability. Trump has suggested that he wants to repair Obamacare but hasn’t publicly ruled out a straightforward extension of the subsidies.
Congressional Republicans have various proposals, including enhancing Health Savings Accounts. The president recently said subsidies should be directed to Americans to buy insurance rather than to health plans on their behalf. Moderates on both sides of the aisle have been discussing potential compromises for extending subsidies.
Democrats got a commitment from Senate Majority Leader John Thune, R-SD, to have a vote on an extension, but House Speaker Mike Johnson, R-LA, has refused to guarantee a bill would be taken up in his chamber.
Additional article: https://www.politico.com/news/2025/11/13/the-white-house-knows-it-needs-to-act-on-health-care-affordability-heres-whats-on-the-table-00649118
#exchanges #healthcare #coverage
CMS Issues Provider Tax Guidance And Announces 2026 Medicare Information
The Centers for Medicare and Medicaid Services (CMS) issued a press release and memo giving guidance on implementation of provider tax changes included in the One Big Beautiful Bill Act (OBBBA). The bill significantly restricts the ability of states to raise revenue utilizing provider taxes and phases down the rate.
The guidance discusses the indirect hold harmless threshold and a transition period.
In addition, CMS announced 2026 figures for Part A and B, premiums, deductibles, and cost-sharing as well as the Part B and Part D Income-Related Monthly Adjustment Amounts.
Additional article: https://www.cms.gov/newsroom/press-releases/cms-issues-guidance-strengthen-oversight-medicaid-financing
#medicare #medicaid #cms #providertaxes
https://www.cms.gov/newsroom/fact-sheets/2026-medicare-parts-b-premiums-deductibles
KFF Finds GLP-1 Use And Cost Challenges
Healthcare policy group KFF’s latest poll finds rising use of GLP-1 weight-loss drugs but major cost challenges faced by Americans.
One in five (18%) adults now report having ever taken a GLP-1 agonist, including 12% who say they are currently taking this type of medication (a 6 percentage point increase from 18 months ago).
Most GLP-1 users say their insurance covered at least some of the cost. But over half (56%) say these drugs were difficult to afford, including one in four who say they were “very difficult” to afford. About a quarter (27%) of GLP-1 users report having insurance but paying the whole cost of the medication themselves.
Few think it is likely the Trump administration’s actions will lower their prescription drug costs.
#glp1s #weightlossdrugs #branddrugmakers #drugpricing
— Marc S. Ryan
