Health Plans Continue Prior Authorization Reforms
Two insurance lobbies, AHIP and the Blue Cross Blue Shield Association, said that leading health plans continue to make significant progress to adopt a standardized approach for providers submitting electronic prior authorization (PA) requests for the majority of medical services. About 88% of Aetna’s prior authorizations already adhere to the standards, with UnitedHealthcare and Cigna saying their standards will apply to more than 70% of their PA volume by the end of the year.
Key reforms include reducing the number of services subject to prior authorization as well.
In addition, lawmakers proposed bipartisan legislation aimed at strengthening Medicare Advantage (MA) plan oversight to ensure seniors receive timely and high-quality care. The bill aims to address barriers to coverage and treatment, including:
- Strengthening oversight and accountability for plans failing to meet compliance standards
- Increasing transparency and streamline prior authorization processes
- Aligning coverage criteria with traditional Medicare
- Reducing administrative burdens through real-time, automated systems
- Expanding access to post-acute care providers
Additional articles: https://www.fiercehealthcare.com/payers/unitedhealthcare-aetna-tout-progress-standardize-prior-authorization-part-industry-wide and https://www.modernhealthcare.com/insurance/mh-cigna-humana-prior-authorization-standardized-requirements/
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#healthplans #priorauthorization #providers
Med Supp Premiums Surging
Complaints that Medicare Supplement or Medigap policy premiums are surging. While hikes were in the single digits annually in the past, double digit hikes have become very common, with some states reporting record hikes in 2026. A range of factors for rising premiums include increases in Medicare utilization, aging of the population (premiums go up with age), other medical increases, and certain rules in states that allow access to such policies. As well, more and more beneficiaries are enrolling in Medicare Advantage (MA), which also impacts the Supplement program.
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#medicare #supplement
https://www.modernhealthcare.com/insurance/mh-medigap-premiums-medicare-enrollees
ACO LEAD May Have Low Participation in Year 1
Providers may be holding off on applying for the Centers for Medicare and Medicaid Services’ (CMS) new value-based care (VBC) model in the first year. ACO LEAD replaces ACO REACH as of January 1, 2027. Some reasons for the anticipated low number of applicants include a short application window and patient enrollment minimums.
The model combines high-risk and lower-risk patients into a single value-based care model. There is excitement for ACO LEAD given major changes to financing in the model. This could lead CMS to extend the application timeframe as it has with the tech-enabled ACCESS model.
(Article may require a subscription.)
#cms #innovation #lead
https://www.modernhealthcare.com/post-acute-care/mh-medicare-lead-aco-model-harmonycare-lifespark
— Marc S. Ryan
