KFF Finds $60B At Risk With Directed Payment Reforms
Healthcare policy group KFF finds that an estimated $60 billion in federal Medicaid spending in 37 states (including the District of Columbia) would likely exceed new federal limits on state directed payments for hospital services once fully implemented under the One Big Beautiful Bill Act (OBBBA).
The eight states with the biggest potential reductions in Medicaid payments to hospitals are: California ($7.4 billion), Illinois ($4.0 billion), Kentucky ($3.9 billion), Texas ($3.5 billion), North Carolina ($3.4 billion), Louisiana ($3.3 billion), Arizona ($3.0 billion) and Michigan ($2.6 billion). This accounts for about half of the total.
While controversial, there is little doubt in my mind that intergovernmental transfers, provider taxes, and state directed payments have been abused by many states and some reforms are needed.
Additional article: https://www.kff.org/medicaid/analysis-at-least-37-states-have-medicaid-state-directed-payments-for-hospital-services-that-could-be-reduced-by-the-2025-reconciliation-law-limits/
#medicaid #obbba #healthcare #coverage
KFF Studies PA Denials
A new analysis by healthcare policy group KFF finds that insurers denied between 12% and 18% of standard prior authorization (PA) requests in 2025 across Medicare Advantage (MA), Medicaid managed care, and federal marketplace Exchange business. Plans that had at least 2.5% market share of enrollment in respective segments were studied. Data was collected from 14 unique insurers, representing approximately 71 million enrollees.
On average, 12% of standard PA requests and 10% of expedited requests were denied in MA, 14% of standard and 12% of expedited requests were denied in Medicaid managed care, and 18% of standard and 16% of expedited requests were denied in the Exchanges.
In MA, UnitedHealth Group denied standard prior authorization requests at the greatest rate (17%) and Centene denied the expedited requests at the greatest rate (13%).
KFF notes that PA denials are rarely appealed, but 67% of denials were overturned when an appeal was undertaken in MA, 47% in Medicaid managed care and 43% in the Exchanges.
Additional article: https://www.fiercehealthcare.com/payers/insurers-denied-between-12-18-prior-auth-requests-2025-kff
#healthplans #priorauthorizations
https://www.healthcaredive.com/news/prior-authorization-denials-vary-widely-among-insurers/827891
TrumpRx Info To Be Distributed Through PBMs
PBM lobby Pharmaceutical Care Management Association announced that its members reached an agreement to offer information on cash prices available through the TrumpRx discount drug website. Nine of the industry’s leading pharmacy benefit managers (PBMs) will do so, including the big three — CVS’ Caremark, UnitedHealth Group’s Optum Rx, and Cigna’s Express Scripts.
#drugpricing #pbms #trumprx
https://www.fiercehealthcare.com/payers/major-pbms-agree-offer-trumprx-pricing-information-members
ICHRAs Could Help With Risk Selection
Proponents of individual coverage health reimbursement arrangements (ICHRA) are touting a new survey as evidence that the novel coverage expansion could help support risk pools for health plans. The HRA Council, a nonpartisan organization that pushes for expanded innovative coverage options, found that a growing number of larger employers are considering it as an option. Most thought the coverage option would be of most interest to small businesses. ICHRAs appear to be most attractive to those under 45, with half of enrollees in this age group.
The HRA Council says larger employers could contribute, and thus health plans maintain, vast numbers of younger, healthier individuals into the market. This would help stabilize risk.
While still a small part of overall coverage, ICHRAs are growing, with major growth in larger firms.
#ichras #healthcare #coverage
— Marc S. Ryan
