Proactive Enrollment Caps Could Be Used in MA in 2027
The Centers for Medicare and Medicaid Services (CMS) is now allowing Medicare Advantage (MA) plans to file for prospective enrollment caps in 2027 that could be used as a way to limit financial exposure. It could be yet another tool in the toolbox for plans seeking to stay in an area but fearful of too much risk. CMS says it will help stem further exits in areas.
It appears existing regulatory authority is being used, perhaps more expansively. Previously, CMS only approved caps after an insurer’s enrollment ballooned to a point at which members’ health and safety was jeopardized.
Network Health has applied for such a cap in 2027. Several protections exist in the regulation.
#medicareadvantage #enrollment
https://www.modernhealthcare.com/insurance/mh-medicare-advantage-enrollment-caps-2027-cms/
Hospitals Bemoaning Expansion Of Site Neutral Payments
A number of hospitals are bemoaning the potential impact on the expansion of site neutral payments in Medicare. Such lower payments are slated to be expanded to various imaging in 2027, after being applied to drug administration in 2026.
Of course, the changes are needed over time to truly implement healthcare reform and lower price throughout the system.
#siteneutral #hospitals #medicare
BCBSMI: Lower Fees For NPs And PAs
Michigan’s private physician practices will soon face a financial blow when Blue Cross Blue Shield of Michigan shifts its reimbursement rules.
The shift away from “incident-to billing” by the Blues targets how providers bill for the care that’s provided by nurse practitioners and physician assistants.
#healthplans #providers #payments
https://www.modernhealthcare.com/insurance/cdb-bcbsm-primary-care-billing-20260827/
PhRMA Loses Again On Medicare Drug Negotiations
A federal appeals court has ruled against a lawsuit filed by representatives of the pharmaceutical industry challenging the federal Medicare drug price negotiation program. As with other cases, it found that Medicare is a voluntary program and drug makers do not have a right to participate.
#drugmakers #medicare #drugpricing
https://thehill.com/policy/healthcare/6055400-fifth-circuit-rejects-phrma-lawsuit/
— Marc S. Ryan
