Proposed Rule Reforms Provider Directories, PBMs
The Centers for Medicare and Medicaid Services (CMS) proposed a far-reaching rule that tackles years-long issues with Medicare Advantage (MA) networks and provider directories, medication compliance, and pharmacy benefits manager (PBM) compensation. These provisions were largely in the 2026 appropriations bill.
In terms of provider directories and networks, CMS proposed these reforms for MA plans:
- MA organizations will need to verify provider directory data at least every 90 days, and they would need to check the data for hospitals and other facilities at least once each year.
- Beginning in 2028, MA organizations will need to grade their provider directory accuracy based on a provider sample. In 2029, CMS would publicly post these scores, and plans would need to show them in their directories.
- If an MA enrollee books a provider listed as in-network, that enrollee would pay no more than the lesser of the in-network or other cost-sharing. This would still apply if the provider ends up being out of network. This begins in 2028.
PBM reforms include:
- PBMs cannot set compensation in Part D to the list price of drugs or rebates and must charge fair market value for services provided. Flat-dollar, itemized service fees would be used. Rebates and related PBM compensation will have to be passed through to the plan sponsor.
- PBMs would have various transparency, reporting and disclosure requirements.
- PBMs would have to allow Part D plan sponsors to audit them at least once a year.
- Insurers would also have to disclose whether they own or have a controlling interest in the provider.
Regarding medication adherence, the rule codifies a reduction in generic drug copayments for dual eligibles at or below the federal poverty limit from a $1 maximum to $0, beginning Jan. 1. The removal is expected to improve medication compliance.
Additional articles: https://www.fiercehealthcare.com/regulatory/cms-proposes-ma-ghost-network-pbm-transparency-requirements and https://www.beckershospitalreview.com/legal-regulatory-issues/cms-proposes-public-scores-for-medicare-advantage-provider-directories-flat-fee-limits-for-pbms/ and https://www.cms.gov/newsroom/fact-sheets/medicare-program-implementation-sections-6219-6220-6224-consolidated-appropriations-act-2026-cms
#medicareadvantage #healthplans #pbms #providers #dualeligibles #partd #providerdirectories #networks #transparency
Centene Expands CHOICE For Employees, Enrollees
Centene is going all in on the Custom Health Option and Individual Care Expense Arrangements (CHOICE) healthcare program, which was formerly known as Individual Coverage Health Reimbursement Arrangements (ICHRAs). CHOICE allows employers to provide tax-free subsidies to employees to buy coverage in the individual market and Exchanges.
Centene is expanding its CHOICE arrangements to its employees in Ohio and Oklahoma in the 2027 plan year. Centene rolled CHOICE out to its Indiana employees this year.
In addition, Centene’s Ambetter Health Solutions, which is its dedicated on- and off-Exchange Marketplace business, is expanding CHOICE arrangements for employers to four more states, Alabama, Iowa, North Carolina and Pennsylvania, in 2027.
#centene #ichras #choice #coverage #healthcare
Trump Backtracks A Little On Exchange Culling
The Trump administration announced that it had cut 760,000 people from the Exchange rolls, saying the fraud and improper enrollments cost billions. But healthcare policy group KFF and its KFF Health News reports that not all were actually fraudulent, and a small number have had to be reinstated. More could follow in the coming weeks.
That said, there is little doubt in my mind that the Exchange process has had fraud and improper enrollments along the way.
Additional article: https://www.fiercehealthcare.com/payers/after-booting-760k-people-aca-plans-trump-administration-has-added-some-back
#exchanges #healthcare #coverage
https://www.modernhealthcare.com/politics-regulation/mh-cms-aca-enrollees-760k-trump-administration
Hospital Warning Signs
Hospitals are already seeing some financial weakening due to various trends, including some government programs already hitting. Year-to-date margins slipped in August after months of recovery. The year-to-date operating margin through August was 2.5%, down from 3.8% through July. August’s monthly margins was 1.8%, the weakest single-month performance since February.
Gross operating revenue grew 9% year-over-year nationally. Net operating revenue per calendar day grew 6% year-over-year. Roughly 43% of hospitals are currently operating at a loss, compared with roughly 33% before the COVID-19 pandemic.
#hospitals #margins
Polls Show Healthcare Resonates
USofCare’s annual People’s Health Care Survey finds that about 75% of Americans across party lines say healthcare will be one of the top three issues in the midterms. This is bad news for the GOP.
Three-quarters of Americans feel frustrated, overwhelmed or helpless about healthcare costs. About 50% of commercial, Exchange, and the uninsured are frustrated with healthcare. That drops to about a third for those with Medicare, Medicaid and veterans’ coverage.
Over half of respondents said healthcare is unaffordable to them, with 49% saying it feels more expensive than a year ago. About 16% delayed care, 16% skipped care, 12% cut back on food, housing or utilities, and 11% went into debt to pay for care.
About 89% of Democrats said healthcare will be a top three issue, with independents at 74% and Republicans at 64%.
#healthcare #coverage #midterms
— Marc S. Ryan
