CMS May Further Rein In Prior Authorization
Bloomberg reports that the Centers for Medicare and Medicaid Services (CMS) is exploring proposals to further rein in prior authorization (PA) and other utilization management. The exploration is likely on Medicare Advantage (MA).
In 2024, CMS introduced sweeping PA restrictions, requiring MA plans largely to follow the traditional program requirements for benefit coverage. When CMS Administrator Dr. Mehmet Oz appeared before the Senate for his confirmation hearings, he bemoaned PA in MA and stated that he wanted to reform it. He specifically mentioned that he wanted to streamline the number of PAs allowed and ensure consistency across plans.
Indeed, Bloomberg reports that the aim of the CMS exploration would be to cut the number of medical procedures subject to PA and drive uniformity across plans. Another recent rule also requires electronic PA and CMS is looking at further driving this.
Health plans also are battling state PA restrictions. Thus, many health plans have already begun lifting PAs and reforming them.
In other news, a package of California bills aiming to streamline PA recently passed Senate and Assembly health committees.
In still other news, the Iowa Senate passed a bill that would set new requirements for pharmacy benefit managers (PBMs). This is a major trend at the state level as well.
Additional articles: https://www.beckerspayer.com/payer/california-prior-authorization-reform-package-takes-a-step-forward/ and https://www.beckershospitalreview.com/pharmacy/iowa-senate-passes-pbm-bill-4-things-to-know/
(Some articles may require a subscription.)
#healthplans #medicareadvantage #priorauthorization
https://www.modernhealthcare.com/policy/cms-insurance-prior-authorizations
Medicaid Cuts Continue To Be Debated
The House Energy and Commerce Committee continues to prepare its spending reductions for a budget reconciliation bill. There is a deep divide in the GOP in the House and perhaps on the committee. Moderates do not want any cuts or only minimal ones, whereas rightists want deep reductions. Still being discussed are a per capita cap for the Medicaid expansion population or a reduction in the state match. Work requirements, waste and fraud, and provider taxes are also under review.
In other news, a Health Affairs Forefront Blog discusses the possibility of a rule impacting state directed payments, which have blossomed to $40 billion a year since liberalization in 2016. The payments are used in a variety of ways to support providers. Proponents argue they are needed to provide vital services, support certain critical providers, and incentivize participation in Medicaid managed care. Opponents argue the payments are excessive, spawned provider tax growth, and have generated huge increases in the program. They also say such payments get around hold harmless provisions due to the multitude of funding sources and reimbursement in Medicaid. As of FFY 2023, provider taxes were about 32% of all state directed payment funding and such payments represented 18% of all federal Medicaid funding.
In still other news, the Supreme Court has sided with the Department of Health and Human Services (HHS) in a dispute over the formula used for calculating disproportionate share hospital (DSH) payments in Medicare.
Last, there has been some speculation that Medicare Advantage (MA) as the default enrollment option could be instituted in the budget reconciliation bill. Healthcare policy group KFF has a briefer explaining it.
Additional articles: https://www.healthaffairs.org/content/forefront/implications-2024-cms-rule-change-state-directed-payment-financing and https://www.fiercehealthcare.com/hospitals/scotus-sides-hhs-case-about-medicare-dsh-payments and https://www.modernhealthcare.com/legal/supreme-court-medicare-dsh-payment-ruling and https://www.kff.org/medicare/issue-brief/5-questions-about-the-idea-of-default-enrollment-into-medicare-advantage-plans/
(Some articles may require a subscription.)
#budgetreconciliation #medicaid #coverage #providertaxes #trump #congress
https://thehill.com/policy/healthcare/5273744-house-republicans-medicaid-cuts/s-policy/provider-taxes-congress-medicaid
— Marc S. Ryan
