Republicans Ask GAO If CMS’ Proposed Part D Premium Stabilization Program Is Legal
A group of House and Senate Republicans are asking the congressional Government Accountability Office (GAO) if the Centers for Medicare and Medicaid Services’ (CMS) proposed additional premium stabilization program for standalone Part D (PDP) plans is legal. CMS announced the creation of the program after it received bids that showed premiums would skyrocket despite some protections in the Inflation Reduction Act (IRA).
The Part D changes in the IRA were much touted as protecting consumers by lowering out-of-pocket (OOP) costs. It also shifted huge costs to plans. These changes were not adequately funded by the government and thus plans had to reduce benefits in other areas and increase premiums. CMS was caught flat-footed and quickly created the program recently to avoid an October Surprise during open enrollment. I have issues with whether CMS has the statutory authority to do this despite broad waiver authority. It will further deplete sparse Medicare funds.
The GOP lawmakers asked the GAO whether the new demo is consistent with the law, to investigate what budgetary analysis CMS did when developing the program, to determine the projected costs, and whether it meets budget neutrality requirements.
See my earlier blogs on this subject: https://www.healthcarelabyrinth.com/part-d-premium-woes-due-to-the-inflation-reduction-act/ and https://www.healthcarelabyrinth.com/will-democrats-be-victim-of-an-october-surprise-of-their-own-making/ .
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#medicareadvantage #pdp #partd #cms #ira
Democratic VP Nominee Tim Walz Active In Healthcare
Democratic VP Nominee Tim Walz appears to be very active in healthcare and is likely even to the left of Kalama Harris. In 2023, Walz signed legislation that prohibited generic drug manufacturers from increasing prices beyond a certain amount. It also established a prescription drug affordability board. He voted for the Affordable Care Act (ACA) and has backed a public option in his state of Minnesota.
Additional articles: https://insidehealthpolicy.com/daily-news/governor-walz-signed-bill-creating-pdab-prohibition-excessive-generic-drug-price-hikes and https://insidehealthpolicy.com/daily-news/walz-emphasizes-health-care-affordability-reproductive-and-lgbtq-rights-harris-vp-pick
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#election2024 #walz #harris #healthcare
https://thehill.com/policy/healthcare/4814551-minnesota-gov-tim-walz-health-care
Another Win In Court For Providers On Surprise Billing
The Biden administration had already been forced to water down its approach to No Surprises Act (NSA) arbitration. Now, an appeals court has upheld a district court ruling that the watered-down version also conflicts with the intent of the act. My view is Congress should step in and allow panels to give greater deference to median in-network rates (the qualifying payment amount). The problem is Democrats and Republicans are heavily influenced by providers. The court ruling will likely mean yet more delays in arbitrations. The act will actually drive costs up in the system – not down – unless Congress gets a backbone.
Additional articles: https://www.healthcaredive.com/news/texas-medical-association-no-surprises-appeals-court-decision-idr-qpa/723399/ and https://insidehealthpolicy.com/daily-news/fifth-circuit-upholds-lower-court-decision-vacate-nsa-qpa-rule
(Some articles may require a subscription.)
#nosurprisesact #surprisebilling #nsa #providers
Clover Health Reports First Margin As Public Company
Medicare Advantage (MA)-focused insurtech Clover Health, one of the darlings of startups, announced its first quarterly net profit as a public company for Q2. It had net income of $7.2 million and an adjusted EBITDA of $36.2 million. It had a $28.9 million loss in the same quarter of 2023. Insurance revenue went up 11% higher year-over-year to $349.9 million due to member retention and growth. It reported a surprising medical loss ratio of 71.3%, down from 77.9% the quarter before. Clover recently had its Star score boosted in MA from 3 to 3.5. Clover also increased its guidance for revenue and margin in 2024.
Additional article: https://www.beckerspayer.com/payer/clover-health-turns-1st-profit.html
#cloverhealth #medicareadvantage
Uninsured Rate To Increase Due To Medicaid Enrollment Losses
The uninsured rate grew from 7.7% to 8.2% earlier this year, but it is sure to increase further as most of the Medicaid redetermination enrollment losses have not been factored in. About 24.8 million have lost Medicaid coverage for some time since redeterminations came back in April 2023. Total Medicaid and state children’s insurance rolls are down by 12.7 million from the peak in 2023. Texas has the highest uninsured rate at 18.8%, in part because it has not expanded Medicaid under the Affordable Care Act (ACA).
Additional articles: https://www.axios.com/2024/08/06/uninsured-americans-texas-map and https://www.axios.com/2024/08/06/us-health-insurance-uninsured-population-grows
#aca #obamacare #exchanges #medicaid #uninsured #underinsured #coverage
https://www.statnews.com/2024/08/06/medicaid-coverage-cuts-raise-uninsured-rate/
A New Study Finds Too Few Challenge Healthcare Denials
A new Commonwealth Fund study says that one in five insured were denied coverage for a doctor-recommended service, but few challenge the denials. Fewer than half challenged such denials. Most are not aware of their rights, especially those from younger generations.
Commonwealth found that challenging coverage denials and medical bills often works. Half of those who challenged coverage denials reported success in getting a part or all of the denied services approved. More than one-third (38%) of those who disputed medical bills from providers saw their balances reduced or eliminated. Success rates were even higher for people enrolled in Medicare and Medicaid.
#surprisebilling #healthcare #coverage
— Marc S. Ryan
