CMS Should Institute Special Enrollment Period in 2025 For Medicare Beneficiaries

CMS needs to stop hiding the ball on coverage impacts and make amends for misleading Medicare beneficiaries I am generally a supporter of the Centers for Medicare and Medicaid Services (CMS). I think it tries very hard to help deliver quality care and regulate Medicare Advantage (MA) and providers reasonably. As a former government official and regulator, I am sympathetic to the agency’s need to constantly walk a tight rope when it comes to policy decisions. I have even backed some CMS decisions when the health plan industry has been vehemently opposed. But I am sorry to say that I have lost some faith in CMS recently. In blogs and newsfeeds I have questioned some of the agency’s actions. I see the agency reacting much more politically of late. This is especially true for MA and Part D decision-making in the last year or so. What happened in Medicare Advantage? While

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October 9, 2024

Despite Some Cutbacks, MA Plans Are Going Big For Special Needs Plans Given their potential for greater margin, Medicare Advantage (MA) plans appear to be making heavy investments in Special Needs Plans (SNPs) in 2025, even as they contract other products in certain areas. Done right, SNPs can generate 6.4% margins, compared with 2.8% for MA generally. This comes from 2021 data. As well, the plans are reacting to the Centers for Medicare and Medicaid Services (CMS) making the integration of Medicare and Medicaid funding streams a huge priority. The growth continues a trend. SNP enrollment is about 6.6 million people this year, up 255% from 10 years ago, 125% from five years ago and 16% from 2023. SNP enrollment is projected to hit 7.2 million in 2025. UnitedHealth Group, Humana, Elevance Health, CVS Health, Centene and Molina are all investing heavily. Some plans are contracting base benefits even in

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October 8, 2024

Harris Announces Medicare At Home, Expands Healthcare Agenda Democratic presidential candidate Kamala Harris announced a new Medicare at Home initiative. She would provide home health aide and other in-home supports for seniors and the disabled in Medicare. This would extend the current scope of benefits officially from short-term home care to chronic home care. I have proposed a comprehensive long-term care program paid through Medicaid and with buy-ins by seniors. As well, Harris wants to have hearing and vision coverage added to the traditional program. She would pay for most of the initiatives by expanding Medicare drug price negotiations and instituting pharmacy benefit manager (PBM) reforms. On other news, Harris is turning up the heat on Trump with a healthcare agenda. The Harris campaign thinks healthcare can be a swing issue and move undecideds to her side. In addition, a new study in Health Affairs has found that, while Medicare

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October 7, 2024

MA Fallout Much Greater Than CMS Indicates The Centers for Medicare and Medicaid Services (CMS) has reported that all is fine in the Medicare Advantage (MA) and standalone Part D worlds. But we know that is just not the case. It is political spin in an election year. We featured some good analysis last week about why choice will drop and some premiums and out-of-pocket costs will go up in standalone Part D. Now, an analysis of MA shows a similar thing. Insurers are exiting geographic markets, reducing benefits, increasing premiums, and imposing higher out-of-pocket costs. An ATI Advisory analysis says more than 7% of beneficiaries, or about two million people, will need to find new offerings. This is up from fewer than 100,000 in past years. This is major displacement right around the election and is the October Surprise I have been talking about. (Article may require a subscription.)

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Docs Need Rate Relief In Medicare Program

The time has come for a real fix to Medicare physician fees. The big stall is hurting healthcare. Poor Medicare docs. They have been on a proverbial reimbursement roller coaster for decades now. The ups and downs have undermined independent practices, led to our primary care deficit, and actually fostered physician group acquisitions that increase costs in the healthcare system in several ways. More background A caution before I give you details on the history of Medicare physician pay — I am by no means a traditional Medicare fee-for-service (FFS) program rate expert. So, I am keeping this short and giving you a broad overview. The long and short of it is that Medicare physicians have had a rather broken rate system dating back to 1992. The bad system has been undermined further with various budget reduction requirements applied to the physician rates along the way. Congress created the Medicare

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October 4, 2024

CBO Says Costs of Medicare Part D Changes Are Ballooning The Congressional Budget Office (CBO) has updated its projections on the cost of the redesign of the Medicare Part D program passed by Democrats in the Inflation Reduction Act (IRA). I have argued in several blogs (see these: https://www.healthcarelabyrinth.com/part-d-premium-woes-due-to-the-inflation-reduction-act/ and https://www.healthcarelabyrinth.com/part-d-restructuring-in-inflation-reduction-act-could-have-huge-implications-on-standalone-part-d-program/ ) that Democrats did not think through the impact on both premiums over time as well as the stability of both Medicare Advantage (MA) and the standalone Part D (PDP) program. The generous out-of-pocket reductions would be paid by higher premiums and benefit changes since the government did not fund the policy changes. The Centers for Medicare and Medicaid Services (CMS) created an emergency demonstration program to stabilize premiums in 2025. But that only lasts for three years. I also think the program is extra-legal. Now, the CBO is saying that the original estimates of the Part D changes have

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43. Employer Coverage Healthcare Trends Driven By Drug Spending

Employer healthcare coverage costs are exploding and it is being driven by drug spending. Listen in to hear why employers are concerned and what they will do about it. About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense

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October 3, 2024

United Healthcare Sues CMS on Call Center Measures For Star Year 2025 Interesting development already on Star Year 2025 even before the public announcement of results on 10/10. In addition to a major drop in Stars for Humana for Star Year 2025, United Healthcare seems to have been hit with lower Stars and is now suing CMS. Humana has appeals on its ratings, too. In the United case, the company is suing over what it says are arbitrary assessments of calls regarding timely connection to TTY or a foreign language translator as well as CMS asking the right questions and following procedures. Just one arguable assessment on a call by CMS for the Part C and D measures can cost you a higher score on those measures but also perhaps impact your overall score. This is what United says happened to them. This builds on what happened in Star Year

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The Biggest Lie Of The VP Debate: Trump Salvaged Obamacare!

Trump did not salvage the Affordable Care Act — he sabotaged it. Tall tales are always part of politics and candidate debates. America takes it for granted. But the biggest lie of the vice-presidential debate Tuesday night was quite the doozy and I could not let it go without some explanation. The big lie can be credited to GOP vice presidential candidate JD Vance. Vance attempted to concoct a story that somehow former President Trump salvaged the Affordable Care Act (ACA) when it was on the verge of collapse. This of course is true only in Vance’s and Trump’s minds. Vance’s fanciful rewrite of history went like this. Vance said Trump “actually implemented some of these regulations when he was president of the United States. … And I think you can make a really good argument that it salvaged Obamacare, which was doing disastrously until Donald Trump came along. I

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October 2, 2024

Trump Won’t Reintroduce Drug Price Reform Donald Trump is backing away from his previous support for some form of drug price reform. In his first administration, Trump proposed drug price negotiations for Part B medical drugs in Medicare and the eventual cap of prices to international benchmarks. The U.S. would pay the lowest of other nations. He indicated he wanted to extend the concept to Part D retail drugs as well. The change is surprising given polls showing overwhelming support for drug price reform across Democrats, Independents, and Republicans. The reform was pulled back by the Biden administration due to rule-making issues and poor design. (Article may require a subscription.) #drugpricing #medicare #branddrugmakers https://insidehealthpolicy.com/daily-news/trump-campaign-trump-won-t-pursue-most-favored-nation-policy-drugs Democratic Senators Urge FTC To Investigate PBM Co-Manufacturing Finance Chair Sen. Ron Wyden, D-OR, and Sen. Sherrod Brown, D-OH, want the Federal Trade Commission to investigate pharmacy benefits managers (PBMs) who have co-manufacturing agreements with drug

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