Logo

Newsfeed

Disappointing Medicare Advantage Enrollment Numbers

Huge disappointment for some during the Medicare Advantage enrollment season. My quick math says that overall MA numbers increased a strong 8.7% from January 2023 to January 2024.  That is up from a year ago, which was a little over 6%. But a number of plans did not fare well during the recent enrollment campaign.  Aetna shined.  While United and Humana grew, it was a much lower rates than before.  Centene took a big hit. I will have my usual annual blog looking at all the data on Monday. Stay tuned.

Additional article here: https://www.healthcaredive.com/news/humana-earnings-outlook-cut-high-medical-costs/704865/

(Some articles may require a subscription.)

#medicareadvantage #healthplans #enrollment

Link to Article

Read More »

CMS Finalizes Interoperability And Prior Authorization Rule

The Centers for Medicare and Medicaid Services (CMS) finalized a sweeping interoperability rule today that also sets much stricter timelines for medical service prior authorizations.  The rule was published some time ago and garnered a great deal of comments. The rule takes effect in January 2026 and requires 7 day standard and 72 hour expedited prior authorization turnaround times (federal Exchange plans excepted). Plans now have until 2027 to have APIs to allow providers to submit authorizations electronically.  A national format exists for retail prescription drugs, but not a consistent one for medical service requests yet.  The final specifications for medical services will tie to the Davinci Project, which will use the new FHIR standard. But plans will be able to use X12 formats as well. The rule applies to Medicare Advantage (MA), Medicaid, children’s coverage, and the federal Exchanges.

The finalization of this rule follows the 2024 MA and Part D rule going into effect, which substantially restricts MA from using outside evidence-based clinical criteria in prior-authorizations.  Plans will be subject to immediate audit on these new rules.

Additional articles here:

https://www.modernhealthcare.com/policy/prior-authorization-rule-cms-medicare-advantage-medicaid-insurance

https://www.healthcaredive.com/news/cms-final-prior-authorization-rule-payer-deadline/704721/

https://www.medpagetoday.com/practicemanagement/reimbursement/108299

https://thehill.com/policy/healthcare/4413508-biden-rule-health-insurer-prior-authorization/

https://insidehealthpolicy.com/daily-news/cms-finalizes-e-prior-auth-rule-proponents-look-congress-next-steps

https://www.cms.gov/newsroom/press-releases/cms-finalizes-rule-expand-access-health-information-and-improve-prior-authorization-process

https://www.hhs.gov/about/news/2024/01/17/cms-finalizes-rule-to-expand-access-to-health-information-and-improve-the-prior-authorization-process.html

(Some articles may require a subscription.)

#priorauthorization #managedcare #healthcare #fhir #interoperability

Link to Article

Read More »

Congressional Leaders Agree on Extension of Funding

The four congressional leaders announced a deal to extend government funding to March 8 to avoid a government shutdown.  This is a concession by House Speaker Mike Johnson, R-LA, who originally said he would not extend government by a short-term continuing resolution (CR). A number of items are left out of the funding package. Conservatives in the House GOP caucus are not happy with Speaker Johnson’s (one of their own) endorsement of the extension.

Additional articles here: https://insidehealthpolicy.com/daily-news/short-term-cr-carries-extenders-through-march-8 and https://thehill.com/homenews/house/4410728-congress-shutdown-conservative-anger/

Additional article on status of healthcare bills, including hospitals’ opposition to site-neutral payments that is in a passed bill that would forestall disproportionate share hospital(DSH) funding cuts: https://www.modernhealthcare.com/politics-policy/congress-spending-deal-hospitals-dsh-medicare-site-neutral

(Some articles may require a subscription.)

#governmentshutdown #crs

Link to Article

Read More »

Good Articles On Takeaways From JPM Healthcare Conference

Two good articles summarizing some major trends and topics at the JPM healthcare conference.  Highlights include:

  • Providers emphasizing creating payviders, where provider organizations set up their own insurance arm.
  • Hospital expansion of outpatient and ambulatory site investments given pressures on inpatient.
  • Medicare Advantage Star woes and risk adjustment changes.
  • PBM transparency reforms.

Additional article here: https://www.modernhealthcare.com/finance/jpm-2024-takeaways-commonspirit-mayo-clinic-centene-cvs-cigna-teladoc

(Some articles may require a subscription.)

#healthplans #providers #hospitals #stars #pbms

Link to Article

Read More »

What Would A Nikki Haley Healthcare Agenda Look Like?

The Republican debates continue with Donald Trump bowing out and Ron DeSantis and Nikki Haley taking center stage.  A recent CNN debate saw the two sparring, sometimes on healthcare issues. Both Haley and DeSantis declared that they would like to replace the Affordable Care Act (ACA) with a block grant.  It is a horrible idea.

With Chris Christie’s departure from the race and Haley rising in the polls, Kaiser Health News (KHN) did a feature on what a Haley administration’s healthcare agenda may look like.

Additional article on Haley’s views on entitlement reform here: https://www.cnn.com/2023/12/05/politics/nikki-haley-social-security-medicare-reform/index.html

#gopprimary #haley #desantis #trump #healthcare #aca #obamacare

Link to Article

Read More »

Dysfunction Junction Update:  Will Government Shutdown?

Faced with an upheaval by the rightists (his very own!) in the House GOP caucus and upended procedural votes, Speaker Mike Johnson, R-LA, met with the Freedom Caucus members to discuss a possible alternative spending bill.  This came as a surprise to other leaders.  But Johnson could face the same purge that former Speaker McCarthy saw when he tried to do the right thing and comprise to keep government operating.  While no one has explicitly said they would call a vote to vacate the speakership, the idea has again been put out there by prominent members of the right-wing fire-setting brigade. Meanwhile, Senate Majority Leader Chuck Schumer, D-NY, has begun drafting a continuing resolution (CR) that extends government while the agreed-upon deal is worked on.  Senate Minority Leader Mitch McConnel, R-KY, has said this is needed. Johnson may be softening, but previously ruled out additional short-term CRs.

Additional articles:

https://thehill.com/homenews/house/4401412-johnson-risks-same-fate-as-mccarthy-with-spending-deal/

https://thehill.com/homenews/senate/4402814-schumer-short-term-stopgap-cr/

#governmentshutdown #crs

Link to Article

Read More »

Oscar Says It Can Be Profitable in 2024 And May Expand To Other Products

Insurtech Oscar says its enrollment will hit 1.3 million members in the Exchanges once open enrollment concludes, a 31% increase year-over-year. It also could see positive margins in 2024, as much as 5%. It could expand into individual coverage health reimbursement arrangements (ICHRA) and Medicare Advantage (MA) in the future.

Both Oscar CEO Mark Bertolini (former Aetna CEO) and Centene CEO Sarah London are right that the Affordable Care Act (ACA) is here to stay with over 20 million enrollees.  

ICHRA is a good Trump-era rule that allows employers to make tax-free contributions toward employees’ individual coverage.  Oscar would be well-placed to offer a total ICHRA administrative solution coupled with enrollment in individual Exchange enrollment. Bertolini is a genius on this issue.

In other news, Alignment Healthcare touted its Star scores.

Additional articles:

https://www.fiercehealthcare.com/payers/jpm24-oscar-health-eyes-2024-profitability-and-ichra

https://www.fiercehealthcare.com/finance/jpm24-day-3-goodrx-expects-least-749m-revenue-2023

https://www.fiercehealthcare.com/payers/jpm24-centene-ceo-london-sees-growing-bipartisan-backing-acas-exchanges

(Some articles may require a subscription.)

#oscar #exchanges #alighnmenthealthcare #medicareadvantage #ichra

Link to Article

Read More »

NY Wins Medicaid Waiver Approval

New York received an 1115 Medicaid waiver approval from the Centers for Medicare and Medicaid Services (CMS) covering a myriad of innovations, including recruitment and retention of Medicaid providers, eligibility to bill social needs spending, primary care investments, behavioral health investments, and health equity pilots. CMS press release here: https://www.cms.gov/newsroom/press-releases/cms-approves-new-yorks-groundbreaking-section-1115-demonstration-amendment-improve-primary-care

#medicaid #cms #waivers #socialneeds #healthequity

Link to Article

Read More »

Aetna Turnaround On Stars And Enrollment Is Amazing

At the JP Morgan conference, CVS President and CEO Karen Lynch was taking a well-deserved victory lap.  With all that is going on at CVS, the Aetna turnaround on enrollment and Stars in Medicare Advantage (MA) is amazing.  It is no small feat given competitiveness in the MA world and the major changes in Star for 2024. 

#cvsaetna #cvshealth #aetna #medicareadvantage

Link to Article

Read More »

FDA Approves Florida Drug Importation

The Food and Drug Administration (FDA) has approved Florida to import prescription drugs from Canada via bulk purchasing.  This would mean Florida residents would have access to Canadian wholesale prices, which are far lower than in the United States.  Brand drug makers immediately attacked the waiver as reckless and claimed it could endanger health.  Nonsense.  Canada is a developed country with a great safety record. The waiver also has strict quality control measures in it. This is yet another stunt by Big Pharma to maintain its high prices in the United States. It likely will sue to stop it. Canada, too, could disrupt the plan if it results in shortages there.  Although the targeted drugs right now look like they are in reasonable supply, look out for a “manufactured” crisis to emerge.

This is a feather in the cap of presidential candidate and Fl. Gov. Ron DeSantis, who has been pressing the Biden administration for the waiver. Biden will surely tout this during his run. Donald Trump too, as he passed the original rules to allow states to do this.  Florida sued the federal government when its application stalled.

Florida says residents could save $150 million annually, but Florida will start very slowly, with a few classes of drugs and government programs now. Other states have pending applications and others could submit as well. So, broad relief will take time and the program would have to grow in Florida and other states.  Many currently import drugs individually through Canadian pharmacies and it is technically illegal. But with Medicare drug price negotiations, this is yet another way to solve a huge affordability crisis in America over time.

Other articles here:

https://insidehealthpolicy.com/daily-news/florida-first-state-receive-fda-nod-rx-drug-importation

https://thehill.com/policy/healthcare/4390990-florida-drugs-canada-approval/

https://www.statnews.com/2024/01/05/ron-desantis-import-drugs-canada-biden-trump/

#drugpricing #drugimportation #fl #brandrugmakers

Link to Article

Read More »

Available Now

$30.00