United And Centene Get Star Hikes For 2025
After a federal court ordered the Centers for Medicare and Medicaid Services (CMS) to revise United Healthcare’s 2025 Star ratings, the agency issued new Star ratings for both United and Centene today.
The agency increased the quality ratings for 12 UnitedHealthcare contracts and 7 Centene contracts. Centene now has a sole 4-Star contract under the agency changes. Two United contracts were upgraded to 5 Stars and three contracts to 4 stars. United now will have 37 contracts rated at least 4 stars.
The United and Centene cases surrounded how CMS handled the two call center ratings.
Centene sued like United and the Centene case is still pending. It likely will be withdrawn.
Humana and Elevance Health also sued and both suits are still pending. No changes to Star ratings have yet been made for Humana and Elevance Health.
One reason could be that the Humana and Elevance suits were rather biting in their suits and went beyond the call center metrics raised in the United and Centene suits.
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#cms #stars #medicareadvantage #centene #unitedhealthcare #elevancehealth #humana
Major New Market Conduct Rule In New York On PBMs
The New York State Department of Financial Services adopted major new market conduct regulations on pharmacy benefit managers (PBMs). The regulation is quite expansive and covers for following areas:
- Prohibition on steering consumers toward PBM-affiliated pharmacies.
- Preventing retroactive reimbursement denials on pharmacies.
- Allowing home delivery from a community pharmacy.
- Requiring pharmacy directories to be listed online.
- Requiring information on the PBM for consumer inquiries, with such inquiries addressed in a reasonable amount of time.
- Electronic submissions and responses to and from the pharmacy.
- Requiring uniform audit standards by the PBM for all in-network pharmacies.
New York pharmacies are excited by the regulations as they say it will equalize treatment with large pharmacies and end discrimination against independent ones.
(Article may require a subscription.)
#ny #pbms #drugpricing #pharmacies
Another Conservative Think Tank Proposal On Medicaid
For the past few weeks, I have been telling you about various GOP think tanks proposing changes to the Affordable Care Act and Medicaid. The range from cosmetic changes, changes in reimbursement, and sweeping restructuring. Now the conservative Manhattan Institute has weighed in on a Medicaid reform proposal.
The Manhattan proposal would reduce Medicaid spending by capping funding for optional services and eligibility expansions. Manhattan says these areas drive 63% of the spending and the proposal would preserve the entitlement and full financing for the core package of services that must be offered to all enrollees.
While poorer states have higher federal reimbursement rates, it would impact them less as these states are generally less generous in terms of optional benefits and expanded populations. It would impact the expansion of benefits and eligibility by the wealthiest states that tend to subsidize their Medicaid programs much more.
Some reimbursement would be changed from the current set federal percentages of expenditures. A dual formula would be used to determine federal reimbursement. A risk-adjusted formula would be used for core services (including prescription drugs) and populations. But the growth for enhanced populations and services would be capped based on the amount of state expenditures that exceeds mandatory costs. The more a state spent on these services the lower the reimbursement.
What is interesting is that most proposals stay away from sweeping changes due to the lack of sufficient congressional support. This Manhattan Institute proposal fits that mold even though it is somewhat controversial. Like other proposals, it centers on immediate and long-term savings to the federal budget.
(Article may require a subscription.)
#medicaid #healthcare #coverage
— Marc S. Ryan
