December 6, 2023

Affordable Care Act 2025 Rule And Ongoing Press On Trump Repeal Remarks

While we have already covered the proposed 2025 Exchange rule, this article from Kaiser Health News discusses the rule as well as some of the history of the Affordable Care Act under Trump and later Biden.

#aca #obamacare #exchanges #medicaid

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Drug Donations Help The Uninsured and Low Income

Great Kaiser Health News article on drug donation programs in states.  Helping to save lives and reduce healthcare costs.


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Exchange Enrollment Doing Very Well But Not Picking Up Many Losing Medicaid Coverage

Nearly 7.3 million people have selected an Affordable Care Act (ACA) Health Insurance Marketplace plan since the 2024 Marketplace Open Enrollment Period (OEP) opened on November 1. It runs through January 15, 2024. The numbers from the Centers for Medicare and Medicaid Services (CMS) represents activity through December 2 (Week 5) for the 32 states using HealthCare.gov and through November 25 (Week 4) for the 18 states and the District of Columbia with State-based Marketplaces (SBMs). More than 1.6 million people (23% of total) are new to the Marketplaces for 2024.

I would note, though, that despite the good news here it would appear that few losing Medicaid eligibility are making it to the Exchanges.

#aca #exchanges #obamacare

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CVS Transparency Changes Challenged

CVS’ PBM announced yesterday that it is moving to a more transparent model to reimburse pharmacies.  This article claims that experts debate the fact.  I am sure we will hear much more about this as more analysis is done. An additional article in Axios recaps some of the moves by PBMs to a more transparent model. Axios article: https://www.axios.com/2023/12/06/cvs-drug-pricing-overhaul

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#cvs #pbms #drugpricing

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Site-Neutral Payment Policies Could Get Vote in House

The Lower Costs, More Transparency Act is on the House’s schedule to be voted on during the week of Dec. 11.  This includes site-neutral payment reforms for Medicare Part B drugs and administration. It would be a good start.

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Medicare Advantage and Part D 2025 Advance Notice At OMB For Approval

CMS’ 2025 Medicare Advantage advance notice is under review at the White House Office of Management and Budget. A myriad of changes were proposed. Will it be another tight year on rate increases for Medicare Advantage? The general rate hike may be very important due to the fallout from poor Star performance.

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#medicareadvantage #stars #rates

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More Controversy On 2024 Prior Authorization Rule For Medicare Advantage

The American Hospital Association (AHA) and Federation of American Hospitals (FAH) have already turned up the heat on Medicare Advantage plans even before a new rule goes into effect on January 1 that substantially restricts the use of outside evidence-based criteria in prior authorization decision-making. There were letters sent by the two groups to the Centers for Medicare and Medicaid Services (CMS) with regard to some MA plans’ intention to continue the use of outside criteria.  The groups maintain the plans’ approach is outside the bounds of the rule and asked for an investigation. The AHA wants to meet with CMS about what the hospitals allege is inappropriate use given the new rule. United Healthcare and Aetna are being cited for their planned activities. United maintains it is in compliance. Hospitals argue that only National Coverage Determinations (NCD) and Local Coverage Determinations (LCD) can be used to assess hospital treatment, especially as it relates to the two-midnight rule.

The article also notes that AHIP, the health plan industry trade group, says if the traditional Medicare population used Part A services at the same rate as beneficiaries with MA plans, the Part A trust fund could be extended by as much as 17 years. The rates are different because the traditional program uses just NCD and LCD and not external criteria used by plans. The findings come from an Avalere study of inpatient, skilled nursing, and certain home health services in certain years. The finding is amazing and just as I expected. Implementing this rule will hurt efforts to rein in fraud, waste and abuse in Medicare.  We should aim for lower utilization or a lower cost-setting when it is warranted.  But, of course, hospitals don’t like that as it means they would have to reform themselves.

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#medicareadvantage #priorauthorization #hospitals #ncd #lcd

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Drug Shortages Being Looked At By Congress

Senate Finance Committee Chair Ron Wyden (D-OR) wants to work on bipartisan legislation to address the drug shortage crisis for certain key drugs.  He believes that the fact that three group purchasing organizations (GPOs) control 90% of the pharmaceutical market is the culprit.

Experts at a recent Finance Committee hearing also have endorsed the use of a long-term purchasing contract model to help solve the crisis. They believe it would create reserve line space for generic manufacturers to continue their production. This would be a preventive measure against future shortages.

Still others, see using Medicare payments policies to fix drug shortages.

Additional article here: https://www.statnews.com/2023/12/05/medicare-policy-drug-shortages/

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— Marc S. Ryan

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