Laws And Rules That Went Into Effect as of January 1
A series of new healthcare federal and state laws and regulations went into effect on January 1.
A federal rule update requires new fields and data related to pricing that must be disclosed by hospitals related to the price transparency requirements. This will create greater compliance, consistency, and better comparisons of prices.
States enacted laws that restrict prior authorization, expand mandated benefits, expand Medicaid, require bias training, require cybersecurity audits, reform pharmacy benefit managers (PBMs), restrict cost-sharing for drugs, and undertake medical-debt reform.
Additional: article: https://www.modernhealthcare.com/government/state-healthcare-laws-2025-california-illinois-minnesota-arkansas
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#2025 #healthcarereform #regulations
https://www.statnews.com/2025/01/02/hospital-price-transparency-rules-2025-cms/
Supporters Urge Making Price Transparency A Law
Many supporters of healthcare price transparency are saying the rules passed by the Trump administration and amended by the Biden administration regarding health plans and hospital price transparency should be passed as a law to ensure it remains in force.
If the rules have not yet reduced costs overall, they have shed light on the disparate pricing in the healthcare sector. Prices vary across regions, within regions and even among individual health plans and hospitals.
Employers say they are using it to reduce their costs. A recent study by Turquoise Health analyzing a set of common healthcare services in the top ten metro areas found that rates in the top quarter tier declined by 6.3% from December 2021 to June 2024. The lowest tier rose. Some argue that means the rules are helping. Others doubt it.
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#pricetransparency #hospitals #healthplans #healthcarereform
Health Plan Acquisitions Announced
Two acquisitions of health plan assets were finalized recently. Elevance Health has officially closed its acquisition of Indiana University Health Plans, which has Medicare Advantage (MA) and fully insured employer group insurance.
CareSource has completed its acquisition of Common Ground Healthcare Cooperative, a provider of Exchange coverage in Wisconsin.
Additional articles: https://www.fiercehealthcare.com/payers/elevance-health-acquire-iu-health-plans and https://www.modernhealthcare.com/mergers-acquisitions/caresource-aca-coop-common-ground-healthcare and https://www.beckerspayer.com/m-and-a/caresource-acquires-wisconsin-insurer.html
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#healthplans #exchanges #employercoverage #medicareadvantage
https://www.beckerspayer.com/m-and-a/elevance-acquires-iu-healths-insurance-business.html
Wall Street Journal Continues Health Plan Investigations
The Wall Street Journal continues its ongoing investigation of health plan operations. Two of its latest installments.
On December 29, the newspaper told of United’s scheme to drive risk adjustment scores on members. Doctors who work for UnitedHealth Group generated billions of dollars in extra payments by adding more diagnoses. The employed doctors used checklists from the insurers of possible diagnoses for their patients and paid bonuses for completing them. Providers did not always agree with the diagnoses. United’s Optum owns about 10% of physicians nationwide.
On December 31, it chronicled the story of how UnitedHealth Group became a healthcare goliath, growing over time to become an insurer, far-reaching health plan and provider service organization, pharmacy benefits manager (PBM), and physician group holder.
Additional article: https://www.wsj.com/health/healthcare/how-unitedhealth-became-an-american-goliath-a039a36d
(Some articles may require a subscription.)
#medicareadvantage #unitedhealthcare #radv #riskadjustment #optum
https://www.wsj.com/health/healthcare/unitedhealth-medicare-payments-doctors-c2a343db
FL Blue Becomes Latest Plan To Sue CMS Over 2025 Star Ratings
Florida Blue, part of Florida Blue Cross and Blue Shield, an independent entity, is the latest insurer to sue the Centers for Medicare and Medicaid (CMS) over its Medicare Advantage (MA) 2025 Star ratings.
The lawsuit is rather technical as opposed to arguments from a number of other plans. Florida Blue argues CMS did not account for the effects of natural disasters when it calculated the insurer’s ratings.
The insurer says a state of emergency declared in 2023 by Florida and the president was not recognized by CMS and should have been. This would have impacted the scores received on several measures. FL Blue says its MA plan would have received a 4.5 vs. an awarded 3.5. The insurer argues it was not consistent in its 1135 waiver declarations. Florida Blue says it will lose out on tens of millions in bonus payments. It wants its overall rating recalculated.
#medicareadvantage #cms #stars #flblue
— Marc S. Ryan
