Victory For Preventive Services
As expected, the Supreme Court ruled 6-3 in favor of allowing preventive services to continue under the Affordable Care Act (ACA). The majority was a mix of conservatives and liberals. The high court determined that members of the U.S. Preventive Services Task Force, which makes recommendations for coverage requirements under the ACA, are selected within the bounds of the Constitution. The court agreed that the task force is appointed by an executive appointee and could be replaced. The religious arguments on the provision of certain services were largely sidelined.
Additional articles: https://www.fiercehealthcare.com/regulatory/scotus-upholds-aca-preventive-services-task-force-6-3-ruling and https://www.healthcaredive.com/news/supreme-court-aca-preventive-care-mandate-decision-braidwood-kennedy/751806/ and https://www.medpagetoday.com/primarycare/preventivecare/116288 and https://www.modernhealthcare.com/politics-regulation/mh-aca-preventive-care-ruling-reactions/ and https://thehill.com/homenews/ap/ap-business/ap-supreme-court-preserves-key-part-of-obamacare-coverage-requirements/?amp_gsa=1&_js_v=a9&usqp=mq331AQIUAKwASCAAgM%253D&tbref=hp
(Some articles may require a subscription.)
#prevention #preventiveservices #aca #obamacare
https://www.modernhealthcare.com/politics-regulation/mh-supreme-court-aca-preventive-coverage
Senate Schedules A Saturday Budget Vote, But Outcome Uncertain
Changes to the Senate version of the budget reconciliation bill is due out Friday night and a vote to proceed on the bill is set for Saturday, but the outcome is very uncertain.
A deal with House moderates was reached where the state and local tax (SALT) deduction allowances will go from $10,000 to $40,000 for a 5-year period. Other concessions could be in the bill to satisfy the right and left in each chamber.
Numerous GOP senators have said they have concerns with the bill, have not seen final changes, or will vote no. Cassidy, Murkowski, and Johnson all refused to say how they would vote. Murkowski, Collins, Hawley, and Moran have all said they have issues with Medicaid cuts. Johnson wants more spending cuts. Tillis wants substantial changes. Paul says he is a hard “no.” That is eight GOPers in doubt. The Senate can only stand to lose three, which would allow the vice president to cast a tie-breaking vote in favor of the package.
Further, a group of five House Republicans says it will vote against the GOP’s tax and spending bill over provisions in the Senate version that would mandate the sale of land owned by the federal government. While some moderates would be on board with the SALT changes, some moderates could oppose the bill due to added Medicaid cuts. Further, House rightists have said they think there are too few spending cuts in the Senate version. All this could sink the bill in the House if it were to pass the Senate.
A positive vote in each chamber is right now very much in doubt and may not come fast.
Additional article: https://thehill.com/policy/energy-environment/5374352-house-republicans-gop-megabill-public-land-sales-big-beautiful-trump-zinke/?tbref=hp
#budgetreconciliation #trump #congress #medicaid #coverage
https://thehill.com/homenews/senate/5374079-gop-senate-budget-reconciliation-debate
BSC Stops Some MA Commissions
Due to its ongoing financial woes, Blue Shield of California will end commissions for new enrollments in some of its wider network Medicare Advantage (MA) plans. It will cease paying broker payments for new members in its preferred provider organization (PPO) plans in Alameda, Orange and San Diego counties effective July 1.
(Article may require a subscription.)
#bsc #medicareadvantage #marketing #brokers #agents
https://www.modernhealthcare.com/insurance/mh-blue-shield-california-medicare-advantage-commissions
PBM Reform May Be Complicated
An interesting article on the potential complexity of pharmacy benefit manager (PBM) reform given the control that the Big 3 PBMs have. Nonetheless, President Trump’s executive orders lay out a good course to holistically attack drug prices in America.
#drugpricing #pbms
https://www.healthcaredive.com/news/congress-should-break-up-pbms-drug-reform/751637
CMS Thinks PA Needed In FFS Medicare
A very schizophrenic view of prior authorization (PA) by Dr. Mehmet Oz and the Centers for Medicare and Medicaid Services (CMS).
CMS has spent the past few years finding ways to rein in PA at Medicare Advantage (MA) plans, arguing it is abusive. It passed a 2024 rule that requires plans to use traditional program coverage guidance. It now forced health plans to agree to additional far-reaching changes.
But a press release today touts the fact that CMS is setting up an innovation model, the Wasteful and Inappropriate Service Reduction (WISeR) Model, to enter into agreements with entities to PA certain services in the traditional Medicare fee-for-service (FFS) program. It points to the fraud and waste in the system. The demonstration will use artificial intelligence, pay vendors based on what they save, and curb unnecessary use.
That is what MA does, but CMS has basically taken the managed care out of managed care. CMS argues the program will ensure “safe, effective, and necessary care.” Again, this is what MA does, but you took the tools away from the program.
Additional article: https://www.cms.gov/newsroom/press-releases/cms-launches-new-model-target-wasteful-inappropriate-services-original-medicare
(Article may require a subscription.)
#medicareadvantage #medicare #priorauthorization
https://www.modernhealthcare.com/insurance/cmmi-prior-authorizations-ai-medicare
— Marc S Ryan
