Bad News On Medicare Advantage Star Ratings
The Centers for Medicare and Medicaid Services (CMS) announced 2025 Star ratings and the news was not good. The percentage of contracts obtaining a 4 Star or greater rating dropped to about 40%. Just 62% of all Medicare Advantage Part D (MA-PD) enrollees will be in a 4 Star or greater plan. These are big drops from even a sluggish 2024 Star year.
Humana saw the biggest drops among large national plans, with United and Elevance having some reductions and Centene continuing to score low. Aetna was roughly flat in terms of achievement. The poor Big Plan results drove the estimated enrollment in high-performing plans down. Big Plans have about three-quarters of the MA market.
Humana and United are challenging their ratings. United has filed a lawsuit against CMS.
My new company, Lilac Software, will have a blog and an infographic on all the Star Year 2025 details as well as historic trends. Watch for this on LinkedIn (my and Lilac’s page and at https://lilacsoftware.com. I will re-publish the blog on https://healthcarelabyrinth.com on Monday.
CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/2025-medicare-advantage-and-part-d-star-ratings
Additional articles: https://www.modernhealthcare.com/insurance/2025-medicare-advantage-ratings-humana-unitedhealth-aetna and https://insidehealthpolicy.com/daily-news/cms-ma-star-ratings-lower-cut-points-increase and https://www.beckerspayer.com/payer/medicare-advantage-star-ratings-decline-5-things-to-know.html and https://www.healthcarefinancenews.com/news/see-list-seven-plans-compared-38-last-year-receive-5-stars-medicare-advantage-star-ratings
(Some articles may require a subscription.)
#cms #stars #medicareadvantage #partd
https://www.fiercehealthcare.com/payers/medicare-advantage-star-ratings-dip-slightly-once-again-2025
CBO Says GLP-1s Would Cost Medicare $35 Billion
The Congressional Budget Office (CBO) has scored fairly liberal coverage of GLP-1s in Medicare and says it would cost $35 billion from FFY 2026 through FFY 2034. The bill assumes coverage for anyone who is obese and some classified as overweight. It says nearly 13 million would be eligible, or about 20% of Medicare beneficiaries. Right now, coverage is limited to those who are obese or overweight and have a qualifying disease state (e.g., diabetes or cardiovascular conditions).
Additional articles: https://thehill.com/policy/healthcare/4924361-medicare-weight-loss-drugs-cbo/ and https://www.fiercehealthcare.com/regulatory/cbo-covering-anti-obesity-drugs-could-cost-medicare-35b-2034
#weightlossdrugs #glp1s #drugpricing
Out-Of-Network Lawsuit Award Shocking
A state court suit in Louisiana filed by a surgery center was decided against Blue Cross and Blue Shield of Louisiana. A jury awarded $421 million in damages to a surgery center over the insurer’s alleged failure to fully pay out-of-network charges. The case would set a huge precedent and further unlevel the playing field between plans and providers. The No Surprises Act (NSA) arbitration is already heavily favorable to providers. The decision will be appealed and likely end up in federal court. The providers have had less success there.
(Article may require a subscription.)
#nsa #nosurprisesact #healthplans #hospitals #providers
Articles Cover What Healthcare Might Look Like Under Each Administration
Two articles here that discuss what healthcare might look like under both a Trump and Harris administration. On the Affordable Care Act, there are fears that Trump could again seek changes or repeal. On Medicaid, it is likely Trump would look for huge savings from the program and again back work requirements.
Additional article: https://www.modernhealthcare.com/politics-policy/joe-biden-healthcare-regulation-aca-medicaid-donald-trump
(Some articles may require a subscription.)
#election2024 #healthcare #trump #harris
Congressional MA Prior Authorization Bill Could Pass
With the price tag on the bill reduced to zero, the bipartisan Improving Seniors Timely Access to Care Act could pass as part of a year-end omnibus bill. The bill would codify prior authorization and transparency requirements for Medicare Advantage (MA) plans. The cost was slashed to zero because of two new rules on prior authorization that were finalized by the administration. I think both this bill and the rules are misguided and essentially will take the managed care out of the program.
(Article may require a subscription.)
#priorauthorization #medicareadvantage
— Marc S. Ryan