October 25, 2024

OIG Says CMS Does Not Ensure Part D Denies Part A Drugs

A new audit report from the Department of Health and Human Services Office of Inspector General (HHS OIG) is calling on CMS to enact certain reforms to prevent Medicare Part D from making additional payments for drugs that are supposed to be covered under the Part A benefit. Certain drugs that might normally be under Part D are under Part A when someone is in hospice or in certain facilities. Medicare Advantage and Part D plans should proactively determine what part of Medicare should be charged.

This has been a long-standing issue in the Medicare program. The audit looked at more than 2.5 million prescription drug events (PDE) for 2018 through 2020. It looked at anomalies in a sample. Extrapolating the results, it says Part D improperly paid up to $465.1 million. About $245.4 million of that amount was for drugs that medical records show were administered to Part D enrollees during their Part A skilled nursing facility stays. Part D enrollees paid approximately $21 million in cost-sharing.

(Article may require a subscription.)

#medicareadvantage #partd #medicare

https://insidehealthpolicy.com/inside-drug-pricing-daily-news/oig-cms-stop-redundant-part-d-payments-covered-drugs

Election Year Healthcare Articles Show Differences Between Trump And Harris

A series of news articles have been published showing the rather stark differences between Trump and Harris on healthcare.

  • Kaiser Health News details Harris’ defense of the Affordable Care Act and Trump’s desire to take a different course than Obamacare.
  • Harris wants to expand the Medicare drug negotiations. While Trump supported a most-favored-nation reform, it is unclear if he would continue pursuing it.
  • Trump seems focused on transparency, choice, and competition.

In other news, the Biden administration is touting the accomplishments of Obamacare and announced an early look at 2025 Exchange enrollment. A Kaiser Family Foundation (KFF) briefer gives you all the details on how the tax credits and cost-sharing reductions work in the Exchanges.

Additional articles:

https://www.beckershospitalreview.com/pharmacy/where-trump-harris-stand-on-prescription-drug-prices-6-notes.html and https://thehill.com/policy/healthcare/4945353-trump-harris-healthcare-costs/ and https://www.cms.gov/newsroom/press-releases/affordability-and-choice-anchor-biden-harris-administrations-launch-window-shopping-12th and https://www.kff.org/affordable-care-act/issue-brief/explaining-health-care-reform-questions-about-health-insurance-subsidies/

#election2024 #healthcare #harris #trump

https://kffhealthnews.org/news/article/trump-harris-affordable-care-act-subsidies-medicaid-expansion/

Centene Reports Good Q3 News

Centene stock was up on a good investor report for Q3. Centene did receive rates that averaged 4.5% to 5% in Medicaid, but revenue declined in Q3. Like Molina, Centene says that Medicaid rate increases could be coming to cover higher adversity in the population after Medicaid redeterminations. Centene was bolstered by winning some Medicaid contracts in several states.

While 4 strong Star and above enrollment continues to elude Centene in Medicare Advantage (MA), it now will have 46% of its members with at least 3.5 stars.

Additional articles: https://www.modernhealthcare.com/insurance/centene-medicaid-pay-reimbursement-drew-asher-sarah-london and https://www.modernhealthcare.com/insurance/centene-earnings-call-share-price-medicaid and https://www.fiercehealthcare.com/payers/centene-shares-rise-it-beats-street-profit-revenue

(Some articles may require a subscription.)

#centene #medicaid #managedcare #medicareadvantage #partd

https://www.beckerspayer.com/payer/centene-posts-713m-in-q3-profit.html

NYC Employee Plan Drops GLP-1 Coverage

New York City announced that it was dropping coverage of GLP-1 weight-loss drugs from its city worker healthcare benefits. It said that the coverage was mistakenly added by EmblemHealth, the insurance plan. The city added that continuing coverage would increase monthly premiums by $48.50 per subscriber.

Public and private employer groups have been more liberal on the use of GLP-1s than other lines of business, but now many are reining in coverage due to the expense.

(Article may require a subscription.)

#weightlossdrugs #glp1s #drugpricing #employercoverage

https://insidehealthpolicy.com/inside-drug-pricing-daily-news/nyc-drops-glp-1-city-health-benefits-over-high-costs

— Marc S. Ryan

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