United Healthcare Sues CMS on Call Center Measures For Star Year 2025
Interesting development already on Star Year 2025 even before the public announcement of results on 10/10.
In addition to a major drop in Stars for Humana for Star Year 2025, United Healthcare seems to have been hit with lower Stars and is now suing CMS. Humana has appeals on its ratings, too.
In the United case, the company is suing over what it says are arbitrary assessments of calls regarding timely connection to TTY or a foreign language translator as well as CMS asking the right questions and following procedures. Just one arguable assessment on a call by CMS for the Part C and D measures can cost you a higher score on those measures but also perhaps impact your overall score. This is what United says happened to them.
This builds on what happened in Star Year 2024, when Scan, Elevance Health, and some others successfully sued CMS and won a recalculation of Stars. Elevance also settled with CMS on a call center issue for 2024 Star and won increased ratings.
So, there is some hope that United and Humana could see higher scores if successful on appeal or in court.
Additional articles: https://www.fiercehealthcare.com/payers/cms-faces-another-star-ratings-lawsuit-time-unitedhealth and https://www.beckerspayer.com/payer/unitedhealthcare-sues-cms-over-1-phone-call.html
#medicareadvantage #stars #cms #unitedhealthcare
CMS Misleads On Premium And Benefit Stability In Standalone Part D
A great deal of news on the Medicare Advantage (MA) and Part D front.
The Congressional Budget Office responded to a GOP question and said that the centers Medicare and Medicaid Services’ (CMS) premium stabilization program for standalone Medicare Part D (PDP) plans will cost $5 billion over three years. Many, including me, have called the demonstration extra-legal and was meant simply to protect the current administration from major fallout when CMS saw huge increases in 2025 when bids came in. The surge was in part related to the passage of unfunded program changes regarding out-of-pocket cost reductions in the program. CMS says the demonstration has substantially ensured premiums did not rise in the PDP program.
But other evidence is emerging that insurers still had to pursue higher deductibles and cost-sharing to get to competitive premiums. Choices were also reined in. And there is a mix of higher, lower, and stable premiums that will impact consumers. A Kaiser Family Foundation (KFF) looked at available 2025 data and found that “While CMS’s headline emphasized stability in terms of average Part D premiums, a quick review of the data shows that many insurers are increasing premiums for their stand-alone drug plan offerings, but not across the board. Some major plan sponsors, including Aetna and UnitedHealthcare, are also reducing their stand-alone prescription drug plan offerings, and overall, there will be fewer PDPs in 2025 than in 2024 – 524 plans nationwide, down from 709 in 2024.”
The KFF analysis is fair and balanced and emphasizes the pros and cons of what happened in the Inflation Reduction Act (IRA) to reduce out-of-pocket costs and the possible impacts on premiums. I stated much the same in many blogs. The analysis points out that premiums still are increasing rather dramatically in some cases and that choice is dropping. I have made the case that the IRA could jeopardize the stability of the program in the future after the demonstration goes away. The data already shows it. This is what I labeled an October Surprise, although it was mitigated by the demo.
In MA news, the Senate Permanent Subcommittee on Investigations says it will release a “dramatic” report on MA in the coming weeks. “Anybody following our hearings and public comments knows our findings will be very dramatic and powerful,” said Sen. Richard Blumenthal, D-CT. “What we have found is, essentially, there is no advantage for people in Medicare Advantage, all too often.” While some reforms are needed, MA plans need to be ready to fight back against what is expected to be an unfair and biased report meant to promote traditional Medicare and likely will repeat tired and false data from MedPAC and other anti-MA researchers.
As well, we have seen major MA plan pullbacks in regions around the country due to the problematic financing of MA in 2025. We have also seen health systems pull out of MA. But there are some expansions by plans and hospitals. Intermountain Health has signed an agreement with Alignment Health Plan, effective Jan. 1, that provides Alignment’s Nevada members access to more than 65 of the health system’s clinics in the state.
Additional articles: https://www.beckerspayer.com/payer/senator-promises-dramatic-medicare-advantage-investigation.html and https://www.kff.org/policy-watch/medicare-part-d-premiums-are-increasing-for-many-but-not-all-stand-alone-plans-in-2025-reflecting-effects-of-new-premium-stabilization-demonstration/ and https://www.beckershospitalreview.com/finance/intermountain-grows-medicare-advantage-network.html
#medicareadvantage #partd #pdp
Vance Backtracks On Declarations On ACA Reform
At the vice presidential debate, GOP VP candidate JD Vance seemed to back track on what he said about Donald Trump’s plan to reform the Affordable Care Act (ACA). On the campaign trail he argued that separate risk pools should be set up. Now he is talking about reinsurance for higher risk members. I do not think Vance understands what he is saying and it seems to prove that Trump does not really have a plan. It is all talk. Risk pools for high-risk individuals have a mixed to terrible record and are incredibly expensive. Reinsurance is indeed a good concept, but sadly it was Trump who underfunded that program when he was president in the Exchanges among taking other negative actions to remove dollars from insurers. I in fact support the return of reinsurance and perhaps risk corridors (the last in some areas) to further stabilize and expand the program footprint. And there are some models that expand reinsurance (as in Minnesota) that might even help those who are unsubsidized. But it certainly is not an alternative to the subsidies we have today.
See my blog today on Vance’s fanciful declaration that Trump salvaged the ACA. https://www.healthcarelabyrinth.com/the-biggest-lie-of-the-vp-debate-trump-salvaged-obamacare/ .
Additional article: https://www.nbcnews.com/health/health-news/vances-obamacare-plans-include-high-risk-pools-pre-existing-conditions-rcna173610 and https://www.statnews.com/2024/10/03/jd-vance-tim-walz-vp-debate-reinsurance-affordable-health-care/
#exchanges #aca #obamacare
Plan Expansions In The Exchanges In 2025
UnitedHealth Group, Centene, and many Big Blues are expanding in the Exchanges in 2025. It continues a trend under the Biden administration. It shows the stability of the Exchanges. Trump could undermine them given his views. See my blog today on the subject: https://www.healthcarelabyrinth.com/the-biggest-lie-of-the-vp-debate-trump-salvaged-obamacare/ .
#exchanges #aca #obamacare
Texas Sues PBMs And Drug Companies On Insulin Prices
In a lawsuit that mimics what the Federal Trade Commission (FTC) has done, the Texas Attorney General is suing major pharmacy benefit managers (PBMs) and drug companies of colluding to raise the cost of insulin. The suit alleges the brand drug makers collude with the PBMs to raise the price of insulin and then pay an undisclosed amount back to the PBMs for preferred formulary status. The Big 3 PBMs are sued. It also notes that insulin costs $2 to produce, could be purchased for $20 in the 1990s, and is now up to $700 a month.
As I said in two recent blogs, the FTC is clumsily suing the PBMs and should have built a case against brand drug makers too. It seems to me the Texas case is the better case. The FTC could learn from this.
#ftc #texas #pbms #drugpricing #rebates #branddrugmakers
https://www.fiercehealthcare.com/payers/texas-sues-pbms-manufacturers-over-insulin-conspiracy
GAO Says CMS Must Have Better Oversight Over Hospital Price Transparency
A Government Accountability Office (GAO) report said that the Centers for Medicare and Medicaid Services (CMS) could take a firmer hand on hospital price transparency and believes it is unclear whether the price data being published are even accurate. It recommends greater oversight and investigation. There is no question we need to up regulation and requirements on both health plans and hospitals when it comes to price transparency data.
#cms #pricetransparency #hospitals #healthplans
Two GLP-1s No Longer In Shortage
Federal regulators announced the shortage of the active ingredient in Mounjaro and Zepbound has been resolved. But that does not mean these GLP-1s will always be available to consumers. Check put my blog on why some pharmacies have not carried them and what you can do for access: https://www.healthcarelabyrinth.com/my-exhaustive-hunt-for-my-glp-1/
#weightlossdrugs #glp1s #drugpricing #branddrugmakers
https://thehill.com/policy/healthcare/4913155-mounjaro-zepbound-no-shortage
Another Questionable WSJ Editorial
This one did not upset me as much as the Wall Street Journal’s (WSJ) editorial on the Federal Trade Commission’s lawsuit on insulin pricing against pharmacy benefits managers, but the WSJ has come back again in defense of big business by arguing that Cigna’s Express Scripts (ESI) has some good points in suing the FTC over a report they issued on the industry. I won’t get into the merits, except to say that ESI faces an uphill battle and the FTC may not have reviewed every data point perhaps justifiably. But what has happened to the WSJ editorial board that they are so knee jerk in their positions now?
(Article may require a subscription.)
#ftc #pbms #drugpricing #antitrust #manda
— Marc S. Ryan
