Paragon Institute Sees Fraud In Enhanced Premium Subsidies
As Democrats are calling for the extension or permanent adoption of enhanced premium subsidies in the Exchange, the conservative Paragon Institute is arguing that the enhanced premium subsidies are creating fraud as enrollees and/or brokers misrepresent income to get better subsidies.
They say this is occurring very much in the 100% to 150% of the federal poverty level (FPL) income group, where free premiums are offered under the enhancement. Paragon says the original subsidies should be put back in place to lessen fraud. In addition, Paragon says small business coverage has eroded since the enhanced subsidies have been in effect.
There is fraud going on in the program, with brokers illegally signing people up or changing their plans. But Paragon is now raising a different issue of fraud – the true misrepresentation of income.
Paragon also raised a possible compromise. While it wants to return to the less-generous law as its preferred option, the Paragon president did suggest that existing enrollees could be grandfathered into the higher subsidies.
I favor some extension of the enhanced premium subsidies. While I do think they have become far too generous at the lower end of the income scale, no one can debate the benefit of the surge in coverage due to the enhancements. Upfront coverage is good. At the same time, no one wants fraud in the program. Perhaps a short-term grandfather may be a good compromise here so that all the issues can be sorted out and we ensure an accountable system.
(Article may require a subscription.)
#aca #obamacare #exchanges
CVS’ Oak Street Settles Kickback Allegations
CVS’ Oak Street Health will pay a $60 million settlement to resolve kickback allegations made by the Justice Department (DOJ). The DOJ said that Oak Street paid insurance agents kickbacks in exchange for encouraging seniors to sign up for its services.
Additional articles: https://www.fiercehealthcare.com/practices/cvs-oak-street-pay-60m-settle-kickback-allegations and https://www.modernhealthcare.com/legal/cvs-oak-street-health-settlement-kickback-allegations-doj
(Some articles may require a subscription.)
#cvshealth #primarycare #fwa
https://www.healthcaredive.com/news/oak-street-kickback-scheme-settlement-doj-cvs/727469
Cigna Says It Will Cut MA Offerings
Cigna is exiting Medicare Advantage (MA) markets or making service area reductions in eight states for 2025. In total, 36 plans and about 5,400 members are impacted. Cigna joins Aetna, Humana, and Centene in making reductions. Other big plans will make changes too. Cigna is selling its MA line to mutual Big Blue Health Care Service Corporation (HCSC).
Additional article: https://www.beckerspayer.com/payer/cigna-to-trim-medicare-advantage-offerings-in-8-states.html
(Some articles may require a subscription.)
#medicareadvantage #coverage #cigna #hcsc
https://www.modernhealthcare.com/insurance/cigna-medicare-advantage-plans-2025
Humana To Further Automate Prior Authorization
Humana President and CEO Jim Rechtin says the company will undertake additional efforts to automate prior authorization approvals. He says Humana approves about 90% of prior authorization requests and that nearly 70% of requests are approved automatically. Other big plans have made a similar announcement. At the same time, the Centers for Medicare and Medicaid Services (CMS) has massively restricted prior authorization rule effective 1/1/2024.
(Article may require a subscription.)
#medicareadvatage #humana #priorauthorization
https://www.modernhealthcare.com/policy/prior-authorization-automation-humana-jim-rechtin
Senate HELP Holds Steward CEO In Contempt
Fearful that his statements before a committee could be used against him, Ralph de la Torre, the CEO of bankrupt Steward Health Care, has refused to appear before the Senate HELP Committee to address what happened to the hospital chain and what role private equity played in it. As such, the Senate HELP Committee unanimously voted to hold him in contempt, which opens him up to civil and criminal penalties. This likely is the least of the CEO’s worries right now, but the American public deserves to understand what happened.
#hospitals #privateequityfirms #healthcare #providers
NAIC Frustrated With Lack Of CMS Insight On Hospital Terminations in MA
State insurance regulators are frustrated that the Centers for Medicare and Medicaid Services (CMS) has been less than forthcoming about hospitals that have exited Medicare Advantage (MA) plans in their state and how states are unable to help protect enrollees. While there is a Special Enrollment Period (SEP) exception for significant provider changes, the NAIC, the insurance commissioners’ organization, may call for a blanket SEP for a hospital termination.
(Article may require a subscription.)
#medicareadvantage #hospitals #coverage
GOP Backs Off Of CR Demands
The Freedom Caucus-driven House GOP leadership has had monumental fails of late. The conservative caucus members demand ridiculous things on spending bills and gum up the legislative works. And so it was again. House Speaker Mike Johnson and the conservative caucus wanted a six-month continuing resolution (CR) to allow the next president to set spending priorities. They also wanted voting changes in the bill.
But there was not enough support in the House to pass it. Weeks, however, have been lost and September 30 is fast approaching and a government shutdown looms. The GOP leadership will now accept a 90-day funding plan. It all comes down to the fact that the caucus is unable to lead. If the GOP leaders were serious about governing, they would have passed all the spending bills on time.
#governmentshutdown #crs #election2024
https://thehill.com/homenews/house/4889602-republicans-plan-b-shutdown-government-funding
— Marc S. Ryan
