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January 31, 2025

Second Judge Enjoins Trump Spending Freeze Indefinitely President Trump’s spending freeze now has been indefinitely reversed by a second federal judge. The order was handed down late Friday. In the first case, a judge is to determine next week if a temporary injunction in the pause will be extended. Despite the rescinding of the Office of Management Budget (OMB) freezing certain spending, Democrats’ cases continued as Trump indicated the freeze is still on to ensure consistency with his executive orders that have been issued. As I have noted, this is a clear misstep by the new administration. The cases will likely weigh in on the issue of whether the executive branch is obligated to execute spending directed by the legislature and signed into law. #trump #congress #spending https://www.fiercehealthcare.com/regulatory/trump-admin-orders-temporary-pause-most-federal-financial-assistance Trump May Challenge 1115 Waivers Issued Just Before Transition The Trump administration is looking at whether it can revoke approval of 1115

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January 30, 2025

More Embarrassing Statements By Robert Kennedy At Second Hearing After a tough day yesterday, Health and Human Services (HHS) Secretary nominee Robert F. Kennedy, Jr. continued his lackluster performance in front of a Senate committee by again confusing key details in Medicaid and Medicare. It seems the man proposed to be the next health and human services chief of the United States does not quite know the four parts of Medicare, a program that has hit over $1 trillion annually. Unfortunately, the two days of grilling shows he really has no business becoming the future secretary. His nomination is hurt by his lack of healthcare policy knowledge as well as controversial positions. Democrats pounded him on these for a second day. He has yet failed to convince three key Republicans to support him – Bill Cassidy, Lisa Murkowski, and Susan Collins. Mitch McConnell might also oppose him. Three GOP no

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2027 Drug Negotiations Off And Running

What will Trump do on Medicare drug price negotiations? In a parting shot at the incoming Trump administration, outgoing President Biden’s administration issued the next list of 15 drugs subject to negotiations in Medicare prior to Biden’s White House exit. The list was due by February 1, so the early release is a challenge to the Trump administration not to repeal the negotiation law included in the Inflation Reduction Act (IRA). The prices on the 15 drugs would go into effect on January 1, 2027 after a process in 2025. In 2024, prices for the first 10 drugs were set and take effect on January 1, 2026. The Centers for Medicare and Medicaid Services (CMS) says that between November 2023 and October 2024 about 5.3 million people with Medicare Part D coverage used these drugs to treat a variety of conditions, such as cancer, type 2 diabetes, and asthma. The

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January 29, 2025

Kennedy Has Subpar Performance Before Committee While Health and Human Services (HHS) nominee Robert F. Kennedy, Jr., did not mortally wound himself before the Senate Finance Committee today at a confirmation hearing, he certainly did himself no favors, either. Kennedy was unable to articulate views on healthcare policy and reform or speak articulately on the Medicare and Medicaid programs. In fact, he confused the two programs at points and perhaps thought Medicaid looked more like the state children’s healthcare or Exchange programs. He even stated that Medicare Advantage (MA) is more expensive than the traditional one. The American public often confuses various healthcare programs, but you do not expect that from the future HHS leader. Just troubling. The hearing likely means he gets no Democratic votes. What is more worrisome for the Trump team is that some Republicans are now worried about Kennedy’s capabilities. Betting odds are that Kennedy still

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January 28, 2025

Trump Spending Freeze Order Creates Chaos A federal judge has stayed a decision by President Trump’s Office of Management and Budget (OMB) to essentially freeze billions in federal grants and disbursements. It capped a whirlwind day of confusion and vitriol. Democrats cried that the executive branch was usurping congressional authority and the lawmakers and a coalition of non-profit groups won the stay until early next week. The administration argued it had the duty to look at outlays after years of runaway spending. Objectively, what happened appeared to be the first major misstep of the administration. Whatever one’s views on the action, it was clearly not well telegraphed or rolled out. The White House had to refine what was indeed stalled at several points today, finally landing on the fact that direct aid to individuals, such as welfare, Medicaid, and Medicare, was not being impacted. But other healthcare grants that do

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January 27, 2025

KFF Finds Major Claims Denials In Exchanges The Kaiser Family Foundation (KFF) finds in a new study that health insurers selling Marketplace plans in states that use the federal Exchange rejected 19% of in-network claims on average in 2023. That is up from 16% in 2022. The rate has been steady over time, ranging from a 14% low in 2018 to a 19% high in 2015 and 2023. Insurers denied 37% of out-of-network claims in 2023. There is a huge range in denial rates among plans, from 1% to 54%. For high volume insurers, the range was 13% to 35%. “Other reasons” represented the largest category of denials (34%), with 16% tagged as excluded services, 9% as lack of prior authorization or referral, and 6% as lack of medical necessity. Other common reasons for denials included administrative issues (18%) and exceeding benefit limits (12%). While I think health plans do

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Lawsuits Against CMS On Stars Show The System Is Breaking

An otherwise responsible agency has an alarming arrogance in its Star oversight and processes For the past two years we have seen major lawsuits against the Centers for Medicare and Medicaid Services (CMS) on how they conduct the Stars program in Medicare Advantage (MA). The Stars program is not only important for grading the quality of outcomes in private managed care, but also is the lifeblood of supplemental benefits and other enhancements to fill in the holes in traditional Medicare fee-for-service (FFS). Without a well-functioning equitable, and reliable Star quality bonus system, we cannot really gauge quality or ensure consistent benefit additions in the MA program. Brief history of 2024 Star lawsuits Lawsuits against CMS on the 2024 Star ratings largely revolved around the implementation of the Tukey outlier adjustment implemented for that year’s ratings. The methodology removes so-called outlier performance at both the top and bottom of performers. Outliers

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January 24, 2025

Change Healthcare Updates Number Of Those Impacted By Cyberattack The Change Healthcare cyberattack brought much of healthcare to a halt in 2024 for many months. UnitedHealth Group, Change’s parent, earlier said that 100 million people were impacted. It now has updated that number to 190 million or about 57% of the nation’s population. The cyberattack posed a significant financial cost to UnitedHealth Group, with the company projecting that it would take a $2.9 billion hit. More important, it had huge costs for providers, health plans, pharmacies, and other healthcare entities. All of these entities relied on Change’s vast service and processing systems. The attackers used stolen credentials and breached a server that did not have two-factor authentication – a rookie mistake in security. The attackers were paid a ransom yet still took information from the servers. United says it is not aware of a misuse of data, but that is

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January 23, 2025

Elevance Health Reports Q4 and 2024 Financial News After some rocky news from UnitedHealth Group earlier, Elevance Health reported some mixed financial news as well. Elevance said it would grow 7% to 9% in Medicare Advantage (MA). The company did say it is attacking growth prudently given rate concerns and utilization trends. Elevance also says that while MA rates are moving in the right direction, rates for 2026 will be inadequate based on the Advance Notice recently released. But like United, year-over-year margins decreased even though Elevance beat Wall Street. Its services unit, Carelon, showed robust revenue growth. On Medicaid, Elevance said Medicaid rate pressures could ease in 2H 2025 and that it is encouraged by some rate hikes it is seeing from states. As has been seen with other insurers, Elevance’s all lines of business medical loss ratio (MLR) rose considerably to 92.4% in the fourth quarter, up from

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The Latest Edition Of The Stars Roadmap

Published in partnership with Lilac Software: https://lilacsoftware.com Figuring out exactly what will happen in the Star measure program over time is no small feat. The Centers for Medicare and Medicaid Services (CMS) certainly does not make it easy to create a Stars roadmap so you are ready for a new measure maturing to Stars.  CMS will use a variety of means to telegraph what might occur. These include annual Medicare Advantage (MA) and Part D rules, the so-called Advanced and Final Notices/Announcement annually, and other CMS communications. Even then, pulling it all together is tough. Things can change from proposed rules to finalized rules. CMS may give direction on a change in one year only to backtrack the next. You can never be 100% sure until the Advance Notice is finalized for the coming year. This usually drops in April of a given year. Sometimes, as they did with Star

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