ftc

CMS Overhauls Grievances, Requests, and Appeals Manual Again

After a major rework and massive consolidation of the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance back in 2019, the Centers for Medicare and Medicaid Services (CMS) is back at it with further updates to the all-important manual and guidance to Medicare Advantage (MA) and Part D plans. As many are aware, the manual is the bible for anything related to a grievance, Part C or D coverage request, and Part C or D appeal. Many of the changes come from updated rules as well as the further refinement of the program audit protocols. When CMS discovers something in an audit that raises confusion among plans, they often take the learnings and clarify the manuals further. Plans should be using the manual as a daily operating guide for their departments. From the manual, plans should create their policies as well as standard operating procedures. The manual

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August 2, 2024

State Affordability Boards Taking On Drug Makers Where The Feds Have Failed Frustrated by high drug prices and inadequate policy changes at the federal level (save for slow-moving Medicare drug price negotiations), states are setting up drug affordability boards that can have vast powers to reduce drug costs. This includes setting an upper limit for sales in their state for certain coverage and the uninsured. This is similar to the Medicare drug price negotiations. Due to federal pre-emption, these boards only apply to commercial plans. Medicaid has a federal rebate law that allows for federal and state rebates. Medicare is not covered as private plans negotiate prices with drug makers through pharmacy benefits managers or directly. Under the self-insured employer ERISA law, employer groups appear to be able to opt in and thus this has been built into some state laws.  So far, eleven states have approved establishing drug affordability

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August 1, 2024

Cigna Exceeds Expectations for Q2 The Cigna Group reported Q2 earnings that exceeded expectations, driven by growth in its services business. Total revenue in Q2 was $60.5 billion, up 24.6% year over year. It reported $1.5 billion in net income, up 6%. Cigna is more isolated from Medicare pressures (small line being sold) and Medicaid pressures (no line). Evernorth’s services revenue rose nearly 30% year over year to $49.5 billion. Pharmacy service revenues grew more than 41% to $26.6 billion. In great measure this was due to the migration of Centene from CVS Caremark to ESI. CEO David Cordani also committed to more aggressive defense of the value of its pharmacy benefit manager, ESI. In related news, Cigna says its GLP-1 weight-loss program has enrolled two million. Additional articles: https://www.healthcaredive.com/news/cigna-aggressive-pharmacy-benefit-manager-defense/722638/ and https://www.beckerspayer.com/payer/cigna-posts-1-5b-profit-in-q2-2.html  and https://www.fiercehealthcare.com/payers/evernorth-drives-double-digit-revenue-growth-cigna-q2 and https://www.beckerspayer.com/payer/cignas-glp-1-program-enrolls-2-million.html (Some articles may require a subscription.) #healthplans #cigna https://www.modernhealthcare.com/insurance/cigna-earnings-call-evernorth-health-services-revenue-growth-medicare-medicaid Alignment Reports Positive Results Alignment

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Special Needs Plans Growing As Is CMS’ Regulatory Approach

Note: See my blog for 7/31/2024 to learn more about how dual eligibles receive their care in the Medicare and Medicaid programs. This would be a good primer before you read this blog on Special Needs Plans (SNPs). In January of 2022, Medicare Advantage (MA) Special Needs Plan (SNP) enrollment was just short of 5 million. In July, SNP enrollment (including Medicare-Medicaid Plans (MMP) has grown to 7.15 million, nearly a 44% growth in just 2.5 years. This is about 21% of MA enrollment. The vast majority of the enrollment in SNPs is in the Dual Eligible type (D-SNPs or MMPs), which is about 87% of total SNP enrollment. In both cases, integration of benefits and care between the Medicare and Medicaid programs is the goal. As growth in SNPs occurs, the Centers for Medicare and Medicaid Services (CMS) is upping its audit oversight as well as its strategy toward

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July 31, 2024

Humana Meets Expectations in Q2 But With Some Mixed News Medicare Advantage (MA)-dominant Humana released its Q2 2024 results. It had $679 million in profit for the second quarter, down from $959 million a year ago. It had $29.5 billion in revenue for the quarter, compared to $26.7 billion in the second quarter of 2023. It affirmed its already conservative guidance. It revealed that MA rates have complicated its financial performance and that it would shutter some plans in geographies and has reduced benefits in others. It expects to lose about 5% of its projected 2024 enrollment next year, or about a few hundred thousand. It will increase its enrollment this year by about 225,000. Only Humana and CVS Aetna performed well on the enrollment front recently. Its medical loss ratio (MLR) was 89.5% in the quarter, compared to 86.8% in the second quarter of 2023. Humana blames the increased

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How Do Dual Eligibles Receive Care?

On August 1, 2024, I will have a blog on what is happening with Special Needs Plans (SNPs) and Medicare-Medicaid integration policy. Coincidentally, the Kaiser Family Foundation (KFF) issued a comprehensive analysis on the status of dual eligible healthcare. As such I decided to publish this short bonus blog today as a good primer for some of the issues we will be talking about in the SNP blog tomorrow. The KFF analysis of dual eligible care in Medicare and Medicaid is quite exhaustive. For those not as familiar with KFF, it is the premier healthcare policy think tank in America. I strongly recommend you review the whole briefer. I have posted the briefer link at the end of this blog. I also posted below what I think is one of the most relevant graphics in the briefer as well. I also posted a separate 2023 KFF briefer on characteristics of

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July 30, 2024

Biden Administration Will Accelerate 2026 MA and Part D Rule Before Leaving Office Interesting article in Modern Healthcare on plans of the Biden administration to accelerate the Medicare Advantage (MA) and Part D rule for 2026. The draft will be published in September, with the final rule sometime before President Biden leaves office. This could mean huge new policy changes for MA and Part D. Trump did something similar. On one hand, Biden may want to leave office proposing some major reforms. On the other hand, the striking of the Chevron deference precedent could complicate enacting major changes. The possible list of changes I see — they can’t do all of them, could they?: Separately, will he do more on antitrust and horizontal and vertical integration? (Article may require a subscription.) #election2024 #biden #healthcare #regulations #medicareadvantage #partd https://www.modernhealthcare.com/policy/health-rules-2024-medicare-pay-prior-authorization Bipartisan Momentum For Site-Neutral Policies The Health and Human Services secretaries of

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July 29, 2024

CMS Releases Part D Data For 2025; Sets Up Premium Stabilization Program The Centers for Medicare & Medicaid Services (CMS) released preliminary technical Medicare Part D bid information for Contract Year 2025. The Part D base beneficiary premium is capped at 6% growth in 2025 due to a stabilization fund set up in the Inflation Reduction Act (IRA). This was because of all the transfers of costs to plans from the government and caps on out-of-pocket (OOP) costs. The anticipated enrollment weighted-average premiums were not released in part because CMS has proposed to create an additional voluntary premium stabilization demonstration program for standalone Part D (PDP) plans. Many critics of the IRA reforms have suggested that premiums in 2025 could go up 50% to 100% (or more) due to the transfer of liabilities. The stabilization subsidy in the IRA only caps the base premium. Plans enhance benefits and will either have to cut enhancements,

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2023 Medicare Advantage and Part D Program Audit Enforcement Report Out. What Does It Tell Us?

Each year, the Centers for Medicare and Medicaid Services (CMS) issues its Part C and Part D Program Audit and Enforcement Report. I liked how CMS did it in years past, where actual plan audit scores as well as average scores by audit area were released. It gave you a great feel for where plans were struggling the most. Nonetheless, the report continues to be a good tool for Medicare Advantage (MA) and Part D plans (MA-PD or standalone PDP) to review and hone their compliance chops. Here are the major findings from this most recent report (link at bottom). As well, I will go through what I heard about 2024 audits from plan friends and contacts. Background CMS has been expanding the audits it does, using both internal and external expertise.  In 2023, a total of 69 MA-PD contracts were audited — 31 of these contracts offered special needs plans (SNPs). CMS also

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July 26, 2024

What If Exchange Premium Subsidy Enhancements Lapse? A new Kaiser Family Foundation (KFF) analysis determines the potential effects of the lapsing of the enhanced premium subsidies in the Exchanges after 2025. KFF concludes that enhanced subsidies have cut premium payments by an estimated 44%. It says if the enhancements lapse, individuals in twelve of the states that use HealthCare.gov would see their annual premium payments at least double on average. Enrollees with low incomes would see the greatest jump in their premium payments, but all income groups would be hurt (including middle-income earners).  The Congressional Budget Office (CBO) said that Exchange enrollment would drop from an estimated 22.8 million in 2025 to 18.9 million the following year if the subsidies lapse. It would drop to 15.4 million in 2030. This would send our uninsured rate up. I expect it to continue to increase now due to the Medicaid redeterminations and losses

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