ftc Archives - Page 17 of 41 - The Healthcare Labyrinth

Special Needs Plans Growing As Is CMS’ Regulatory Approach

August 1, 2024 No Comments

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

July 31, 2024

July 31, 2024 No Comments

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

How Do Dual Eligibles Receive Care?

July 31, 2024 No Comments

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

July 30, 2024

July 30, 2024 No Comments

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

July 29, 2024

July 29, 2024 No Comments

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,

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

July 29, 2024 No Comments

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

July 26, 2024

July 26, 2024 No Comments

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

July 25, 2024

July 25, 2024 No Comments

Paragon Proposes Medicaid Reforms The conservative think tank Paragon Institute proposes to phase out the current 90 percent federal matching rate for the Affordable Care Act’s (ACA) Medicaid expansion and begin applying the regular federal match after eight years. It would also reduce the 50% Medicaid reimbursement floor to 40% for the richest states, also phased in over eight years. It says spending would be reduced by $600 billion from 2026 to 2034. Trump is known to pay attention to Paragon. While radical and it threatens to reduce coverage nationally, the proposal is less disruptive than the fundamental remake of the ACA and Medicaid attempted by Republicans during Trump’s first term. #aca #medicaid #coverage #reimbursement https://finance.yahoo.com/news/paragon-proposes-bold-medicaid-funding-100000986.html?guccounter=1&guce_referrer=aHR0cHM6Ly93d3cuZ29vZ2xlLmNvbS8&guce_referrer_sig=AQAAAJzUe6HiQKz3okVpdso7A0yLeZAIPW1Ub2ostzrg7ZONyQ8z1KWrDGM859gWDHSx-g-178HChmqc40o8i1lMq0Z0f8O1tXErWp6qrflxRiOQ5GwC6iEyxQ2Yhd9fdz-o9EckMhY6Yljg3gA_7GDG6JdxppPhxUpCV_1324WzFyBd CMS May Take A Tougher Oversight Stance On Medicaid Enrollment The Centers for Medicare and Medicaid Services (CMS) says it will adopt greater oversight of the Medicaid enrollment process in states given the major problems

Part D Premium Woes Due To The Inflation Reduction Act

July 25, 2024 No Comments

Major concerns are emerging that standalone Part D (PDP) plans are seeing skyrocketing premiums due to the unintended consequences of major Part D restructuring and out-of-pocket (OOP) cost reduction passed as part of the Inflation Reduction Act (IRA). A new report by the Council for Affordable Health Coverage (CAHC) asks Congress to intervene on what will be growing impacts in 2025 after premium rises in 2024. The increased costs in Part D are tied to a number of changes in the IRA. I went in-depth on all the Part D changes included in the IRA in an earlier blog on April 15, 2024: https://www.healthcarelabyrinth.com/major-changes-occurring-in-medicare-part-d/ . New costs to plans in Part D due to IRA Here is a brief summary of additional costs in the IRA now borne or will be borne in whole or part by plans since the IRA passed: 2023: 2024: 2025: In addition, PBMs are now

July 24, 2024

July 24, 2024 No Comments

Medicare Advantage Inpatient Days Rising Hospitals cry foul at every pass over Medicare Advantage (MA) plans’ efforts to control inpatient hospital utilization. But a new analysis from the Kaiser Family Foundation (KFF) shows that inpatient days attributable to MA have increased considerably over time. Medicare Advantage’s share of inpatient days grew from 13% to 23% from 2015 to 2022. As of 2022, nearly half (48%) of all Medicare inpatient hospital days were attributable to MA. The MA penetration in that year averaged just short of 46%. There are numerous other great statistics in the analysis. This year, MA plans are required to follow traditional program standards for deciding whether a stay is required and thus the share will increase more. #medicareadvantage #hospitals #priorauthorization https://www.kff.org/medicare/issue-brief/medicare-advantage-enrollees-account-for-a-rising-share-of-inpatient-hospital-days/ 2020 Exchange Risk Adjustment Payment Data Published The Centers for Medicare and Medicaid Services (CMS) published the annual risk adjustment reconciliation data today. Risk adjustment is

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