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Part D changes will raise premiums and destabilize the program I have been all over this even before it was fashionable. After reading up on some analyses of the Part D cost-sharing changes in the Inflation Reduction Act (IRA), I declared that seniors and those with disabilities would see an October surprise in the form of increased costs going into the election as they chose 2025 Medicare Advantage (MA) or Part D benefits. The Centers for Medicare and Medicaid Services (CMS) initially scoffed at my and others’ predictions, arguing the IRA anticipated this with a premium stabilization program. The problem: it applied just to the base benefit. We know that seniors have come to rely on enhanced Part D drug benefits from MA and standalone Part D (PDP) plans. And since the out-of-pocket (OOP) changes raised plan costs for both the base and enhanced benefits, recipients would have seen major

While cuts will occur, things could be looking a bit better for Medicaid and the Exchanges In a series of blogs just before and after Donald Trump retook office, I speculated that, while there would be spending reductions impacting healthcare, I did not foresee a massive revamp in healthcare programs, specifically for the Affordable Care Act (ACA) and Medicaid. Now that we are about two weeks into the new administration and a fully GOP-controlled Congress, I felt it might be good to update readers on this all-important issue. As you know, I am a pro-coverage Republican. I think reasonably robust coverage is important for the health of our nation and to reduce costs in the future. So, based on some happenings in the past month or so, here are some of the reasons to think healthcare may not be impacted as much as one would think as the budget reconciliation

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

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

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