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November 27, 2023

Pro Publica Article on Health Plans Not Covering Mandated Services Pro Publica article recounts where health plans have not covered mandated services in state laws.  It is easy to sensationalize mistakes, but health plans every day are approving treatments timely. (May require subscription.) #plandenials #healthplans Link to Article Will New Marketing Rules Hurt Big Plan Performance? Interesting article that says the new Medicare Advantage (MA) marketing rules could mean smaller plans now have a fighting chance against bigger ones, which seemed to enter into the variable and extraordinary compensation with agents and other entities to attract members.  A new marketing clampdown in the 2025 rule would stop most of this. Note, too, a plan official saying that there may be loopholes in the new proposed rule. (May require subscription.) #marketing #medicareadvantage Link to Article Per Worker Healthcare Costs Increased 5.2% in 2023 More evidence that inflation is increasing for employer-provided

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The Importance of Price Transparency In Healthcare Reform

While website postings of hospital and health plan negotiated prices may not seem of particular importance, the nation’s modest move toward price transparency should bear fruit over time. It is one of the more important initiatives we have seen in healthcare reform as of late. With interoperability of data, price transparency will finally give us some useful information on the inner workings (even machinations) of negotiations between health plans and providers. What are the price transparency requirements? Both health plans (effective July 1, 2022) and hospitals (effective January 1, 2021) have been required to post various pricing information on their websites. Hospitals must report all their gross and net charges in a machine-readable format as well as at least 300 shoppable services (cash and payer prices) in a consumer-friendly format. Health plans must report allowed amounts and contracted rates for hospitals and other provider services for all in-network covered services

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November 23 and 24, 2023

The Healthcare Labyrinth Newsfeed will be off on November 23 and 24 for the Thanksgiving holiday. We will be back on November 27. Happy Thanksgiving to all! Stay safe! — Marc S. Ryan

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November 22, 2023

CMS’ UM Rule for Medicare Advantage Already Being Debated The new CMS 2024 Medicare Advantage (MA) rule prohibiting the use of most evidence-based criteria by MA plans is already being debated. Hospital lobbies are saying plans are out of compliance and January 1 has not even hit yet. Read my new companion blog at the blog tab on this site. I tell you why this rule is a terrible idea. Additional article here: https://www.modernhealthcare.com/politics-policy/health-plans-2024-medicare-advantage-rule-aha-cms-unitedhealthcare #hospitals #medicareadvantage #medicare #ncd #lcd #priorauthorization Link to Article Interesting Article on Cancer Care Between MA and FFS Interesting study on cancer care differences between MA and FFS. Touches on prior authorization and networks. Something for MA plans to think about as the PA debate heats up and the new UM rule comes unto effect. #medicare #medicareadvantage #cancercare #priorauthorization #networkadequacy Link to Article FL Blue Using AI to Speed Authorizations While many plans are being criticized

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CMS’ Medicare Advantage Utilization Management Rule Sets A Terrible Precedent

I have mentioned the new 2024 Medicare Advantage (MA) Utilization Management (UM) rule in two of my blogs recently.  But here is a relatively short one to drive home the idea that the rule sets a terrible precedent. What does the rule do?  It takes external evidence-based criteria off the table in favor of the policies used in the traditional Medicare program. Unless a FFS policy is not fully established, an MA plan must rely strictly on the traditional FFS program criteria instead of outside evidence-based clinical criteria. “Fully established” is not well defined, but CMS likely will argue that the NCDs and LCDs are fully established except in some small and extreme circumstances. Let’s set my argument up with three points. First, the rule was a direct result of the aggressive lobbying by provider groups opposed to the growth of managed care in Medicare.  The Biden administration is sympathetic

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Medicare Advantage Will Have Huge Challenges Ahead

Medicare Advantage (MA) has been known as the most profitable sector of any health plan. With high premiums, a lucrative Star quality bonus, and chance to reduce medical expenses compared to the traditional fee-for-service program, plans have been able to register higher percentage and overall dollar margins in MA as compared with commercial and Medicaid. But as we have seen throughout the last few years, MA is not without its challenges and that will continue into the future. Surprisingly, at least one major player could be shopping its Medicare Advantage portfolio and getting out of the business. Here are the top challenges I see and areas MA plans need to keep an eye on. The collapse of the insurtechs Just a few years ago, the insurtechs were the darlings of investors. Investors believed that the insurtechs would leverage technology to transform healthcare, reduce costs, and drive quality. The investors also

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2024 Star Ratings Turmoil Creates Huge Vulnerability for Medicare Advantage Plans

While the Medicare Advantage (MA) Star Program has always made it difficult for plans to achieve and maintain high Star scores, the Star roller coaster ride has been much more profound over the past several years.  We now have had two years of pretty bad news, which puts a blemish on the program (fair or not). What’s more, the percentage of high-scoring contracts and the percentage of enrollment in them are now below pre-COVID years.  To refresh a bit on this, during the COVID pandemic, the Centers for Medicare and Medicaid Services (CMS) created fairly major calculation allowances for both Star 2021 (2019 and 2020 data) and 2022 (2020 and 2021 data). These allowances had the effect of boosting Star scores. We saw a surge in Star scores in 2022, including for plans that historically did not have a great track record of consistently hitting 4 Stars and above.  However,

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Major Changes in Medicare Advantage Oversight

The Centers for Medicare and Medicaid Services (CMS) have been active this year proposing major new restrictions on Medicare Advantage (MA) plans. Many of the changes are in reaction to provider lobbying efforts on Capitol Hill as well as public outcry over misleading tactics by third-party entities who enroll individuals in the popular senior and disabled plans. Let’s start out with the changes effective January 1, 2024, from the 2024 MA and Part D rule finalized earlier this year.  It is important to note that CMS issued a memo that states that it will enforce the 2024 rule beginning January 1, 2024.  Usually, such rules are enforced through the regular program audit process and it takes a number of years before regulatory changes are rolled into the audit protocols.  That seemed fair as major changes take time for plans to implement.  But in the October 24, 2023, memo issued through

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