quality

Major Medicaid Managed Care Changes Follow Medicare Ones

Following major changes in Medicare Advantage (MA) and Part D, the Centers for Medicare and Medicaid Services (CMS) finalized a number of rules impacting Medicaid, but specificially managed care. With the vast majoirty of Medicaid beneficiaries in managed care, CMS is targeting numerous prorgams to the managed care programs in states.  What are the major changes impacting Medicaid managed care? Waiting times/access Rates, spending, and transparency Quality and satisfaction Nursing homes The Biden administration finalized numerous changes impacting nursing homes, including minimum staffing requirements and directing that 80% of all payments from Medicaid (over a six-year period and with some flexibility) go to wages for aides and nurses.  The problem with the rule is that rates just are not sufficient enough to meet these requirements and proposals Biden has made. Proposals to increase dollars have not yet passed.  The fear is that the moves in each case could force many

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Strong Growth Closes Out Major Enrollment Seasons In Medicare Advantage

I have posted several blogs now on the exciting news that Medicare Advantage (MA) growth has been very robust not only in the traditional enrollment period from October 15 to December 2023, but also in the supplemental period from January 1 to March 31, 2024. While growth will continue throughout the year (due to aging primarily), we should see a slowing. So, this will conclude my enrollment blogs for the year unless we see some strange developments. So what have we seen.  As I have reported, growth from January 2023 to January 2024 was a robust 8.7% increase or 2.674 million.  Enrollment in MA reached 30.799 million in January.  Since that time, enrollment has continued to climb: The growth from January 1 to April 1 represents an additional 1.2% increase or 413,000 lives. MA enrollment has now increased beyond 51% of all Medicare beneficiaries. As we saw with January 2023

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Major Changes Occurring in Medicare Part D

As a result of the Inflation Reduction Act (IRA), major changes are occurring in the Medicare Part D retail drug program.  Here is my best effort to explain the changes.  Phases of the program  It is first important to understand the four phases of the program.  Figures change from year to year with inflation so I am outlining the 2024 phases here. Deductible Phase: Here, the Part D member is required to cover all costs of his or her drugs up to the deductible amount.  In 2024, the deductible amount is set at $545.  But remember that both standalone Part D plans (PDPs, who enroll beneficiaries in Medicare Advantage (MA) Part C Only plans or traditional Medicare fee-for-service (FFS)) and MA-Part D plans can lower the deductible in their benefit design.  Some even eliminate it for some or all drugs. Initial Coverage Phase:  Here, costs are split between the plan

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Out-Of-Network Provider Billing Is Yet Another Provider Attack Issue Against Plans

The health plan industry has been in turmoil since an April 7, 2024 New York Times article appeared attacking prominent insurers and a data technology vendor, MultiPlan, for seemingly transferring huge out-of-network bills to commercial product patients.  Insurers are already battling major headwinds related to two other issues: So, is the MultiPlan issue yet another front on which health plans may have to fight? The public relations on the article alone has raised lawmakers’ eyebrows. The American Hospital Association has asked the federal Department of Labor to investigate both MultiPlan and large insurers to determine whether they engage in business practices that disadvantage patients and providers under the self-insured ERISA law and regulations. So what does MultiPlan do on behalf of health plans While the data and technology firm has networks and negotiation services, more and more MultiPlan is hired by insurers to scrutinize claims coming in from out-of-network providers

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Finalization of 2025 Policies: Major Changes Coming To Medicare Advantage and Part D

Just recently, the Centers for Medicare and Medicaid Services (CMS) finalized two important notices and rules impacting CY 2025: the 2025 annual rate-setting and policy notice as well as the draft 2025 Medicare Advantage and Part D rule. In this blog, I will write about both the 2025 final rule as well as the policy changes in the 2025 final notice. In my blog on April 4, 2024, I discussed the rate-setting components of the annual rate-setting and policy notice.  That blog is here: https://www.healthcarelabyrinth.com/final-2025-rates-for-medicare-advantage-remain-as-proposed/ . In addition, my February 1, 2024 blog on the draft notice is here and has more details: https://www.healthcarelabyrinth.com/2025-rates-for-medicare-advantage-plans-look-tight/ . They should be read together due to a few changes. In addition to the below, you can see my November 13, 2023 blog on the 2025 Medicare Advantage and Part D rule when it was first announced.  This has additional details but also should be

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Final 2025 Rates For Medicare Advantage Remain As Proposed

In my February 1, 2024 blog, I walked you through the Advance Notice from the Centers for Medicare and Medicaid Services (CMS) regarding proposed Medicare Advantage (MA) rates for calendar year 2025.  Many health plans and industry-friendly trade groups lobbied CMS hard for a change in the proposal. Even lawmakers got into the game. But the final notice came out this week and almost nothing changed on the rate front.  On February 1, I told you that MA plans were very worried about the proposed 2025 rate because of a series of negative trends that were hitting them: So let’s take a look at what happened between the Advance Notice and the Final Notice of 2025 MA rates. 2024 and 2025 Medicare Advantage Rate Comparisons   2024 Final 2025 Proposed 2025 Final Effective Growth Rate 2.28% 2.44% 2.33% Changes in Star Revenue (Overall) -1.24% -0.15% -0.11% Rebasing 0.00% TBD 0.07%

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What’s All The Clamor Over GLP-1s For Weight Loss?

Hollywood supposedly is addicted to them. More and more Americans are now trying GLP-1s for weight loss. What is happening here with GLP-1s is something repeated often in the drug world. First, what is a GLP-1? The drugs were introduced in the U.S. beginning in the mid-2000s and have been used for those with type 2 diabetes who were overweight. These are a class of drugs that perform much like a hormone called glucagon-like peptide 1. As blood sugars rise in the blood stream, the drugs stimulate the production of more insulin, which lowers blood sugar levels. This is essential for controlling type 2 diabetes. It’s not clear how the GLP-1 drugs lead to weight loss overall, although the drugs do appear to slow the movement of food through the digestive tract and make you feel fuller. How did it become popular for weight loss? Now let’s get into off-label use of

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Surprise! Surprise! No Surprises Act Favors Providers And Is Driving Up Costs

Since the No Surprises Act (NSA) was passed in late 2020, I have argued that the baseball-style arbitration process is heavily stacked against health plans and favors providers.  The law went into effect on January 1, 2022, with some portions still forestalled by the federal government.  But the main components  that stop surprise billing to patients and the process to settle what is paid by plans to providers has been in force now for about 2 years.  The implementation of the arbitration has been rocky.  The number of cases is demonstrably above what was expected.  That said, more and more data is now available that shows how well providers are doing from the process. In commercial coverage, the main component of the law disallows providers from billing patients for out-of-network services beyond plan outlined in-network cost-sharing for emergency situations, post-emergency stabilization, and non-emergency in-network facility-based procedures where non-network services may

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The Audacity of Mark Cuban

Mark Cuban is known as a bold entrepreneur — a smart-thinking guy who cuts through all the nonsense to come up with the right solution. But how audacious was he at a recent White House forum when he suggested that federal and state programs as well as employers essentially cut the top three pharmacy benefits managers (PBMs) out of the pharmacy spending equation altogether in favor of a transparent model? However difficult in the short term, I believe the provocative Cuban has the right answer and wants to aggressively go after it. The entrepreneur is a recent entrant into the world of healthcare. His Cost Plus Drug Company (CPD or Cost Plus) is taking the nation by storm by showing how going direct to the manufacturer — and then to the consumer — can make money and lower costs. He would argue it is not a new model in free

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March 21, 2024

Medicare To Cover GLP-1s For Specific Conditions Medicare Part D will cover obesity drugs if they are approved for specific medical conditions. For example, Novo Nordisk’s Wegovy, just received approval from the Food and Drug Administration (FDA) to reduce risk of stroke or heart attack in people with cardiovascular disease and who are obese/overweight. The same rule will apply to Medicaid. The decision does not make these weight-loss drugs available more broadly. Additional article on trials showing GLP-1s slowing kidney disease progress and cardiovascular events: https://www.managedhealthcareexecutive.com/view/ozempic-reduces-kidney-disease-progression-cardiovascular-events-by-24- Additional articles: https://www.fiercehealthcare.com/payers/wsj-cms-broadens-part-d-coverage-obesity-drugs and https://www.medpagetoday.com/publichealthpolicy/medicare/109305 #weightlossdrugs #medicare #medicaid Link to Article GOP Senators Want HHS To Explain Delay In Responding To Cyberattack Senate HELP Committee Ranking Member Bill Cassidy, R-LA, and member Tommy Tuberville, R-AL, have asked why it took the Department of Health and Humans Services (HHS) almost two weeks to respond to the Change Healthcare cyberattack. Check out my blog here on

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