redeterminations

It was a little over two years ago that the brand drug makers and PhRMA, the drug lobby, were crying apocalypse – that drug innovation and the industry itself would be in tatters if the Inflation Reduction Act (IRA) passed and Medicare drug price negotiations were ushered in. Well, as is the case with almost every “Chicken Little” declaration, their world and ours did not come to an end and the public just might see some – I emphasize some — relief from high drug prices. This past week, the Centers for Medicare and Medicaid Services (CMS) announced that drug prices have been set for the first ten drugs covered by the IRA for January 1, 2026. Five of the drugs’ prices were set by mutual negotiation between the drug makers and CMS. In fact, CMS accepted the counterproposals on four of them. The remaining half were set by CMS

There was a great deal of health plan news the past month, so I decided to do an insurer news roundup blog. Of course, you can find all the details on these topics in my newsfeeds, blogs, and podcasts on this website. Here goes: Q2 2024 investor calls Q2 was a mixed bag for the publicly traded insurers. While some reported great news and others mixed, the message from many of the biggest plans was that Medicare Advantage (MA) and Medicaid rates have led to some financial uncertainty. The insurtechs – Alignment Healthcare, Clover Health, and Oscar Health – reported overall good news, showing they seem to be gaining traction against the big guys. Cigna, Elevance Health, and United reported good news, largely as they are more isolated from government program uncertainty. CVS Health, Humana, and Centene reported more mixed news and seem most impacted by government program issues. United

New Humana CEO Jim Rechtin made some waves recently when he made a compelling case on his Q2 2024 investor call that Medicare Advantage (MA) needs to transform and be more accountable to the government and the Americans it serves. Several other prominent MA executives, including Andrew Toy of Clover Health, John Kao of Alignment Healthcare, and Sachin Jain of Scan Health Group, also have signaled views that are similar. Rechtin made the case that greater collaboration with the Centers for Medicare and Medicaid Services (CMS) is needed and that the industry must better show its value and have some of it accrue back to CMS, Medicare, and Medicaid. Read closely, Rechtin is saying that MA has to be willing to allow Medicare to realize more of the savings. I think Rechtin is right. Let’s break the issue down a bit. Today, MA plans are in a cat-and-mouse game with

Many are asking whether insurers, and specifically Medicare Advantage (MA), would do better under a Kamala Harris or Donald Trump administration. Well, the answer is not so easy. There are pros and cons for each. Further, some of this could be determined by the makeup of Congress as well. But here is my quick take on the issue. I am sure we will be covering more of this as Election 2024 rolls on. The pros and cons are strictly from the standpoint of a health plan. Trump Pros Trump Cons Harris Pros Harris Cons Areas They May See Eye To Eye #election2024 #harris #trump #healthcare #coverage #medicare #medicareadvantage #medicaid #managedcare #exchanges #obamacare #aca — Marc S. Ryan

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

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

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