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CMS May Further Rein In Prior Authorization Bloomberg reports that the Centers for Medicare and Medicaid Services (CMS) is exploring proposals to further rein in prior authorization (PA) and other utilization management. The exploration is likely on Medicare Advantage (MA). In 2024, CMS introduced sweeping PA restrictions, requiring MA plans largely to follow the traditional program requirements for benefit coverage. When CMS Administrator Dr. Mehmet Oz appeared before the Senate for his confirmation hearings, he bemoaned PA in MA and stated that he wanted to reform it. He specifically mentioned that he wanted to streamline the number of PAs allowed and ensure consistency across plans. Indeed, Bloomberg reports that the aim of the CMS exploration would be to cut the number of medical procedures subject to PA and drive uniformity across plans. Another recent rule also requires electronic PA and CMS is looking at further driving this.   Health plans

Drug Tariffs’ Impact A new study from Fitch says that health plans will not see immediate impact from tariffs on drugs. Providers will bear the brunt upfront and pay higher costs in operations. But over time, providers will pass through the costs to insurers through increased rates. In other news, a dozen states with Democratic attorneys general have filed suit over President Donald Trump’s use of the International Economic Emergency Powers Act (IEEPA) to enact new tariffs. The states argue they have a role due to the fact the tariffs could significantly increase costs for hospitals, manufacturers, and other stakeholders. Additional article: https://insidehealthpolicy.com/daily-news/citing-health-costs-democratic-states-sue-trump-over-tariffs (Some articles may require a subscription.) #tariffs #drugpricing #healthplans #providers https://www.fiercehealthcare.com/payers/fitch-ratings-how-higher-tariffs-could-impact-health-insurers Vendors Strike Deal With GLP-1 Drug Companies More and more weight-loss vendors are striking deals with GLP-1 drug makers, signaling the ability for compounders to create copycats is over now that shortages have been addressed. Hims

Centene Reports Decent Financial News With Some Uncertainty Centene reported relatively sound financial news, but did raise policy issues that could impact the company over time. The uncertainty ties to what will happen in Congress in the next year on Medicaid and the Exchanges. Centene says it believes sweeping Medicaid cuts will not occur and are still pushing hard for extending the premium enhancements in the Exchanges, focusing on swing states and general support for government programs. They do admit some changes, such as work requirements, could occur. The medical loss ratio (MLR) was 87.5%, about the same as the prior year’s same quarter. But expenses could rise. Centene posted $1.3 billion in net income in the first quarter. Total revenues in the first quarter were $46.6 billion, up 15.4% year over year. The company reaffirmed its year-end adjusted guidance. A few complications for Centene could occur. Even modest Medicaid changes

340B Reform May Be Coming Senate HELP Committee Chairman Bill Cassidy, R-LA, on Thursday released a years-long staff investigation of the 340B drug discount program and listed legislative reforms he may push to rein in practices that don’t meet the intent of the program. Cassidy suggests the following: A recent executive order from President Trump orders the conditioning of community health centers’ future grants to ensuring insulin and injectable epinephrine are made available to patients at the 340B discounted price or lower. Additional article: https://www.fiercehealthcare.com/regulatory/sen-cassidy-releases-340b-report-recommending-greater-transparency-oversight-hospitals (Some articles may require a subscription.) #340b #drugpricing #communityhealthcenters #hospitals https://insidehealthpolicy.com/inside-drug-pricing-daily-news/cassidy-unveils-staff-report-underpinning-potential-340b-legislative Molina Reports Mixed Results Rising costs in Medicaid and the health insurance exchanges depressed Molina Healthcare’s first-quarter performance, but the company Beat the Street in terms of earnings and revenue. Molina Healthcare saw net income slip less than 1% to $298 million as revenue grew 12.2% to $11.1 billion in the first quarter. The company reaffirmed

Medicaid Reimbursement Back On Budget Table House Republicans are still considering a proposal that would reduce the 90% federal match for the Medicaid expansion population down to normal state match rates. In addition, both work requirements and provider tax changes are being considered. The House could be influenced by the powerful Paragon Health Institute, a Trump-leaning think tank whose staffers and fellows have been in Trump 45 and 47. Paragon recently unveiled a Medicaid landing page that talks provider taxes, enhanced federal matches, fraud and waste, and more. Meanwhile, Axios reports that a Trump pollster reveals that Medicaid is popular among America, even with Trump voters. About 78% of Trump supporters support Medicaid. And an analysis from the Center for American Progress (CAP) found that about 34,200 more people would die annually if the federal government reduced its current 90 percent match for the expansion costs and states dropping their Medicaid

Elevance Reports Mixed But Better News Than United Elevance Health reaffirmed its 2025 earnings outlook, but did report some mixed news. Elevance beat The Street with revenue of $48.9 billion, up almost 15% year over year. It had profit of $2.2 billion, down 3% year over year. Elevance spent less money on medical care than analysts expected in Q1. Elevance did see higher costs in the first quarter, but premium hikes covered the trend. Still, the company advised it will approach 2025 cautiously. Elevance noted it is ramping up care coordination with new members to prepare for medical cost trends that have dogged the health insurance sector. I have noted that plans will begin to pivot from utilization management to care management moving forward. Additional articles: https://www.modernhealthcare.com/insurance/elevance-health-cost-predictions-medicare-advantage and https://www.healthcaredive.com/news/elevance-brushes-off-medicare-advantage-cost-fears-q1-2025/745961/ and https://www.modernhealthcare.com/insurance/elevance-health-lower-medical-costs and https://www.beckerspayer.com/payer/medicare-advantage-costs-manageable-for-elevance-health-8-notes/ (Some articles may require a subscription.) #medicareadvantage #healthplans #elevancehealth #margins https://www.fiercehealthcare.com/payers/elevance-health-beats-street-22b-q1-profit-elevated-cost-trends-pressure-industry Health Insurer CEO Salaries Despite financial woes,

Supreme Court Leans Toward Safeguarding Preventive Services After oral arguments before the Supreme Court on whether preventive services will be protected, many are speculating that the nod goes to the government’s defense of the free services decided by several task forces wihin the Department of Health and Human Services (HHS). Plaintiffs are challenging the provision on religious grounds and arguing that those who decide what services should be provided are not properly appointed to make such decisions. The government argues the task forces have the right oversight and correctly appointed officials have the final say. It is important to note that conclusions reached by reading the tea leaves from justices’ questions does not always match the final ruling. Additional article: https://www.medpagetoday.com/publichealthpolicy/publichealth/115218 and https://insidehealthpolicy.com/daily-news/scotus-appears-poised-back-uspstf-s-role-free-preventative-services and https://www.modernhealthcare.com/legal/supreme-court-aca-case-prep and https://insidehealthpolicy.com/health-insider/house-ec-plans-post-recess-budget-markup-scotus-appears-sympathetic-aca-preventative and https://thehill.com/policy/healthcare/5259118-supreme-court-obamacare-insurance/ (Some articles may require a subscription.) #prevention #preventiveservices #aca #obamacare https://www.fiercehealthcare.com/payers/supreme-court-appears-willing-save-aca-preventive-services-task-force Arkansas Bars PBM Operation If Parent Owns Pharmacies Arkansas Gov.