This is Jacob Emerson with the Becker payer
issues podcast.
Here's your bi weekly industry news briefing for
June seventeenth.
Cms has recalculate Medicare Advantage plans star ratings
after insurers, challenging the agency's methodology were handed
recent court injuries. In a memo sent to
Medicare Advantage carriers on June thirteenth. The agency
said it would recalculate plans star ratings for
20 24 without eliminating extreme outliers.
Back in early June, a judge ruled in
favor of scan health plan, which sued over
the agency's Star Ratings new methodology.
Days later, a judge handed El health, a
partial victory in a similar case. Both scan
and El challenged Cms
implementation of the tu key outlier rule, which
eliminates extreme outliers from datasets used to calculate
the star ratings, making its more difficult to
achieve a high rating.
Insurers had argued that Cms did not follow
proper administrative procedures in implementing the route rule.
Judges presiding over those 2 lawsuits ruled, the
agency had violated the administrative procedure Act when
it implemented the new methodology. Rule In the
letter, Cms said it will revise star ratings
for plans using 20 23 cut points. Cms
will not decrease any plans ratings.
Plans must achieve a 4 star rating or
hired to receive quality bonus payments from Cms.
The ratings determine how much plans will earn
in bonus payments in 20 25 with some
insurers standing to bring in millions more with
the revised ratings.
In its letter to plan directors, Cms said
plans that see their star rating go up
as a result of the change. Will have
until June 20 eighth to revise their 20
25 bids.
Well Blue Cross Blue Shield of Michigan says
it will no longer cover Gl 1 drugs
to treat obesity
beginning this January.
A spokesperson for Michigan's largest and sure told
Bloomberg that it will drop coverage of Gl
1 drugs for weight loss under its fully
insured large group commercial health plans. That change
will affect nearly 10000
members.
A spokesperson for the company cited concerns over
safety, effectiveness, and costs as the reason for
the decision.
Back in March, Bc,
Michigan reported its pharmaceutical costs increased by 1800000000.0
dollar in 20 23,
including a 350000000
dollar increase in Gl 1 costs. Gl 1
medications can cost upward to 15000 dollars versus
a year.
Research published by the Bc
Association in May found that nearly 06:10 adults
prescribed a Gl 1 of a drug for
weight loss
discontinue the drug before seeing any meaningful clinical
benefits.
Well, speaking of weight loss drugs around 1
in 3 employers covering Gl ones for weight
loss in 20 23. 1 in 3 employers
now are. A survey from the international, foundation
of employee benefit plans found. In 20 23,
34 percent of employers surveyed cover Gl ones
for weight loss, and 57 pro percent covered
the drug to treat type 2 diabetes.
The number of employers covering the cost of
the drugs for weight laws increased from 28
percent in 20 22.
So The nonprofit educational platform survey was published
June port thirteenth and pulled 279
large. Lawyers.
Well, in El Health executives said the company
is comfortable with its Medicare Advantage business as
other major insurers project loss lawyers in the
market.
Speaking of the Goldman Sachs Healthcare conference on
June twelfth. El Vice President of Investor Relations
said The company is comfortable predicting market plus
growth for the company's Medicare Advantage business in
20 25.
Now exact growth is difficult to predict without
knowing what El competitors are offering next year,
but the company could pick up members who
leave other insurers. Difficult Medicare Advantage market of
course is facing 2 major headwind, rising medical
costs and utilization among the M population and
reduced reimbursement from Cms.
Cbs and Human men have both said they
will exit some markets next year and potentially
reduce benefit offerings to accommodate
those rising costs.
Sea Cvs has predicted Ae could lose 10
percent of its M membership next year.
El
expects its Medicare Advantage business to be profitable
in 20 24, though below the company's target
margin. United Health has also maintains. Did is
well positioned to weather market headwind.
Executives there told investors in May that the
company is comfortable with its M positioning for
20 25 and but were non commit on
growth numbers.
A large group of Us lawmakers have introduced
legislation aimed at reforming the Medicare Advantage prior
auth authorization process. The legislation is an updated
version of legislation that passed the house of
representatives in 20 22 but stalled in the
senate.
If Bass, that bill would establish an electronic
prior authorization process for M plans, including a
standardized 20
standardization for transactions and clinical attachments, it would
include increased transparency around M prior authorization requirements
and use.
It would clarify
Hhs authority to establish time frames for electronic
prior authorization requests, including but expedited did determinations,
real time decisions for between the approved items
and services,
and other prior auth requests. It also
expand beneficiary protections to improve enroll experiences and
outcomes, and it would require Hhs and other
federal agencies to report to congress on program,
integrity efforts and other ways to further improve
the electronic prior authorization process.
That bill is sponsored by a hundred and
30 members in the house and 42. And
senators.
In response to the February, Ransom attack on
change healthcare, Cms is introducing special measures to
assist affected organization in navigating the federal independent
dispute resolution process under the no surprises Act.
Cms reported receiving numerous complaints from healthcare providers
since facilities and air ambulance services
about difficulties in
initiating open negotiation. These challenges are due disruptions
in receiving ness necessary payment information and disclosures
from plans or issuers caused by the change
of cybersecurity incident, which has
significantly delayed claims processing nationwide.
To address these issues, Cms designated a special
period for affected organizations These entities can initiate
open negotiation for any service provided on or
after January first at any time from June
fourteenth to October twelfth.
This special period applies regardless of when they
received payment or denial notices.
To utilize this special period, parties must submit
an anti station form along with the standard
open negotiation negotiation form,
certifying that the incident
impacted their ability to start open
negotiation.
Let edison us, new Jersey based Hack and
Sack Meridian Health and Ae, they'll be out
of network on July first without a new
contract in place. Ae Medicare Advantage members could
lose coverage July first across hack and Sa,
18 hospitals along with the systems urgent care
centers, outpatient clinics and 7000
physicians. Ae members with self insured plans will
be out of network on September 20 ninth.
Members with fully insured plants which include employer
and Aca plans will be out of network
on October 20 ninth.
And finally, Blue Shield of California has Na
day contract, managing care for 400000
California state employees.
Blue Shield won out over Anthem Blue Cross,
which has held the extra more than 2
decades.
That contract is for the California Public employee's
retirement system
for its Ppo contract. Cal,
provides health coverage to 1 and a half
million current and retired state employees.
The Ppo contract covers 250000
employee in basic Ppo plans and a hundred
and 50000 with Medicare supplement coverage. The 5
year contract will begin in 20 25.
These The agency also awarded a contract to
included health to provide virtual care and population
health management.
The new contract with Blue Shield includes risk
based thresholds, for medical cost trends and outcomes.
Blue shield and included health will put 464000000
dollars at risk if they do not meet
cost trend goals.
The contracts set the initial medical cost trend
target at 5 and a half percent in
20 25,
and that will low lower each year until
it reaches a 3 percent in 20 29.
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