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This is Jacob Emerson with the Becker's payer

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issues podcast.

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Here is your biweekly industry news briefing for

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August 19th.

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Humana will pay $90,000,000

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to settle allegations

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it submitted fraudulent bids for its Medicare Part

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B Plans between 2,011

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and 2017.

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Settlement is the first of its kind to

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resolve allegations of Part T Contracting Fraud.

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Phillips and Cohen, the law firm that represented

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the whistleblower in the case, said August 16th.

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The lawsuit was first filed in federal court

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in California back in 2016.

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Steven Scott, a former actuary at Humana, alleged

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in the lawsuit that the company submitted fraudulent

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bids to CMS for its Walmart Part d

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drug plan.

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He alleged that Humana submitted bids to CMS

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based on one set of cost assumptions while

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it maintained its own internal estimates on cost.

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Bids Humana submitted to CMS indicated the company

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would pay 75% of the cost of drugs

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for members, but it paid as little as

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64 a half percent in practice with members

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left to pay the difference.

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A Humana spokesperson told Becker's that Humana firmly

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believes the actuarial assumptions in its prescription drug

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plan were reasonable and in full compliance with

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all laws and regulatory requirements,

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and that the plaintiff's claims in the case

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are without merit.

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A settlement was reached before the case headed

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to trial.

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Well, a swirl of challenges is looming for

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Medicare recipients ahead of the annual enrollment period

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beginning October 15th.

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As we approach this year this year's annual

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enrollment period, it's evident that the process will

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be more complex and overwhelming than ever before,

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said Franz Voizmann,

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the CEO of insurance marketplace, Ehealth.

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He said we're facing a perfect storm of

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challenges,

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a presidential election that will distract beneficiaries during

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the critical early weeks, a late thanksgiving that

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compresses decision making time and significant market changes.

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Some large Medicare Advantage insurers have also warned

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that certain supplemental benefits could be cut next

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year as they fake focus on regaining profitability.

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The annual enrollment period, of course, takes place

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from October 15th to December 7th with coverage

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starting January 1st.

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Ehealth is advocating for CMS to delay the

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enrollment deadline by 5 days to provide enrollees

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with more time to make a decision.

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Along with some insurers exiting MA markets for

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next year, MA beneficiaries

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will see several big changes next year. The

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inflation reduction act has capped annual out of

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pocket costs for prescription drugs at $2,000

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under Medicare part

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d. MA plans will also be required to

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send beneficiaries

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an unused supplemental benefits report in July, which

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will explain out of pocket costs and how

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to use any unused benefits,

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and brokers will no longer receive incentives for

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enrolling older adults in MA plans next year.

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Well, as Medicare Advantage continues to grow and

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health insurers prioritize their margins in the segment,

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hospitals are the most vulnerable health care provider

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to rising administrative and financial Medicare Advantage burdens.

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That's according to a new report from S&P

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Global.

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The August 15th report highlighted the major growth

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Medicare Advantage has seen over the last few

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years with 32,800,000

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people or 54%

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of the eligible Medicare population now enrolled in

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an MA plan.

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S and P's analysts wrote that this growth

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poses challenges to health care service providers credit

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quality,

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given growing risks to reimbursement from a MA

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plans relative to traditional Medicare, as well as

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the payment risk and higher complexity around prior

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authorization

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requirements.

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We also see future risks to providers if

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at some point CMS addresses

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the MA program's higher than expected spending.

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And as MA enrollment has grown, so too

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have the financial headwinds facing major carriers.

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Government scrutiny is rising, CMS regulations and payments

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are tightening,

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and the cost of care is going up.

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In response, Aetna, Humana, and Centene are among

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the larger insurers that have said they will

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exit some markets in 2025

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and potentially reduce benefit offerings to accommodate the

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changing reimbursement environment and rising costs.

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Notably, UnitedHealthcare

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and Elevance Health have said they are prepared

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to weather the changing landscape

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and price their 2025

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MA plans to reflect that.

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S and Ps analysts wrote, though, that if

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already elevated utilization rates remain high for an

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extended period, we would expect payers to further

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squeeze payments to providers.

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Overall, we expect these challenges, coupled with further

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expansion of MA as a percentage of total

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Medicare beneficiaries,

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will continue to pressure margins on the Medicare

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portion of the provider payer mix. S and

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Ps analyst continued saying, thus, we expect insurers

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to prioritize

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margin over membership, and we expect large insurers

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will use their scale and market clout to

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limit provider rate increases

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over what will prove to be a challenging

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contract negotiation season.

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Well, CMS has approved Georgia's plan to transition

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to a state based ACA exchange called Georgia

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Access.

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Georgia Access will go live on November 1st

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this year. Coverage will begin next year for

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consumers who select a plan by December 16th.

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According to CMS, 18 states and Washington DC

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currently run their own exchanges rather than using

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the federal marketplace,

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and Illinois will join that list in 2025.

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And finally, in 2023,

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more than 61% of Ozempic prescriptions went to

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patients with commercial health insurance, and less than

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10% of all semaglutide prescriptions

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went to Medicaid enrollees.

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That's according to a new study published August

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2nd in JAMA Health Forum.

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The researchers used data that captures 92% of

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prescriptions

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dispensed at used

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US retail pharmacies between January 2021 December

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of 2023.

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The study analyzed monthly prescriptions for semaglutide brands

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Ozempic, Wegovy, and Rybelsus

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that were paid for through commercial insurance, Medicaid,

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Medicare Part D, or cash.

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The number of semaglutide fills increased 442%

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between the study time period, which again was

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January 2021 through December of 2023.

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Ozempic accounted for more than 70% of prescriptions

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during that period.

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Commercial insurance accounted for 61.4

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percent of Ozempic payments, almost 90%, for Wegovy,

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and 58%

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for Rybelsus.

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Medicare Part D accounted for 28.5%

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of Ozempic and 33%

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of Rybelsus fills, and only about 1% of

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Wegovy fills. And then for Medicaid, that accounted

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for less than 10% of fills for all

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3 brands

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last year.

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