This is Jacob Emerson with the Becker's payer
issues podcast.
Here is your biweekly industry news briefing for
August 19th.
Humana will pay $90,000,000
to settle allegations
it submitted fraudulent bids for its Medicare Part
B Plans between 2,011
and 2017.
Settlement is the first of its kind to
resolve allegations of Part T Contracting Fraud.
Phillips and Cohen, the law firm that represented
the whistleblower in the case, said August 16th.
The lawsuit was first filed in federal court
in California back in 2016.
Steven Scott, a former actuary at Humana, alleged
in the lawsuit that the company submitted fraudulent
bids to CMS for its Walmart Part d
drug plan.
He alleged that Humana submitted bids to CMS
based on one set of cost assumptions while
it maintained its own internal estimates on cost.
Bids Humana submitted to CMS indicated the company
would pay 75% of the cost of drugs
for members, but it paid as little as
64 a half percent in practice with members
left to pay the difference.
A Humana spokesperson told Becker's that Humana firmly
believes the actuarial assumptions in its prescription drug
plan were reasonable and in full compliance with
all laws and regulatory requirements,
and that the plaintiff's claims in the case
are without merit.
A settlement was reached before the case headed
to trial.
Well, a swirl of challenges is looming for
Medicare recipients ahead of the annual enrollment period
beginning October 15th.
As we approach this year this year's annual
enrollment period, it's evident that the process will
be more complex and overwhelming than ever before,
said Franz Voizmann,
the CEO of insurance marketplace, Ehealth.
He said we're facing a perfect storm of
challenges,
a presidential election that will distract beneficiaries during
the critical early weeks, a late thanksgiving that
compresses decision making time and significant market changes.
Some large Medicare Advantage insurers have also warned
that certain supplemental benefits could be cut next
year as they fake focus on regaining profitability.
The annual enrollment period, of course, takes place
from October 15th to December 7th with coverage
starting January 1st.
Ehealth is advocating for CMS to delay the
enrollment deadline by 5 days to provide enrollees
with more time to make a decision.
Along with some insurers exiting MA markets for
next year, MA beneficiaries
will see several big changes next year. The
inflation reduction act has capped annual out of
pocket costs for prescription drugs at $2,000
under Medicare part
d. MA plans will also be required to
send beneficiaries
an unused supplemental benefits report in July, which
will explain out of pocket costs and how
to use any unused benefits,
and brokers will no longer receive incentives for
enrolling older adults in MA plans next year.
Well, as Medicare Advantage continues to grow and
health insurers prioritize their margins in the segment,
hospitals are the most vulnerable health care provider
to rising administrative and financial Medicare Advantage burdens.
That's according to a new report from S&P
Global.
The August 15th report highlighted the major growth
Medicare Advantage has seen over the last few
years with 32,800,000
people or 54%
of the eligible Medicare population now enrolled in
an MA plan.
S and P's analysts wrote that this growth
poses challenges to health care service providers credit
quality,
given growing risks to reimbursement from a MA
plans relative to traditional Medicare, as well as
the payment risk and higher complexity around prior
authorization
requirements.
We also see future risks to providers if
at some point CMS addresses
the MA program's higher than expected spending.
And as MA enrollment has grown, so too
have the financial headwinds facing major carriers.
Government scrutiny is rising, CMS regulations and payments
are tightening,
and the cost of care is going up.
In response, Aetna, Humana, and Centene are among
the larger insurers that have said they will
exit some markets in 2025
and potentially reduce benefit offerings to accommodate the
changing reimbursement environment and rising costs.
Notably, UnitedHealthcare
and Elevance Health have said they are prepared
to weather the changing landscape
and price their 2025
MA plans to reflect that.
S and Ps analysts wrote, though, that if
already elevated utilization rates remain high for an
extended period, we would expect payers to further
squeeze payments to providers.
Overall, we expect these challenges, coupled with further
expansion of MA as a percentage of total
Medicare beneficiaries,
will continue to pressure margins on the Medicare
portion of the provider payer mix. S and
Ps analyst continued saying, thus, we expect insurers
to prioritize
margin over membership, and we expect large insurers
will use their scale and market clout to
limit provider rate increases
over what will prove to be a challenging
contract negotiation season.
Well, CMS has approved Georgia's plan to transition
to a state based ACA exchange called Georgia
Access.
Georgia Access will go live on November 1st
this year. Coverage will begin next year for
consumers who select a plan by December 16th.
According to CMS, 18 states and Washington DC
currently run their own exchanges rather than using
the federal marketplace,
and Illinois will join that list in 2025.
And finally, in 2023,
more than 61% of Ozempic prescriptions went to
patients with commercial health insurance, and less than
10% of all semaglutide prescriptions
went to Medicaid enrollees.
That's according to a new study published August
2nd in JAMA Health Forum.
The researchers used data that captures 92% of
prescriptions
dispensed at used
US retail pharmacies between January 2021 December
of 2023.
The study analyzed monthly prescriptions for semaglutide brands
Ozempic, Wegovy, and Rybelsus
that were paid for through commercial insurance, Medicaid,
Medicare Part D, or cash.
The number of semaglutide fills increased 442%
between the study time period, which again was
January 2021 through December of 2023.
Ozempic accounted for more than 70% of prescriptions
during that period.
Commercial insurance accounted for 61.4
percent of Ozempic payments, almost 90%, for Wegovy,
and 58%
for Rybelsus.
Medicare Part D accounted for 28.5%
of Ozempic and 33%
of Rybelsus fills, and only about 1% of
Wegovy fills. And then for Medicaid, that accounted
for less than 10% of fills for all
3 brands
last year.
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