1 00:00:00,080 --> 00:00:02,319 This is Jacob Emerson with the Becker's Payer 2 00:00:02,319 --> 00:00:05,440 Issues podcast. Here is your biweekly industry news 3 00:00:05,440 --> 00:00:07,299 briefing for August 28th. 4 00:00:08,000 --> 00:00:10,900 Centene will no longer pay commission to insurance 5 00:00:11,039 --> 00:00:14,115 brokers enrolling or renewing members in its Medicare 6 00:00:14,255 --> 00:00:15,234 Part d plans. 7 00:00:15,535 --> 00:00:18,094 In a message sent to brokers on August 8 00:00:18,094 --> 00:00:18,594 25th, 9 00:00:19,054 --> 00:00:21,774 Centene said it will continue paying compensation to 10 00:00:21,774 --> 00:00:24,974 brokers enrolling members in its WellCare Medicare Advantage 11 00:00:24,974 --> 00:00:27,550 Plans. In its message, Centene said the inflation 12 00:00:27,550 --> 00:00:30,449 reduction act has resulted in significant changes 13 00:00:30,910 --> 00:00:31,969 to Part d. 14 00:00:32,429 --> 00:00:35,070 Company wrote that to continue providing access to 15 00:00:35,070 --> 00:00:37,070 high quality health care and Part d coverage 16 00:00:37,070 --> 00:00:39,255 that helps families and individuals, we have made 17 00:00:39,255 --> 00:00:42,315 the difficult decision that effective January 1, 2025 18 00:00:42,855 --> 00:00:46,054 to cease new and renewal commissions for prescription 19 00:00:46,054 --> 00:00:49,115 drug plans beginning with the 2025 plan year. 20 00:00:49,655 --> 00:00:52,315 In 2024, provisions of the IRA that eliminated 21 00:00:52,454 --> 00:00:53,914 co pays for party beneficiaries 22 00:00:55,659 --> 00:00:58,379 who enter the catastrophic phase of coverage took 23 00:00:58,379 --> 00:01:01,420 effect. In 2025, a $2,000 out of pocket 24 00:01:01,420 --> 00:01:04,000 spending cap will apply to part d members. 25 00:01:04,459 --> 00:01:06,879 Medicare Advantage and Part d plans pay brokers 26 00:01:06,939 --> 00:01:09,420 compensation for new enrollments and renewals in their 27 00:01:09,420 --> 00:01:09,920 plans. 28 00:01:11,155 --> 00:01:13,895 The National Association of Benefits and Insurance Professionals 29 00:01:14,194 --> 00:01:16,355 said in an August 27th statement that the 30 00:01:16,355 --> 00:01:18,594 decision to cut commissions threatened not only the 31 00:01:18,594 --> 00:01:21,495 livelihoods of Medicare agents, but also the communities 32 00:01:21,555 --> 00:01:23,795 they serve and the seniors who rely on 33 00:01:23,795 --> 00:01:24,959 their expert guidance. 34 00:01:25,439 --> 00:01:27,359 Centene was the 4th largest Part d plan 35 00:01:27,359 --> 00:01:28,500 sponsored in 2023. 36 00:01:29,119 --> 00:01:30,579 The company had 6,600,000 37 00:01:31,280 --> 00:01:33,299 Part d members as of June. 38 00:01:34,560 --> 00:01:37,280 Well, Cigna is removing Humira from its largest 39 00:01:37,280 --> 00:01:39,060 commercial formularies in 2025. 40 00:01:39,814 --> 00:01:42,855 Express Scripts will have several biosimilar alternatives to 41 00:01:42,855 --> 00:01:45,275 the biologic drug available through its formulary. 42 00:01:45,655 --> 00:01:49,335 A new Humira biosimilar is available for $0 43 00:01:49,335 --> 00:01:52,155 for patients of Cigna's Accredo specialty pharmacy. 44 00:01:54,000 --> 00:01:56,000 Express Scripts is the 2nd major PBM to 45 00:01:56,000 --> 00:01:58,180 replace Humira with its biosimilar competitors 46 00:01:58,560 --> 00:02:02,240 following CVS Caremark replacing Humira with biosimilars from 47 00:02:02,240 --> 00:02:04,659 its main formularies on April 1. 48 00:02:06,365 --> 00:02:09,324 Well, CMS dropped a proposed regulation that would 49 00:02:09,324 --> 00:02:12,305 have required Medicare Advantage Plans to return overpayments 50 00:02:12,444 --> 00:02:13,665 found during chart reviews, 51 00:02:14,525 --> 00:02:16,224 amid industry opposition. 52 00:02:16,525 --> 00:02:19,004 That's according to a KFF report on August 53 00:02:19,004 --> 00:02:19,504 27th. 54 00:02:20,120 --> 00:02:22,360 In 2014, CMS proposed a rule that would 55 00:02:22,360 --> 00:02:25,180 have required health plans reviewing patients' medical records 56 00:02:25,400 --> 00:02:28,199 to identify potential overpayments and return them to 57 00:02:28,199 --> 00:02:28,780 the agency. 58 00:02:29,239 --> 00:02:32,120 CMS dropped the proposed rule later that year 59 00:02:32,120 --> 00:02:33,900 after pushback from payers. 60 00:02:34,455 --> 00:02:36,635 Records released from a 2022 deposition 61 00:02:36,935 --> 00:02:39,415 show that CMS officials decided to abandon the 62 00:02:39,415 --> 00:02:42,534 rule after concern from insurers, and the rule 63 00:02:42,534 --> 00:02:44,775 change was at the center of a civil 64 00:02:44,775 --> 00:02:47,175 fraud case against UnitedHealth Group that has been 65 00:02:47,175 --> 00:02:48,960 pending for more than a decade. 66 00:02:49,520 --> 00:02:52,560 In those records recently made public, CMS officials 67 00:02:52,560 --> 00:02:54,240 said they decided not to move ahead with 68 00:02:54,240 --> 00:02:55,860 the regulations because of, quote, 69 00:02:56,159 --> 00:02:58,260 stakeholder concern and pushback. 70 00:02:58,879 --> 00:03:00,719 The case was filed in 2,011 by a 71 00:03:00,719 --> 00:03:03,280 former UnitedHealth employee and was taken over by 72 00:03:03,280 --> 00:03:04,935 the justice department in 20 73 00:03:05,414 --> 00:03:07,574 17. The DOJ is alleging that it paid 74 00:03:07,574 --> 00:03:08,715 UnitedHealth $2,100,000,000 75 00:03:09,735 --> 00:03:11,514 between 2,009 and 2016 76 00:03:11,814 --> 00:03:15,254 for unsupported billing codes, which it says United 77 00:03:15,254 --> 00:03:16,235 should have removed. 78 00:03:16,534 --> 00:03:18,955 But because the proposed rule was not finalized, 79 00:03:19,250 --> 00:03:20,930 UnitedHealth said in court rulings it should not 80 00:03:20,930 --> 00:03:23,430 be penalized for failing to follow a regulation 81 00:03:23,889 --> 00:03:25,590 that CMS did not adopt. 82 00:03:27,729 --> 00:03:29,590 Well, Aetna will cover intrauterine 83 00:03:30,050 --> 00:03:30,550 insemination 84 00:03:30,930 --> 00:03:33,395 as a medical benefit for eligible plans, 85 00:03:33,694 --> 00:03:36,435 a move the insurer called a, quote, landmark 86 00:03:36,574 --> 00:03:37,555 policy change. 87 00:03:37,935 --> 00:03:38,435 Intrauterine 88 00:03:38,895 --> 00:03:42,094 insemination or IUI is usually only covered if 89 00:03:42,094 --> 00:03:45,074 employers offer a separate fertility benefit plan. 90 00:03:45,375 --> 00:03:47,375 This new change from Aetna will apply to 91 00:03:47,375 --> 00:03:49,370 fully insured commercial plans. 92 00:03:49,750 --> 00:03:52,069 Back in May, Aetna settled a lawsuit alleging 93 00:03:52,069 --> 00:03:55,370 its fertility coverage policies discriminated against LGBTQ 94 00:03:55,830 --> 00:03:56,569 plus couples. 95 00:03:56,870 --> 00:03:58,389 As part of that settlement, Aetna said it 96 00:03:58,389 --> 00:04:00,550 would introduce a new health plan that includes 97 00:04:00,550 --> 00:04:03,189 artificial insemination as a standard benefit for all 98 00:04:03,189 --> 00:04:03,689 members 99 00:04:04,025 --> 00:04:05,724 regardless of sexual orientation. 100 00:04:06,185 --> 00:04:07,784 The company said it will also take steps 101 00:04:07,784 --> 00:04:10,504 to ensure its covered its coverage policies for 102 00:04:10,504 --> 00:04:11,564 in vitro fertilization 103 00:04:12,104 --> 00:04:13,965 are not more burdensome for LGBT 104 00:04:14,344 --> 00:04:16,050 couples than heterosexual couples. 105 00:04:16,849 --> 00:04:19,589 Fertility treatments are often not covered by insurance. 106 00:04:19,649 --> 00:04:20,389 In 2017, 107 00:04:20,689 --> 00:04:23,569 23% of employers with more than 500 employees 108 00:04:23,569 --> 00:04:25,509 covered IUI, and 35% 109 00:04:25,810 --> 00:04:28,789 of employers with more than 2,000 20,000 employees 110 00:04:29,089 --> 00:04:30,149 covered the treatment. 111 00:04:31,355 --> 00:04:34,235 And finally, Elavance Health is reportedly no longer 112 00:04:34,235 --> 00:04:35,615 among the potential purchasers 113 00:04:36,154 --> 00:04:39,355 of Evolent Health. That's according to exclusive reporting 114 00:04:39,355 --> 00:04:40,175 from Reuters. 115 00:04:40,475 --> 00:04:42,955 On August 22nd, Reuters had reported that Elavance 116 00:04:42,955 --> 00:04:45,295 was considering purchasing the health care software 117 00:04:46,040 --> 00:04:48,519 company, and sources familiar with the deal told 118 00:04:48,519 --> 00:04:49,819 Reuters on August 26th 119 00:04:50,199 --> 00:04:52,600 that the company had dropped out of that 120 00:04:52,600 --> 00:04:53,100 process. 121 00:04:53,480 --> 00:04:56,519 Evolent Health, launched by UPMC Health Plan, creates 122 00:04:56,519 --> 00:04:59,079 software to help providers transition from fee for 123 00:04:59,079 --> 00:05:00,975 service to value based arrangements. 124 00:05:01,514 --> 00:05:03,355 If you'd like the latest health insurance industry 125 00:05:03,355 --> 00:05:05,435 news delivered straight to your inbox every morning, 126 00:05:05,435 --> 00:05:07,774 subscribe to the Becker's payer issues e newsletter 127 00:05:08,154 --> 00:05:09,774 on our website atbeckerspayer.com.