1 00:00:00,080 --> 00:00:02,319 This is Jacob Emerson with the Becker's Payer 2 00:00:02,319 --> 00:00:03,459 Issues Podcast. 3 00:00:03,839 --> 00:00:06,799 Here is your biweekly industry news briefing for 4 00:00:06,799 --> 00:00:07,940 October 14th. 5 00:00:08,720 --> 00:00:11,839 Average Medicare Advantage star ratings declined for the 6 00:00:11,839 --> 00:00:14,160 3rd year in a row according to new 7 00:00:14,160 --> 00:00:16,414 CMS data published on October 10th. 8 00:00:16,954 --> 00:00:19,135 The average MA star rating for 2025 9 00:00:19,595 --> 00:00:20,414 is 3.92 10 00:00:21,114 --> 00:00:23,214 stars. That's down from 4.07 11 00:00:23,914 --> 00:00:24,655 in 2024. 12 00:00:25,515 --> 00:00:27,690 Plans must earn a rating of 4 or 13 00:00:27,690 --> 00:00:30,190 higher to receive bonus payments from CMS. 14 00:00:30,490 --> 00:00:33,609 2025 star ratings affect the quality bonus payments 15 00:00:33,609 --> 00:00:35,229 plans receive in 2026. 16 00:00:36,250 --> 00:00:38,969 Just 7 plans received a 5 star rating 17 00:00:38,969 --> 00:00:39,710 in 2025. 18 00:00:40,054 --> 00:00:42,155 That's down from 38 in 2024. 19 00:00:43,094 --> 00:00:46,134 Around 40% of Medicare Advantage Part D plans 20 00:00:46,134 --> 00:00:49,574 received 4 stars or higher. Around 62% of 21 00:00:49,574 --> 00:00:53,015 MAPD enrollees are in plans rating rated 4 22 00:00:53,015 --> 00:00:53,800 or higher. 23 00:00:54,260 --> 00:00:56,179 CMS did not make any major changes in 24 00:00:56,179 --> 00:00:57,320 star ratings methodology. 25 00:00:57,780 --> 00:01:00,020 Medicare Advantage Part d plans are rated on 26 00:01:00,020 --> 00:01:02,600 40 clinical quality and member service measures. 27 00:01:02,980 --> 00:01:06,180 CMS determines cut points for each per measure 28 00:01:06,180 --> 00:01:07,744 each year. For 2025, 29 00:01:08,045 --> 00:01:10,685 many cut points increased, meaning plans had to 30 00:01:10,685 --> 00:01:12,784 perform better to get higher star ratings. 31 00:01:13,164 --> 00:01:15,724 Several factors influenced the tougher cut points. The 32 00:01:15,724 --> 00:01:18,284 agency removed extreme outliers from the lower end 33 00:01:18,284 --> 00:01:21,244 of performance, a more compressed distribution on scores, 34 00:01:21,244 --> 00:01:23,729 and an increasing number of high scoring contracts. 35 00:01:25,709 --> 00:01:28,750 Potential challenges to CMS's star ratings could loom. 36 00:01:28,750 --> 00:01:31,069 Earlier in October, Humana said its star ratings 37 00:01:31,069 --> 00:01:34,430 for 2025 dropped significantly from last year. For 38 00:01:34,430 --> 00:01:37,105 next year, just 25% of Humana's members will 39 00:01:37,105 --> 00:01:39,344 be in contracts rated plans 4 stars and 40 00:01:39,344 --> 00:01:41,284 above. That's down from 94% 41 00:01:41,665 --> 00:01:42,484 in 2024. 42 00:01:43,344 --> 00:01:43,844 UnitedHealthcare 43 00:01:44,225 --> 00:01:47,125 is also challenging CMS's star ratings. The company 44 00:01:47,129 --> 00:01:48,909 filed a lawsuit September 30th 45 00:01:49,289 --> 00:01:52,329 challenging CMS's inclusion of a secret shopper phone 46 00:01:52,329 --> 00:01:54,670 call in its star ratings that UnitedHealthcare 47 00:01:55,049 --> 00:01:56,109 said never connected. 48 00:01:56,810 --> 00:01:58,670 Back in June, CMS recalculated 49 00:01:59,625 --> 00:02:02,444 2024 star ratings for all Medicare Advantage plans. 50 00:02:02,825 --> 00:02:05,484 Judges sided with Scan Health Plan and Elavance 51 00:02:05,545 --> 00:02:08,844 Health in lawsuits challenging the methodology CMS used 52 00:02:08,905 --> 00:02:10,284 to calculate the ratings. 53 00:02:10,664 --> 00:02:13,625 In addition to determining bonus payments, star ratings 54 00:02:13,625 --> 00:02:16,449 guide beneficiaries' decision on which plans to enroll 55 00:02:16,449 --> 00:02:19,349 in. Open enrollment begins October 15th. 56 00:02:19,889 --> 00:02:22,689 Well, CMS is proposing new regulations on the 57 00:02:22,689 --> 00:02:24,629 ACA marketplace in 2026, 58 00:02:25,250 --> 00:02:27,454 which includes some aimed aimed at cracking down 59 00:02:27,454 --> 00:02:28,114 on fraud. 60 00:02:28,414 --> 00:02:30,574 The agency published its proposed rules for the 61 00:02:30,574 --> 00:02:32,114 marketplace October 4th. 62 00:02:32,414 --> 00:02:34,834 It proposed holding lead agents at insurance agencies 63 00:02:34,894 --> 00:02:36,914 accountable for violations of marketplace 64 00:02:37,215 --> 00:02:37,715 standards. 65 00:02:38,014 --> 00:02:40,650 The agency also proposed using its authority to 66 00:02:40,729 --> 00:02:43,289 suspend an agent or broker's ability to operate 67 00:02:43,289 --> 00:02:45,769 on the exchange if the agency deems the 68 00:02:45,769 --> 00:02:49,310 agent poses an unacceptable risk to marketplace operations. 69 00:02:49,849 --> 00:02:52,430 The policy would improve security on the exchange 70 00:02:52,489 --> 00:02:55,229 resulting in fewer unauthorized changes to coverage. 71 00:02:55,794 --> 00:02:57,634 CMS has moved to crack down on brokers 72 00:02:57,634 --> 00:03:00,454 making changes to enrollees coverage without their knowledge. 73 00:03:00,594 --> 00:03:02,034 In the 1st 6 months of this year, 74 00:03:02,034 --> 00:03:04,055 CMS said it received nearly 74,000 75 00:03:04,674 --> 00:03:07,474 complaints about a plan being changed without the 76 00:03:07,474 --> 00:03:09,574 enrollees consent and nearly 130,000 77 00:03:10,114 --> 00:03:11,254 complaints about individuals 78 00:03:11,689 --> 00:03:13,789 being enrolled in plans without their knowledge. 79 00:03:14,169 --> 00:03:17,129 CMS has suspended at least 200 marketplace agents 80 00:03:17,129 --> 00:03:19,710 for reasonable suspicion of fraud since June. 81 00:03:20,169 --> 00:03:22,169 The proposed rules would also add a new 82 00:03:22,169 --> 00:03:24,330 model consent form designed to help agents and 83 00:03:24,330 --> 00:03:27,004 brokers better document a customer's consent to enroll 84 00:03:27,004 --> 00:03:29,185 in a plan or change their coverage. 85 00:03:29,485 --> 00:03:31,884 The agency is also proposing allowing insurers to 86 00:03:31,884 --> 00:03:35,084 implement fixed dollar or percentage based thresholds to 87 00:03:35,084 --> 00:03:35,905 allow individuals 88 00:03:36,205 --> 00:03:38,044 to maintain their coverage even if they have 89 00:03:38,044 --> 00:03:40,680 not paid their full monthly premium. The agency 90 00:03:40,680 --> 00:03:43,420 proposed capping that amount at $5 or less. 91 00:03:43,879 --> 00:03:46,040 CMS has also proposed several updates to the 92 00:03:46,040 --> 00:03:48,840 risk adjustment program, which spreads out costs between 93 00:03:48,840 --> 00:03:50,139 insurers in state marketplaces. 94 00:03:50,760 --> 00:03:52,920 The agency proposed updating its models with data 95 00:03:52,920 --> 00:03:54,460 from 2020 to 2022. 96 00:03:55,314 --> 00:03:57,074 In addition to updating the models, CMS is 97 00:03:57,074 --> 00:04:00,194 proposing phasing out special adjustments for hepatitis c 98 00:04:00,194 --> 00:04:03,094 drugs and adding new adjustments for pre exposure 99 00:04:03,155 --> 00:04:05,014 prophylaxis drugs to treat 100 00:04:05,395 --> 00:04:05,895 HIV. 101 00:04:06,675 --> 00:04:08,650 CMS is also seeking comment on how to 102 00:04:08,650 --> 00:04:11,129 reduce the risk of insurer insolvencies in the 103 00:04:11,129 --> 00:04:12,030 ACA marketplace. 104 00:04:12,409 --> 00:04:15,389 In recent years, multiple plans have become insolvent, 105 00:04:15,530 --> 00:04:18,490 leaving enrollees without coverage and insurers without risk 106 00:04:18,490 --> 00:04:19,550 adjustment payments. 107 00:04:19,894 --> 00:04:22,535 Those proposed rules are open for comment until 108 00:04:22,535 --> 00:04:23,514 November 12th. 109 00:04:24,375 --> 00:04:27,735 Vice president Kamala Harris has proposed expanding Medicare 110 00:04:27,735 --> 00:04:30,455 coverage for home health care. Miss Harris explained 111 00:04:30,455 --> 00:04:32,615 the due details of her proposal on the 112 00:04:32,615 --> 00:04:34,314 daytime talk show, The View, 113 00:04:34,680 --> 00:04:36,699 Campaign AIDS told NPR. 114 00:04:37,240 --> 00:04:39,319 The benefit would cover the cost of in 115 00:04:39,319 --> 00:04:41,420 home health aids and other home services. 116 00:04:41,879 --> 00:04:44,839 Medicare usually does not cover intermittent skilled nursing 117 00:04:44,839 --> 00:04:46,839 care at home or long term in home 118 00:04:46,839 --> 00:04:47,204 care. 119 00:04:47,685 --> 00:04:50,805 Miss Harris' campaign did not provide specific estimates 120 00:04:50,805 --> 00:04:52,964 for how much the proposal would cost. The 121 00:04:52,964 --> 00:04:55,444 proposal would be partially paid for by expanding 122 00:04:55,444 --> 00:04:56,985 Medicare drug price negotiations. 123 00:04:57,844 --> 00:04:59,759 The policy is designed to appeal to the, 124 00:04:59,759 --> 00:05:02,639 quote, sandwich generation or adults who care for 125 00:05:02,639 --> 00:05:05,379 both aging parents and children. More than 40% 126 00:05:05,519 --> 00:05:07,699 of Americans provide unpaid caregiving. 127 00:05:08,720 --> 00:05:11,439 Donald Donald Trump's campaign said the former president's 128 00:05:11,439 --> 00:05:14,319 platform also includes a commitment to at home 129 00:05:14,319 --> 00:05:14,819 care. 130 00:05:15,285 --> 00:05:18,485 UPMC Health Plan is named Marybeth Jenkins president 131 00:05:18,485 --> 00:05:21,764 and CEO. That's effective January 1st. Miss Jenkins 132 00:05:21,764 --> 00:05:24,404 has also been named president of UPMC Insurance 133 00:05:24,404 --> 00:05:27,045 Services Division. She served in several roles at 134 00:05:27,045 --> 00:05:27,545 UPMC 135 00:05:27,860 --> 00:05:30,920 since 1998, most recently as EVP and COO 136 00:05:31,139 --> 00:05:34,819 at UPMC Insurance Services Division. She's replacing current 137 00:05:34,819 --> 00:05:37,540 president and CEO Diane Holder, who is retiring 138 00:05:37,540 --> 00:05:39,220 at the end of the year after 4 139 00:05:39,220 --> 00:05:40,439 years with the organization. 140 00:05:41,754 --> 00:05:44,254 And finally, CVS Health will lay off 416 141 00:05:44,795 --> 00:05:47,774 employees at Aetna's headquarters in Hartford, Connecticut. 142 00:05:48,314 --> 00:05:50,235 In a more notice filed October 6th, the 143 00:05:50,235 --> 00:05:52,394 company said 93 employees work at the facility 144 00:05:52,394 --> 00:05:54,750 in Hartford. The other employees work remotely in 145 00:05:54,750 --> 00:05:57,410 several states but report to the Connecticut facility. 146 00:05:57,949 --> 00:06:00,770 Most of those layoffs are effective December 7th. 147 00:06:01,245 --> 00:06:03,165 If you like the latest health insurance industry 148 00:06:03,165 --> 00:06:05,405 news delivered straight to your inbox every morning, 149 00:06:05,405 --> 00:06:07,905 subscribe to the Becker's Payer Issues e newsletter 150 00:06:08,045 --> 00:06:09,665 on our website at beckerspayor.com.