This is Jacob Emerson with the Becker's payer
issues podcast. Here's your biweekly industry news briefing
for December 2nd.
CMS has proposed major reforms for the Medicare
Advantage and Part D programs in its final
rule for 2026,
including changes to prior authorization and weight loss
drug coverage.
The agency is also looking for public feedback
on how Medicare Advantage medical loss ratios are
calculated in order to address concerns surrounding vertical
integration across the industry.
As part of its proposal for contract year
26, the agency is proposing that Part d
plans and Medicaid programs provide coverage of GLP
ones for obesity after previously being excluded, unless
those drugs were being used to treat
conditions such as diabetes.
CMS is also looking to address concerns about
the overuse of prior authorization
by introducing clearer definitions for internal coverage criteria,
stricter transparency requirements for insurers,
ensuring enrollees are informed about their appeal rights,
and collecting more data on initial coverage decisions
and appeals.
CMS is also proposing new standards for MA
medical loss ratios reporting to better align with
Medicaid and commercial requirements.
The agency is issuing a request for information
on potential policies that it could adopt regarding
how the MA and Part D MLRs are
calculated in order to enable policymakers to address
concerns surrounding vertical immigration across the industry.
The agency is also proposing to expand the
definition of marketing to cover more materials and
activities related to MA and Part D plans,
requiring more advertisements and communications to be reviewed
by the agency
before being shared with the public. The new
rule also focuses on improving consumer tools on
medicare.gov,
and brokers are it's proposed that brokers must
discuss additional topics with enrollees such as Medigap
rights and low income subsidy eligibility.
On the topic of artificial
intelligence, CMS said it aims to enforce equitable
access to care regardless of delivery by humans
or AI tools.
MA plans
using AI must comply with anti discrimination laws
and provide fair, unbiased access to services.
On Becker's website, there's a full analysis of
the full proposed rule for contract year 2026.
UnitedHealthcare
has prevailed in its lawsuit against CMS regarding
the methodology used to calculate its 2025
Medicare Advantage Star ratings.
That lawsuit was filed at the end of
September in a federal court in Texas, and
it revolved around the inclusion of a single
disputed customer service phone call in the agency's
calculation.
The judge ruled that CMS must recalculate
United's 2025 star ratings without consideration of the
disputed call and immediately republish those recalculated
star ratings online.
The courts found that CMS had acted contrary
to its own guidelines when evaluating that phone
call, which was marked as unsuccessful
despite evidence showing it lasted over 8 minutes
and connected to a call center representative.
United's lawsuit is one of several filed by
insurers this year challenging the agency's 2025
MA star ratings.
The agency reported a significant drop in 5
star plans for this year with only 7
achieving the top rating compared to 38
last year. Humana, Centene, Elevance, and Blue Cross
Blue Shield of Louisiana have all raised legal
challenges about the methodology CMS employed for the
2025 ratings.
Some of those challenges have centered on the
agency's use of secret shopper phone calls to
assess customer service metrics.
In November, the deputy CMS administrator doctor Mina
Seshamani announced that call center measures will carry
less weight in future MA star ratings starting
in 2026.
Well, Humana
misrepresented the providers its Medicare Advantage Plans will
be in network with in 2025.
That's according to Minnesota's attorney general, Keith Ellison.
Mister Ellison sent a letter to Humana CEO
Jim Rechten on November 22nd
expressing concern that the insurer listed Essentia Health
and other health systems
as in network for its for its 2025
Medicare Advantage plans on its website.
Accenture has said it will be out of
network with Humana MA plans in 2025.
Mister Ellison alleged that Humana also listed Avera
Health, North Memorial Health, and Sanford Health as
in network in Minnesota for 2025,
though all three systems have said they intend
to exit Humana's m a MA network in
the state at the end of 2025.
Well, at least 8 health systems are getting
out of the insurance business.
Earlier this year, Baystate Health in Massachusetts
reached a deal to sell Health New England
to 0.32 Health for a $165,000,000.
Massachusetts regulators approved that deal on November 26th.
Baystate has around a 180,000 members across Medicare,
Medicaid, and commercial plans.
Point 32 Health has more than 1,000,000 members.
Also, in November, Astana Health entered into a
definitive agreement to acquire certain assets from Prospect
Health System in Los Angeles, including Prospect's health
plan. In September, Indiana University Health said it
plans to sell its insurance business to Anthem
Blue Cross and Blue Shield for an undisclosed
amount.
In May, ProMedica in Toledo, Ohio sold its
insurance subsidiary, Paramount Health, to the insurer, Medical
Mutual of Ohio.
Subsidiary, Paramount Health, to the insurer, Medical Mutual
of Ohio.
And back in 2023, Ascension Wisconsin finalized a
deal to sell all of its stake in
the insurer, Network Health, to Froedtert Health. The
Milwaukee system freighter is now the sole owner
of network health, which offers health plans in
23 Wisconsin counties.
And other health systems have chosen to close
rather than sell their health plans. Southwestern Health
Resources out of Farmers Branch, Texas is shutting
down Care and Care, its Medicare Advantage Business
at the end of this year.
And Michigan Medicine out of Ann Arbor said
in November it plans to discontinue its health
plan at the end of 2025
after experiencing significant financial losses over the last
few years. And finally, Mary Washington Healthcare in
Fredericksburg, Virginia closed its MA plan at the
beginning of 2024.
Well, CVS Health is laying off an additional
42 employees at Aetna's headquarters in Hartford, Connecticut
after laying off 100 of employees at the
insurer earlier this year.
Those layoffs will take place between January 25th
February 7, 2025.
Though all of the infect affected employees report
to Aetna's Hartford headquarters,
just 12 reside within the state. Back in
October, Aetna reported that it would lay off
more than 400 employees at Aetna. The layoffs
are part of an initiative to cut more
than $2,000,000,000
in costs at CVS.
Across the company, CVS is laying off more
than 29100
employees as part of its efforts to cut
costs, though that accounts for less than 1%
of the company's workforce, and most of those
jobs are in corporate roles.
Also at Aetna, a former employee with the
company has been sentenced to 5 years in
prison in Ohio over his involvement in several
fraudulent claims schemes. The in individual
pleaded guilty to 13 felony counts of insurance
fraud, telecommunications
fraud, tampering with records, identity fraud, forgery, and
attempted theft,
according to a November 26 news release from
the Ohio Department of Insurance.
He's also been ordered to pay $229,000
in restitution.
That sentencing in Ohio comes shortly after 2
other Aetna employees were arrested in Florida in
November
for allegedly orchestrating a $1,100,000
fraud scheme involving the submission of 42 false
claims between 2019 and 2023.
In Ohio, an investigation uncovered the individual's pattern
of submitting altered documents, falsified claims, and identity
theft to fraudulently secure payouts from multiple insurers,
including Aetna.
Between November 2022 October 2023,
the individual filed 21 fraudulent claims while employed
at Aetna, receiving more than a $162,000
for false hospitalizations,
accidents, and a fabricated cancer diagnosis.
Additionally, he submitted fraudulent claims totaling over $67,000
to property and pet insurers.
Aetna told Becker's in a statement that the
company is committed to maintaining the highest standards
within its business practices
and that it takes legal allegations seriously and
cooperated fully with the Ohio Department of Insurance's
investigation.
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