1 00:00:00,080 --> 00:00:02,480 This is Jacob Emerson with the Becker's payer 2 00:00:02,480 --> 00:00:06,259 issues podcast. Here's your biweekly industry news briefing 3 00:00:06,319 --> 00:00:07,620 for December 2nd. 4 00:00:08,080 --> 00:00:10,960 CMS has proposed major reforms for the Medicare 5 00:00:10,960 --> 00:00:13,199 Advantage and Part D programs in its final 6 00:00:13,199 --> 00:00:14,259 rule for 2026, 7 00:00:15,425 --> 00:00:18,625 including changes to prior authorization and weight loss 8 00:00:18,625 --> 00:00:19,364 drug coverage. 9 00:00:19,744 --> 00:00:22,244 The agency is also looking for public feedback 10 00:00:22,304 --> 00:00:25,105 on how Medicare Advantage medical loss ratios are 11 00:00:25,105 --> 00:00:28,144 calculated in order to address concerns surrounding vertical 12 00:00:28,144 --> 00:00:29,660 integration across the industry. 13 00:00:30,120 --> 00:00:32,200 As part of its proposal for contract year 14 00:00:32,200 --> 00:00:35,240 26, the agency is proposing that Part d 15 00:00:35,240 --> 00:00:38,200 plans and Medicaid programs provide coverage of GLP 16 00:00:38,200 --> 00:00:42,060 ones for obesity after previously being excluded, unless 17 00:00:42,119 --> 00:00:43,755 those drugs were being used to treat 18 00:00:44,155 --> 00:00:45,215 conditions such as diabetes. 19 00:00:45,835 --> 00:00:48,234 CMS is also looking to address concerns about 20 00:00:48,234 --> 00:00:49,935 the overuse of prior authorization 21 00:00:50,315 --> 00:00:54,094 by introducing clearer definitions for internal coverage criteria, 22 00:00:54,554 --> 00:00:57,054 stricter transparency requirements for insurers, 23 00:00:57,439 --> 00:01:00,579 ensuring enrollees are informed about their appeal rights, 24 00:01:00,640 --> 00:01:03,280 and collecting more data on initial coverage decisions 25 00:01:03,280 --> 00:01:03,939 and appeals. 26 00:01:04,400 --> 00:01:06,719 CMS is also proposing new standards for MA 27 00:01:06,719 --> 00:01:10,079 medical loss ratios reporting to better align with 28 00:01:10,079 --> 00:01:11,780 Medicaid and commercial requirements. 29 00:01:13,155 --> 00:01:15,734 The agency is issuing a request for information 30 00:01:15,795 --> 00:01:18,194 on potential policies that it could adopt regarding 31 00:01:18,194 --> 00:01:20,435 how the MA and Part D MLRs are 32 00:01:20,435 --> 00:01:23,155 calculated in order to enable policymakers to address 33 00:01:23,155 --> 00:01:26,375 concerns surrounding vertical immigration across the industry. 34 00:01:27,109 --> 00:01:29,350 The agency is also proposing to expand the 35 00:01:29,350 --> 00:01:31,909 definition of marketing to cover more materials and 36 00:01:31,909 --> 00:01:34,170 activities related to MA and Part D plans, 37 00:01:34,310 --> 00:01:37,270 requiring more advertisements and communications to be reviewed 38 00:01:37,270 --> 00:01:38,010 by the agency 39 00:01:38,310 --> 00:01:40,755 before being shared with the public. The new 40 00:01:40,755 --> 00:01:43,474 rule also focuses on improving consumer tools on 41 00:01:43,474 --> 00:01:43,974 medicare.gov, 42 00:01:44,834 --> 00:01:47,635 and brokers are it's proposed that brokers must 43 00:01:47,635 --> 00:01:50,834 discuss additional topics with enrollees such as Medigap 44 00:01:50,834 --> 00:01:53,094 rights and low income subsidy eligibility. 45 00:01:53,819 --> 00:01:54,719 On the topic of artificial 46 00:01:55,180 --> 00:01:57,760 intelligence, CMS said it aims to enforce equitable 47 00:01:57,819 --> 00:02:00,379 access to care regardless of delivery by humans 48 00:02:00,379 --> 00:02:01,519 or AI tools. 49 00:02:01,979 --> 00:02:02,879 MA plans 50 00:02:03,180 --> 00:02:06,299 using AI must comply with anti discrimination laws 51 00:02:06,299 --> 00:02:09,664 and provide fair, unbiased access to services. 52 00:02:10,444 --> 00:02:12,925 On Becker's website, there's a full analysis of 53 00:02:12,925 --> 00:02:15,664 the full proposed rule for contract year 2026. 54 00:02:17,245 --> 00:02:17,745 UnitedHealthcare 55 00:02:18,205 --> 00:02:20,844 has prevailed in its lawsuit against CMS regarding 56 00:02:20,844 --> 00:02:23,549 the methodology used to calculate its 2025 57 00:02:23,930 --> 00:02:25,789 Medicare Advantage Star ratings. 58 00:02:26,169 --> 00:02:28,169 That lawsuit was filed at the end of 59 00:02:28,169 --> 00:02:30,729 September in a federal court in Texas, and 60 00:02:30,729 --> 00:02:32,650 it revolved around the inclusion of a single 61 00:02:32,650 --> 00:02:35,310 disputed customer service phone call in the agency's 62 00:02:35,530 --> 00:02:36,030 calculation. 63 00:02:36,705 --> 00:02:38,884 The judge ruled that CMS must recalculate 64 00:02:39,185 --> 00:02:42,384 United's 2025 star ratings without consideration of the 65 00:02:42,384 --> 00:02:45,364 disputed call and immediately republish those recalculated 66 00:02:45,664 --> 00:02:46,884 star ratings online. 67 00:02:47,425 --> 00:02:49,985 The courts found that CMS had acted contrary 68 00:02:49,985 --> 00:02:52,280 to its own guidelines when evaluating that phone 69 00:02:52,280 --> 00:02:54,219 call, which was marked as unsuccessful 70 00:02:54,520 --> 00:02:57,000 despite evidence showing it lasted over 8 minutes 71 00:02:57,000 --> 00:02:58,939 and connected to a call center representative. 72 00:02:59,960 --> 00:03:02,520 United's lawsuit is one of several filed by 73 00:03:02,520 --> 00:03:05,580 insurers this year challenging the agency's 2025 74 00:03:06,040 --> 00:03:07,099 MA star ratings. 75 00:03:07,555 --> 00:03:09,875 The agency reported a significant drop in 5 76 00:03:09,875 --> 00:03:12,034 star plans for this year with only 7 77 00:03:12,034 --> 00:03:14,294 achieving the top rating compared to 38 78 00:03:14,675 --> 00:03:17,955 last year. Humana, Centene, Elevance, and Blue Cross 79 00:03:17,955 --> 00:03:20,115 Blue Shield of Louisiana have all raised legal 80 00:03:20,115 --> 00:03:23,310 challenges about the methodology CMS employed for the 81 00:03:23,310 --> 00:03:24,530 2025 ratings. 82 00:03:24,909 --> 00:03:26,990 Some of those challenges have centered on the 83 00:03:26,990 --> 00:03:29,710 agency's use of secret shopper phone calls to 84 00:03:29,710 --> 00:03:31,569 assess customer service metrics. 85 00:03:32,030 --> 00:03:35,229 In November, the deputy CMS administrator doctor Mina 86 00:03:35,229 --> 00:03:38,495 Seshamani announced that call center measures will carry 87 00:03:38,495 --> 00:03:41,455 less weight in future MA star ratings starting 88 00:03:41,455 --> 00:03:42,354 in 2026. 89 00:03:44,655 --> 00:03:45,395 Well, Humana 90 00:03:45,935 --> 00:03:48,495 misrepresented the providers its Medicare Advantage Plans will 91 00:03:48,495 --> 00:03:50,194 be in network with in 2025. 92 00:03:50,974 --> 00:03:54,069 That's according to Minnesota's attorney general, Keith Ellison. 93 00:03:54,370 --> 00:03:56,849 Mister Ellison sent a letter to Humana CEO 94 00:03:56,849 --> 00:03:58,629 Jim Rechten on November 22nd 95 00:03:59,169 --> 00:04:02,050 expressing concern that the insurer listed Essentia Health 96 00:04:02,050 --> 00:04:03,270 and other health systems 97 00:04:03,569 --> 00:04:06,724 as in network for its for its 2025 98 00:04:07,025 --> 00:04:09,205 Medicare Advantage plans on its website. 99 00:04:09,584 --> 00:04:11,185 Accenture has said it will be out of 100 00:04:11,185 --> 00:04:13,525 network with Humana MA plans in 2025. 101 00:04:14,224 --> 00:04:17,185 Mister Ellison alleged that Humana also listed Avera 102 00:04:17,185 --> 00:04:20,384 Health, North Memorial Health, and Sanford Health as 103 00:04:20,384 --> 00:04:22,399 in network in Minnesota for 2025, 104 00:04:22,939 --> 00:04:24,779 though all three systems have said they intend 105 00:04:24,779 --> 00:04:26,860 to exit Humana's m a MA network in 106 00:04:26,860 --> 00:04:28,560 the state at the end of 2025. 107 00:04:32,459 --> 00:04:34,540 Well, at least 8 health systems are getting 108 00:04:34,540 --> 00:04:36,105 out of the insurance business. 109 00:04:36,985 --> 00:04:39,645 Earlier this year, Baystate Health in Massachusetts 110 00:04:40,105 --> 00:04:42,045 reached a deal to sell Health New England 111 00:04:42,185 --> 00:04:44,444 to 0.32 Health for a $165,000,000. 112 00:04:45,865 --> 00:04:49,485 Massachusetts regulators approved that deal on November 26th. 113 00:04:50,220 --> 00:04:54,060 Baystate has around a 180,000 members across Medicare, 114 00:04:54,060 --> 00:04:55,680 Medicaid, and commercial plans. 115 00:04:56,300 --> 00:04:59,199 Point 32 Health has more than 1,000,000 members. 116 00:04:59,900 --> 00:05:02,379 Also, in November, Astana Health entered into a 117 00:05:02,379 --> 00:05:05,339 definitive agreement to acquire certain assets from Prospect 118 00:05:05,339 --> 00:05:08,504 Health System in Los Angeles, including Prospect's health 119 00:05:08,504 --> 00:05:11,785 plan. In September, Indiana University Health said it 120 00:05:11,785 --> 00:05:14,264 plans to sell its insurance business to Anthem 121 00:05:14,264 --> 00:05:16,444 Blue Cross and Blue Shield for an undisclosed 122 00:05:16,665 --> 00:05:17,165 amount. 123 00:05:17,704 --> 00:05:19,865 In May, ProMedica in Toledo, Ohio sold its 124 00:05:19,865 --> 00:05:20,078 insurance subsidiary, Paramount Health, to the insurer, Medical 125 00:05:20,078 --> 00:05:20,855 Mutual of Ohio. 126 00:05:21,740 --> 00:05:24,699 Subsidiary, Paramount Health, to the insurer, Medical Mutual 127 00:05:24,699 --> 00:05:25,520 of Ohio. 128 00:05:27,420 --> 00:05:30,699 And back in 2023, Ascension Wisconsin finalized a 129 00:05:30,699 --> 00:05:32,300 deal to sell all of its stake in 130 00:05:32,300 --> 00:05:35,660 the insurer, Network Health, to Froedtert Health. The 131 00:05:35,660 --> 00:05:38,675 Milwaukee system freighter is now the sole owner 132 00:05:38,675 --> 00:05:41,235 of network health, which offers health plans in 133 00:05:41,235 --> 00:05:42,935 23 Wisconsin counties. 134 00:05:43,314 --> 00:05:45,394 And other health systems have chosen to close 135 00:05:45,394 --> 00:05:48,355 rather than sell their health plans. Southwestern Health 136 00:05:48,355 --> 00:05:51,089 Resources out of Farmers Branch, Texas is shutting 137 00:05:51,089 --> 00:05:53,569 down Care and Care, its Medicare Advantage Business 138 00:05:53,569 --> 00:05:54,709 at the end of this year. 139 00:05:55,810 --> 00:05:57,969 And Michigan Medicine out of Ann Arbor said 140 00:05:57,969 --> 00:05:59,889 in November it plans to discontinue its health 141 00:05:59,889 --> 00:06:01,430 plan at the end of 2025 142 00:06:01,969 --> 00:06:05,490 after experiencing significant financial losses over the last 143 00:06:05,490 --> 00:06:08,355 few years. And finally, Mary Washington Healthcare in 144 00:06:08,355 --> 00:06:11,154 Fredericksburg, Virginia closed its MA plan at the 145 00:06:11,154 --> 00:06:12,855 beginning of 2024. 146 00:06:15,154 --> 00:06:17,235 Well, CVS Health is laying off an additional 147 00:06:17,235 --> 00:06:20,535 42 employees at Aetna's headquarters in Hartford, Connecticut 148 00:06:20,839 --> 00:06:22,680 after laying off 100 of employees at the 149 00:06:22,680 --> 00:06:24,220 insurer earlier this year. 150 00:06:24,600 --> 00:06:27,339 Those layoffs will take place between January 25th 151 00:06:27,480 --> 00:06:29,180 February 7, 2025. 152 00:06:30,040 --> 00:06:32,680 Though all of the infect affected employees report 153 00:06:32,680 --> 00:06:34,139 to Aetna's Hartford headquarters, 154 00:06:34,454 --> 00:06:37,415 just 12 reside within the state. Back in 155 00:06:37,415 --> 00:06:39,254 October, Aetna reported that it would lay off 156 00:06:39,254 --> 00:06:41,814 more than 400 employees at Aetna. The layoffs 157 00:06:41,814 --> 00:06:43,254 are part of an initiative to cut more 158 00:06:43,254 --> 00:06:43,915 than $2,000,000,000 159 00:06:44,294 --> 00:06:45,834 in costs at CVS. 160 00:06:46,454 --> 00:06:48,694 Across the company, CVS is laying off more 161 00:06:48,694 --> 00:06:49,435 than 29100 162 00:06:49,879 --> 00:06:51,720 employees as part of its efforts to cut 163 00:06:51,720 --> 00:06:54,360 costs, though that accounts for less than 1% 164 00:06:54,360 --> 00:06:56,680 of the company's workforce, and most of those 165 00:06:56,680 --> 00:06:58,699 jobs are in corporate roles. 166 00:07:01,560 --> 00:07:03,784 Also at Aetna, a former employee with the 167 00:07:03,784 --> 00:07:05,944 company has been sentenced to 5 years in 168 00:07:05,944 --> 00:07:08,904 prison in Ohio over his involvement in several 169 00:07:08,904 --> 00:07:11,644 fraudulent claims schemes. The in individual 170 00:07:12,185 --> 00:07:14,985 pleaded guilty to 13 felony counts of insurance 171 00:07:14,985 --> 00:07:15,884 fraud, telecommunications 172 00:07:16,824 --> 00:07:20,649 fraud, tampering with records, identity fraud, forgery, and 173 00:07:20,649 --> 00:07:21,790 attempted theft, 174 00:07:22,329 --> 00:07:25,129 according to a November 26 news release from 175 00:07:25,129 --> 00:07:26,829 the Ohio Department of Insurance. 176 00:07:27,529 --> 00:07:29,389 He's also been ordered to pay $229,000 177 00:07:31,050 --> 00:07:31,790 in restitution. 178 00:07:32,644 --> 00:07:35,365 That sentencing in Ohio comes shortly after 2 179 00:07:35,365 --> 00:07:37,925 other Aetna employees were arrested in Florida in 180 00:07:37,925 --> 00:07:38,425 November 181 00:07:38,725 --> 00:07:40,824 for allegedly orchestrating a $1,100,000 182 00:07:41,605 --> 00:07:44,245 fraud scheme involving the submission of 42 false 183 00:07:44,245 --> 00:07:46,425 claims between 2019 and 2023. 184 00:07:47,389 --> 00:07:51,069 In Ohio, an investigation uncovered the individual's pattern 185 00:07:51,069 --> 00:07:54,850 of submitting altered documents, falsified claims, and identity 186 00:07:54,990 --> 00:07:58,290 theft to fraudulently secure payouts from multiple insurers, 187 00:07:58,509 --> 00:07:59,410 including Aetna. 188 00:07:59,745 --> 00:08:02,324 Between November 2022 October 2023, 189 00:08:02,944 --> 00:08:06,145 the individual filed 21 fraudulent claims while employed 190 00:08:06,145 --> 00:08:08,084 at Aetna, receiving more than a $162,000 191 00:08:09,105 --> 00:08:10,165 for false hospitalizations, 192 00:08:11,105 --> 00:08:13,605 accidents, and a fabricated cancer diagnosis. 193 00:08:14,269 --> 00:08:17,410 Additionally, he submitted fraudulent claims totaling over $67,000 194 00:08:18,350 --> 00:08:20,129 to property and pet insurers. 195 00:08:20,669 --> 00:08:22,349 Aetna told Becker's in a statement that the 196 00:08:22,349 --> 00:08:24,430 company is committed to maintaining the highest standards 197 00:08:24,430 --> 00:08:25,889 within its business practices 198 00:08:26,224 --> 00:08:28,865 and that it takes legal allegations seriously and 199 00:08:28,865 --> 00:08:32,324 cooperated fully with the Ohio Department of Insurance's 200 00:08:32,625 --> 00:08:33,125 investigation. 201 00:08:34,065 --> 00:08:35,605 If you'd like to receive 202 00:08:36,304 --> 00:08:38,164 more health care insurance 203 00:08:38,509 --> 00:08:40,830 news directly to your inbox every morning, subscribe 204 00:08:40,830 --> 00:08:43,309 to the Becker's Payer Issues e newsletter on 205 00:08:43,309 --> 00:08:44,769 our website at beckerspayer.com.