Datapoint

The FDA on Sept. 22 approved Eli Lilly and Boehringer Ingelheim's Jardiance “to reduce the risk of sustained decline in estimated glomerular filtration rate (eGFR), end-stage kidney disease, cardiovascular death and hospitalization in adults with chronic kidney disease (CKD) at risk of progression.” The approval means Jardiance will go up against its rival SGLT2 inhibitor, AstraZeneca’s Farxiga, which gained approval for CKD in 2021. For the treatment of CKD, Farxiga holds covered or better status for 95% of all insured lives under the pharmacy benefit. 47% of lives have preferred access to Farxiga without utilization management restrictions.

North Carolina will expand Medicaid on Dec. 1, according to a Sept. 25 press release from the state. “Finally expanding Medicaid in North Carolina is a monumental achievement that will extend health insurance to people who need it,” Gov. Roy Cooper (D) said in the statement. “This action is long overdue, and we aren’t wasting a moment in beginning enrollment in North Carolina.” The move will bring health coverage to about 600,000 people. North Carolina currently serves 2.34 million Medicaid beneficiaries, with 78.8% enrolled in managed care plans.

As part of an effort to combat gun violence, New Mexico Gov. Michelle Lujan Grisham (D) is requiring health insurers operating in the state cover out-of-network behavioral health care at in-network rates, according to a Sept. 19 report in the Albuquerque Journal. The mandate applies to all fully insured individual and employer group plans (including ACA exchange plans). The three largest insurers in the state are Blue Cross and Blue Shield of New Mexico (626,241 members), Presbyterian Health Plan (594,457 members) and UnitedHealthcare (234,800).

CMS will reinstate coverage for approximately 500,000 Medicaid and CHIP enrollees after they were improperly disenrolled from the safety net insurance programs. According to CMS, on Aug. 30 the agency sent a letter to all states “requiring them to determine and report whether they have a systems issue that inappropriately disenrolls children and families, even when the state had information indicating that they remained eligible for Medicaid and CHIP coverage.” The agency said 30 states have reported that they are working through the “systems issue” behind the improper disenrollments and have paused procedural disenrollments for affected beneficiaries. There were 73.8 million Medicaid and CHIP enrollees at the outset of the COVID-19 pandemic in March 2020, growing to 95.6 million by April 2023, when redeterminations began.

Blue Cross and Blue Shield of North Carolina (BCBSNC) said that the price of its average marketplace plan premium in 2024 will decrease by 4% compared to plan year 2023. The Blues affiliate projects that the rate change will result in $130 million in premium savings for plan members. A press release touted BCBSNC’s pharmacy management, particularly in specialty, as a reason for the reduced rates: “while pharmaceutical costs in the U.S. grew 9.4% in 2022, Blue Cross NC successfully held down the overall pharmacy trend for its individual ACA market to 0.7% in 2022 and to 2.9%, so far in 2023.” The Blues affiliate is currently the largest insurer in its home state, serving 2,359,756 members, with 378,370 enrolled in exchange plans.

Idaho is the first state to complete its Medicaid eligibility redeterminations process, the state’s Medicaid agency announced on Sept. 8. The state “processed 153,196 renewals, and 31,900 were determined eligible, and 121,296 were ineligible,” according to a post from the state’s Dept. of Health and Welfare (DEW). To handle redeterminations, DEW “committed more than 300 eligibility staff to the effort and an additional 42 staff from our call center,” the agency added. The news is somewhat surprising, as Idaho paused redeterminations earlier this year. Idaho served 267,963 Medicaid beneficiaries at the outset of the COVID-19 pandemic in March 2020, growing to 454,187 lives by April 2023, when redeterminations began.

Empire BlueCross BlueShield and Rockville Center, N.Y.-based health system Catholic Health are partnering on a new multi-year value-based care initiative that will establish new care delivery models with the goal of lowering the overall cost of care. “Our partnership with Empire BlueCross BlueShield helps us to proactively identify opportunities to reduce the costs of care while improving patient health,” Julie Kapoor, senior vice president, revenue management and managed care at Catholic Health, said in a statement. “The signing of this agreement will allow us to stay focused on the delivery of exceptional care while also improving access to affordable health services on Long Island.” Empire Blue’s parent company, Elevance Health, is the largest insurer in New York, serving 4,303,825 members.

The FDA last week approved GSK’s JAK inhibitor Ojjaara (momelotinib) for broad use in intermediate or high-risk myelofibrosis, a rare blood cancer, in patients with anemia. GSK says it is the only approved myelofibrosis therapy available for both newly diagnosed and previously treated patients “that addresses the key manifestations of the disease, namely anaemia, constitutional symptoms and splenomegaly (enlarged spleen).” While Ojjaara is only available to anemic patients, it will still present a challenge to Incyte’s JAK powerhouse Jakafi (ruxolitinib) in the myelofibrosis market basket. Under the pharmacy benefit, Jakafi holds covered or better status as a myelofibrosis therapy for virtually all insured lives. About 16% of lives have preferred access to Jakafi, growing to 34% with utilization management restrictions applied.

Mississippi could be the next state to expand Medicaid, according to a Sept. 12 report in Mississippi Today. Representative Jason White (R), who will likely become Speaker of the House for the 2024 legislative session, told the outlet that Medicaid expansion “will be on the table,” despite Gov. Tate Reeves’ (R) strong opposition. “I think we as Republicans have probably earned a little bit of the bad rap we get on health care in Mississippi,” White continued. “Part of that is that we haven’t had a full-blown airing or discussion of Medicaid expansion. We’ve just said, ‘No.’” The state currently serves 849,912 Medicaid beneficiaries, with 51.4% enrolled in managed care plans.

The state of Texas recently unveiled contract awards to seven payers for its STAR+PLUS Medicaid program, which serves older adults with disabilities. Incumbents UnitedHealthcare, Molina Healthcare, Elevance Health’s Amerigroup and Centene subsidiary Superior HealthPlan will continue to serve the program, to be joined by new entrants Community First Health Plans, El Paso Health and Community Health Choice Texas. The STAR+PLUS program currently serves 577,219 members, about 11% of the state’s managed Medicaid population.