Changing coverage requirements for a slew of preventive services may be coming to health plans, as CMS eyes an update to Affordable Care Act provisions that may eventually extend to insurance markets beyond the federal and state marketplaces.

On August 30, a new proposed rule, Enhancing Coverage of Preventive Services under the Affordable Care Act, was posted to the Office of Management and Budget’s (OMB) dashboard.

The release date of the rule remains uncertain, but it may contain new coverage requirements for preventive services such as contraceptive care and vaccines, Richard Hughes IV, health care lawyer with Epstein Becker Green in Washington, D.C., tells AIS Health, a division of MMIT.

The Biden administration on Sept. 9 finalized a sweeping set of regulations that aim to ensure health plans are covering behavioral health treatment as comprehensively as they cover medical care. The move was met by rapid criticism from a coalition of trade groups representing health insurers and large employers, which argued the new regulations “will not address the inadequate supply of mental health providers.”

But other groups, such as a mental health advocacy organization tied to the Kennedy family, welcomed the rules as a necessary step forward to ensure compliance with the Mental Health Parity and Addiction Equity Act (MHPAEA). And one health policy expert tells AIS Health, a division of MMIT, that there are reasons to be skeptical of some criticisms lobbed at the new regulations by plan sponsors and insurers.

The Food and Drug Administration’s top gene therapy regulator issued what he acknowledged is a “provocative” call to consider setting a “target product profile” for gene therapy that includes not just what is expected from a clinical perspective, but “what we need to expect out of them from an economic perspective and from a clinical benefit perspective versus cost perspective.”

The FDA, by virtue of legal mandates and historical precedent, tends to avoid discussing the costs of novel medical interventions. But when a senior leader like Center for Biologics Evaluation and Research Director Peter Marks discusses cost-effectiveness tradeoffs, eyebrows raise.

The Inflation Reduction Act (IRA) was a sweeping piece of legislation that impacted multiple industries, but the prescription drug aspects of the law have arguably gotten the most attention, both positive and negative. CMS recently released the eagerly anticipated negotiated prices for the first 10 drugs, which will go into effect on Jan. 1, 2026. In preparation for the law’s potential impact, research from Zitter Insights found that both Medicare and commercial plans already have begun to modify their drug management approach.

Among the pharma provisions of the IRA, which was signed into law by President Joe Biden on Aug. 16, 2022, are requiring Medicare to negotiate the prices of the most expensive Medicare drugs, starting with the top 10 Part D agents; sanctioning companies whose Part B drugs’ prices increase faster than the rate of inflation; and implementing a phased-in Medicare Part D redesign that modifies the percentages different stakeholders are responsible for and caps beneficiaries’ out-of-pocket costs at $2,000 starting next year.

A California law designed to help people transition from the state’s Medi-Cal Medicaid program to Affordable Care Act exchange plans has been successful at keeping people insured since its launch last year, according to a recent report from the nonprofit California Health Care Foundation. JoAnn Volk, the study’s lead author, tells AIS Health the analysis is based on “early data,” so it is too soon to draw any long-term conclusions, although she noted that insurers have praised the rollout.

Starting in July 2023, people in California who lost Medi-Cal coverage could opt to be automatically enrolled in Covered California, the state’s marketplace. Those people were enrolled in a zero-premium or subsidized marketplace plan as the default option, although they also had the chance to opt out of coverage or select a different plan.

As CMS firms up plans to collect more granular information from Medicare Advantage organizations on service coverage denials, a timely analysis from KFF finds that their use of prior authorization (PA) surged to over 46 million requests in 2022. This marks a notable increase from the 37 million requests recorded in 2019, reflecting both the growing enrollment in MA plans and the expanding scope of services requiring prior approval. And while several insurers this year have publicized their efforts to eliminate PA requirements, providers say they’re still feeling the burden, and at least one major MA insurer is adding new PA restrictions.

While PA helps control costs and prevent unnecessary utilization, it can introduce potential barriers to timely care and frustrations for providers. Nearly all MA enrollees (99%) are subject to prior authorization for some services, particularly high-cost ones like inpatient hospital stays, skilled nursing facility stays and chemotherapy.

People enrolled in Affordable Care Act marketplace plans had access to 40% of their local physicians in-network, on average, and those who enrolled in more expensive plans generally could access broader networks, according to a KFF analysis.

The analysis studied the percentage of physicians participating in the provider networks of Qualified Health Plans offered in the individual market in the federal and state ACA marketplaces in 2021. It found that only 4% of ACA exchange enrollees were in plans that included more than three-quarters of local doctors in-network, while 23% of enrollees were in a narrow network plan that included fewer than a quarter of the local doctors.

Most people enrolled in Affordable Care Act exchange plans had in-network access to fewer than half of clinicians in their area in 2021, according to a KFF study published on Aug. 26. Matthew Rae, the report’s lead author, tells AIS Health the number of physicians in networks varies widely even within states and counties, yet it is still difficult for consumers to compare and choose plans.

Rae adds that insurers often limit their exchange networks to keep their costs down and competitive in a crowded field, where often dozens of plans vie for enrollees. He points out that insurers seek to price their offerings based on the second-lowest cost plan in the marketplace’s silver category, which is linked to the premium tax credits that most enrollees receive. Plans that are more expensive than the second-lowest cost silver option often only get a small number of enrollees, according to Rae.

Starting in 2025, The Cigna Group’s Express Scripts will drop Humira (adalimumab) from its largest commercial formularies and instead cover only select biosimilars for the blockbuster autoimmune condition treatment.

The move will make Express Scripts the second major PBM to prefer biosimilars over Humira after CVS Health Corp. did so in April. And it comes as both Cigna and CVS recently voiced their support for the FDA issuing draft guidance that would make it easier for biosimilars to get an “interchangeable” designation.

In 2023, the federal government received more than three times as many surprise billing payment disputes it received in 2022, and provider groups continued to win the vast majority of cases while reaping higher payment amounts, according to new CMS data.

The No Surprises Act (NSA), passed in 2021, banned the practice of billing patients for the difference between what their insurer pays and what a provider charges when patients unknowingly receive care from an out-of-network provider. The law also established a Federal Independent Dispute Resolution (IDR) process that out-of-network providers and insurers can use to determine the OON rate that providers should receive if the two parties fail in their own attempts to negotiate.