Policy & Politics

CMS on Nov. 6 released a proposed rule that aims to address multiple parts of the Medicare Advantage program that recently have been the target of criticism — including broker compensation, access to behavioral health care, and the use of supplemental benefits and prior authorization. However, a major trade group for health insurance brokers and agents says the part of regulation targeting their industry is both misguided and potentially disastrous.

Should the rule be implemented as proposed, “I think that the MA distribution [system], which is the agents and brokers, will collapse,” says John Greene, senior vice president of government affairs at the National Association of Benefits and Insurance Professionals (NABIP).

A KFF report released on Nov. 8 found that 3,959 Medicare Advantage plans are available for individual enrollment next year, the second-largest number of plans since 2010 and a 1% decrease from this year. Meanwhile, the average beneficiary will be able to choose from 43 plans, the same as this year's record high. Eighty-nine percent of MA plans will offer prescription drug coverage in 2024; while 83% will offer telehealth benefits; and at least 97% will offer some dental, vision, fitness or hearing benefits.

A group of 32 Reps. led by Jerrold Nadler (D-NY) and Judy Chu (D-CA) sent a letter on Nov. 3 to CMS Administrator Chiquita Brooks-LaSure requesting increased oversight of artificial intelligence tools (AI) used to guide coverage decisions for Medicare Advantage plans. The elected officials wrote that “in recent years, problems posed by prior authorization have been exacerbated by MA plans’ increasing use of AI or algorithmic software managed by firms such as NaviHealth, myNexus, and CareCentrix to assist in their coverage determinations in certain care settings.” They asked CMS to require MA plans to report prior authorization data, compare guidance generated by AI tools with actual coverage decisions and assess whether plans are inappropriately using AI tools.

The Senate Finance Committee on Nov. 8 unanimously approved legislation to block pharmacy benefit manager practices that result in higher cost-sharing for beneficiaries.

The bill does not include provisions that were included in an earlier draft that would ensure “high discount” biosimilars get favorable formulary tiering. But those policies may be added back before the bill reaches the Senate floor for a vote.

The committee is planning to combine the bill with other PBM reform legislation it approved in July which includes a policy that would de-link PBM compensation from the list price of drugs.

The state of California is facing delays in its efforts to produce low-cost insulin and is unlikely to meet its 2024 timeline, Bloomberg Law reports. Gov. Gavin Newsom (D) announced in March that the state had formed a partnership with Civica Rx to produce an insulin known as CalRx that would cost no more than $30 per 10ml vial and no more than $55 for a box of five, 3 mL pre-filled pens. However, California Health and Human Services Secretary Mark Ghaly, M.D., told Bloomberg Law the launch date would extend beyond 2024 due to unanticipated delays.

A group of 48 senators sent a letter to HHS Secretary Xavier Becerra, Dept. of Treasury Secretary Janet Yellen and Dept. of Labor Acting Secretary Julie A. Su asking for the Biden administration to require all insurers to fully cover over-the-counter (OTC) contraceptives. The politicians want the plans to cover the medications with no copays or out-of-pocket costs and without requiring a prescription. Opill, the first FDA-approved OTC birth control pill, is expected to become available early next year. The senators signing the bill included Patty Murray (D-Wash.), chair of the Senate Appropriations Committee; Bernie Sanders (I-Vt.), chair of the Senate Health, Education, Labor and Pensions Committee; and Ron Wyden (D-Ore.), chair of the Senate Finance Committee.

As of Nov. 1, nearly 10.1 million people had been disenrolled from Medicare during the resumed eligibility redetermination process, according to KFF’s Medicaid Enrollment and Unwinding Tracker. KFF, which compiles data from CMS and state websites, noted that 35% of people with a completed renewal application were disenrolled from Medicaid, while the remaining 65% had their coverage renewed. The disenrollment rates range from 10% in Illinois to 65% in Texas. During most of the COVID-19 public health emergency, states have been banned from conducting routine eligibility checks on Medicaid beneficiaries, but that process restarted on April 1.

Medica, which offers health insurance coverage in 12 states, has promoted Lisa Erickson to president and CEO, replacing John Naylor, who announced his resignation in July. Erickson joined Medica as chief financial officer in April after spending three and a half years as senior vice president of industry and network relations at Optum, UnitedHealth Group’s health services subsidiary. Medica is based in Minnetonka, Minnesota, a Minneapolis suburb.

Although PBMs are taking increasing heat for spread pricing — or charging payers more for a drug than pharmacies are reimbursed — they aren’t the only players in the drug supply chain that engage in the practice, a new study points out. And one of the study’s authors says its findings suggest that patients may be better off if generic drugs are simply removed from insurance coverage entirely.

The study, published in JAMA Health Forum on Oct. 20, examined data associated with 45 high-utilization Medicare Part D-covered generic drugs.

Although PBMs are taking increasing heat for spread pricing — or charging payers more for a drug than pharmacies are reimbursed — they aren’t the only players in the drug supply chain that engage in the practice, a new study points out. And one of the study’s authors says its findings suggest that patients may be better off if generic drugs are simply removed from insurance coverage entirely.

The study, published in JAMA Health Forum on Oct. 20, examined data associated with 45 high-utilization Medicare Part D-covered generic drugs.

In January, the U.S. Supreme Court is slated to hear two cases brought by fishing companies that, at first glance, would seem to have nothing to do with health insurers. However, the outcome of those cases could profoundly change how insurers — and companies of all stripes — interact with the many regulations that govern their businesses.

That’s because the cases — Loper Bright Enterprises, et al. v. Gina Raimondo and Relentless Inc., et al. v. Dept. of Commerce, et al — concern a legal doctrine known as Chevron deference, which for decades has given federal agencies considerable leeway when interpreting laws via rulemaking. If the high court strikes down that longstanding legal precedent, the regulatory landscape that governs every industry could become much more chaotic, legal experts tell AIS Health, a division of MMIT.

This summer, Opill (norgestrel) became the first over-the-counter (OTC) daily contraceptive pill approved by the FDA, and it’s slated to hit the U.S. market in early 2024. However, Opill’s OTC designation — which on the surface would seem to increase access to birth control — may have the opposite effect for patients seeking reimbursement from their health plans, experts said during a recent KFF web event.

“Having over-the-counter contraceptives is definitely a positive step,” said Christine Gilroy, M.D., chief medical officer of The Cigna Group’s PBM, Express Scripts. “I am concerned, though, that while it removes the barrier of needing to pay for a physician visit and get a prescription from the physician…in order to be processed against a pharmacy benefit, it does need to be entered into a system that essentially turns it into a prescription.”

Payer anxieties about lower Star Ratings for the 2024 plan year came to fruition last week with CMS’s release of the annual Part C and Part D quality measurements. The average Medicare Advantage Prescription Drug (MA-PD) contract scored a 4.04, down from 4.14 last year and the lowest average rating since 2017. Just 31 contracts received 5 stars, representing 6.8% of current MA-PD enrollment, vs. 57 contracts serving 21.5% of enrollees last year.

Several methodology changes fueled the ratings decline, which Stars experts have dubbed "TukeyGate," referring to CMS efforts to remove outliers from calculating the cut points for non-Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures. The agency also added two new Part C measures, one for care transitions and another for follow-ups after emergency visits for people with high-risk chronic conditions. A Part C measure on kidney disease monitoring for diabetes patients was removed.