Policy & Politics

News Briefs: Politicians Probe Change Cyberattack

A bipartisan group of politicians wrote a letter on April 15 to UnitedHealth Group CEO Andrew Witty seeking information about the cyberattack on Change Healthcare, a UnitedHealth subsidiary since 2022. They wrote that they were interested in UnitedHealth’s “efforts to secure Change Healthcare’s systems since it was acquired by your company and the efforts you are taking to restore systemic functionality and support patients and providers affected by the attack.” The letter noted that Change’s systems process about 15 billion transactions each year and are linked to about 900,000 physicians, 118,000 dentists, 33,000 pharmacies and 5,500 hospitals. House Energy and Commerce Committee Chair Cathy McMorris Rodgers (R-Wash.) and Ranking Member Frank Pallone, Jr. (D-N.J.), Subcommittee on Health Chair Brett Guthrie (R-Ky.) and Ranking Member Anna G. Eshoo (D-Calif.) and Subcommittee on Oversight and Investigations Chair Morgan Griffith (R-Va.) and Ranking Member Kathy Castor (D-Fla.) signed the letter.

0 Comments
© 2024 MMIT

News Briefs: Startup PBM Closes $100m Funding Round

Startup PBM Rightway on March 30 closed a $100 million Series C financing round, the firm said. According to Rightway, that means the startup is now valued at $1.1 billion. A press release discussing the funding round claims that the firm now serves more than 500,000 members and 850 clients. Rightway, which touts its transparency to prospective clients, also claimed that it generates “an average of 20% reduction in year 1 pharmacy cost savings.”

Payers doubt that state prescription drug affordability boards (PDABs) will have an effect on prescription costs any time soon, according to a survey by Avalere Health. As part of its survey, Avalere conducted “six double-blinded interviews with health plan representatives.” Among the states that have established PDABs, Colorado, Maryland, Minnesota and Washington granted their boards the authority to set upper payment limits (UPLs.) According to Avalere, “all interviewees agreed that UPL-affected drugs or their competitors in the therapeutic class could see greater utilization management…depending on how manufacturers respond to supply chain changes, rebating, and UPL implementation.” In addition, five of six interviewees said they “expect formulary adjustments.” Colorado’s was the first PDAB to propose a UPL, but that has been challenged by the affected drug manufacturer. As a result, interviewed Colorado payers “are not yet actively preparing for a UPL,” expecting that the actual UPL won’t come into effect for “more than a year.”

0 Comments
© 2024 MMIT

Ground Ambulance Surprise Billing Committee Will Back Rate Setting, Medicare On-Site Coverage

A panel of experts will recommend in a formal report to Congress that ground ambulance-related balance bills should be settled using a rate-setting benchmark rather than arbitration, according to one member of the panel; in addition, the report will recommend that Medicare should begin to cover care that is delivered by ambulance personnel but does not result in a hospital transport. The report is under review by CMS, and is expected to kick off another battle on Capitol Hill over surprise billing policy.

Balance or surprise billing generally occurs when a person unwittingly receives care from an out-of-network provider and is then billed by that provider for whatever balance remains after insurance reimbursement. According to a member of the panel, the report will recommend that balance bills for ground ambulance care should be banned in virtually all circumstances, including emergency transports to a hospital, interfacility transports and care delivered by EMTs in the field that does not result in a transport to a hospital.

0 Comments
© 2024 MMIT

AHIP Panelists: Improving Aging in Place Requires Cross-Stakeholder Support

When it comes to aging in place, seniors in the U.S. have a hodgepodge of programs and services available to them, and health plans can be a connector to and integrator of those services in their respective markets. Speakers at AHIP’s 2024 Medicare, Medicaid, Duals & Commercial Markets Forum, held March 12 to 14 in Baltimore, agreed that health plans can also play a valuable role in driving innovations across the Medicare and Medicaid programs, such as providing emergency and acute care in the home, supporting family caregivers, and advocating for policy solutions.

Before CMS in 2020 introduced the Hospital Without Walls program enabling health systems to provide acute hospital care in the home, integrated insurer-provider Kaiser Permanente (KP) launched the Advanced Care at Home (ACAH) model. One of several KP initiatives that support aging in place, ACAH leverages expert care teams and technology to provide 24/7 physician-led acute care and coordinate patients’ recovery in the familiar setting of the home. Eligible patients are identified in urgent care, emergency and/or inpatient settings but must also meet certain social and clinical criteria, explained Rachna Pandya, regional strategic implementation leader of Medicare operations and strategy, during the session, “Best Practices to Support Aging in Place.”

0 Comments
© 2024 MMIT

No Surprises Act Arbitration Drives Up Health Care Prices, Report Says

A new report by Brookings Institution researchers concludes that the No Surprises Act, the 2020 law that banned surprise medical billing, may cause prices — and consequently premiums — to increase, even though policymakers hoped the law would slow or reverse price growth. The report also concludes that a small group of providers, particularly physician staffing groups owned by private equity entities, are responsible for most of the price increases.

This unintended consequence raises the stakes of ongoing litigation between the Texas Medical Association (TMA) and the Biden administration. Those lawsuits challenge regulations governing the NSA-created, HHS-backed arbitration process, called Independent Dispute Resolution (IDR), which resolves balance billing disputes between payers and providers when patients unintentionally receive out-of-network care. The TMA and other provider groups have successfully sued multiple times to block IDR rulemaking that many experts believe would have kept price growth in check.

0 Comments
© 2024 MMIT

News Briefs: Biden Administration Finalizes Rules Limiting ‘Junk Insurance’ Plans

HHS and the Labor and the Treasury departments on March 28 released final rules pertaining to short-term, limited-duration (STLDI) health plans. Those plans will be limited to last no more than four months, compared to up to three years under the previous rules. The rules will also require issuers of STLDIs “to include a clear, easy-to-understand consumer notice on marketing, application, enrollment, and reenrollment materials, so that consumers can make informed coverage purchasing decisions.” The departments called STLDI plans “junk insurance” and noted they are not subject to consumer protections enacted in the Affordable Care Act, including guaranteeing coverage for people with preexisting conditions.

Jamie Raskin (D-Md.), the ranking member of the House Oversight and Accountability Committee, sent a letter on March 25 to UnitedHealth Group CEO Andrew Witty requesting information about the ongoing cyberattack on Change Healthcare, a UnitedHealth subsidiary. Raskin inquired about details such as what data may have been exposed and what policies UnitedHealth has in place to prevent an attack, and he asked Witty to respond to the 12 questions in writing by April 8. Meanwhile, Reuters reported that UnitedHealth said on March 22 that it would start processing its medical claims backlog of more than $14 billion.

0 Comments
© 2024 MMIT

Health Plans Welcome CMS Moves to Curtail Medicaid Coverage Losses

As it marked the 14th anniversary of the Affordable Care Act, the Biden administration in recent days announced several new steps that aim to build on the Medicaid coverage gains achieved by the ACA — and reduce the coverage losses due to Medicaid redeterminations.

On March 27, CMS finalized a rule that aims to streamline eligibility and enrollment processes for Medicaid and Children’s Health Insurance Program (CHIP) beneficiaries. Among other provisions, the rule prohibits states from conducting coverage eligibility renewals any more frequently than 12 months apart.

0 Comments
© 2024 MMIT

News Briefs: ACA Plan Signups Totaled 21M During 2024 Open Enrollment

More than 21 million people selected or were automatically reenrolled in health plans during the most recent Affordable Care Act open enrollment period (OEP). That’s according to one of four reports issued by HHS on March 22 marking the 10-year anniversary of the ACA. HHS also said that 5.1 million more people signed up for coverage during the 2024 OEP compared to the 2023 OEP, representing a 31% increase. Another report found that over 45 million people now have coverage thanks to the creation of the ACA marketplaces and Medicaid expansion -- “the highest total on record.”

The Oregon Health Authority (OHA) on March 14 began a review of UnitedHealth Group’s proposed acquisition of Amedisys Inc., a home health provider. Amedisys disclosed the OHA’s review in a March 19 Securities and Exchange Commission filing. UnitedHealth made a $3.26 billion unsolicited offer for Amedisys last June, shortly after Amedisys had agreed to merge with Option Care Health, Inc., a home infusion provider. Amedisys’s shareholders approved the UnitedHealth deal in September, but the transaction is subject to regulatory approval. In a preliminary analysis published this month, the OHA wrote “this transaction has the potential to reduce competition in Oregon’s market for home health and hospice services and other health care markets in the state.”

0 Comments
© 2024 MMIT

Actuaries Back Move to Undo 2018 Association Health Plan Rule

The American Academy of Actuaries has urged the Biden administration to follow through on its proposal to rescind a controversial 2018 rule that granted more regulatory leeway to association health plans (AHPs). Rescinding the 2018 AHP regulations will protect consumers and strengthen the actuarial health of the Affordable Care Act exchanges, according to Academy Senior Health Fellow Cori Uccello and a February public comment letter from the organization.

The comments by the professional association are in response to a December 2023 regulatory proposal that followed through on long-expected plans to rescind the 2018 rulemaking. Those regulations, put forward by the Trump administration, significantly loosened the requirements that apply to AHPs and their close cousins, multiple employer welfare arrangements (MEWAs). The 2018 rule was never implemented, however, because it was largely blocked by a summary judgment issued as a result of litigation by 11 states and the District of Columbia.

0 Comments
© 2024 MMIT

Medicaid Officials Warn Insurers: Reform Prior Auth Before Politicians Do

Speaking at an AHIP conference in Baltimore on March 13, two state’s top Medicaid officials shared frank views about the tensions that arise from working with private managed care plans to run their Medicaid programs — especially as scrutiny of insurer practices like prior authorization is intensifying.

“We talk a lot internally about the fact that if I were to stand somebody from my agency — the Medicaid agency — next to somebody from a Medicaid managed care company, from a mission perspective, you will not see a single difference between the two,” said Jay Ludlam, deputy secretary of NC Medicaid, during the AHIP Medicare, Medicaid, Duals & Commercial Markets Forum.

0 Comments
© 2024 MMIT