Policy & Politics

CMS Extends Regs Allowing Medicaid Plans to Assist Renewals

CMS on May 9 extended through June 2025 waivers meant to help states and Medicaid managed care organizations navigate the unwinding of COVID-19 pandemic-related eligibility rules. The waivers, which include provisions allowing MCOs to reach out to members about redeterminations and help members complete eligibility paperwork, were originally set to expire in January 2025.

The extension of the waivers — specifically, 1902 (e)(14) waivers — could help MCOs leave behind the upheaval caused by the return of eligibility redeterminations, which resumed in spring 2023 after a multiyear pause tied to the COVID-19 public health emergency. The crush load of eligibility checks has been difficult for states to manage. Many states disenrolled eligible Medicaid beneficiaries for administrative reasons, typically because the beneficiary made an error in their eligibility check or didn’t return paperwork in time to meet a redetermination deadline. The chaos, which was the subject of mutual recrimination between states and CMS, has caused no shortage of headaches for MCOs.

0 Comments
© 2024 MMIT

Hospitals Charged Private Health Plans 2.5 Times Medicare Rates in 2022

Employers and private insurers, on average, paid 254% of what Medicare did for the same inpatient and outpatient services at the same facilities in 2022, according to a new RAND Corp. study.

The report examined data from more than 4,000 hospitals across all U.S. states except Maryland and found that average relative prices paid by private insurers increased from 241% of Medicare rates in 2020 to 254% in 2022, which was largely driven by growth in inpatient relative prices.

0 Comments
© 2024 MMIT

California’s 3% Health Care Spending Target Prompts Angst, Anxiety

California recently became the latest state to implement a limit on health care spending growth, with a new state agency targeting an increase of no greater than 3% by 2029. Commercial payers have largely backed the spending targets, but providers have argued that the targets aren’t reachable and Medicaid stakeholders — including the state’s largest managed care organization — are concerned that the target may curtail access for beneficiaries and harm the solvency of safety net providers.

The spending target was set by the board of the Office of Health Care Affordability (OHCA), which was established in 2022. The board’s membership was appointed by Gov. Gavin Newsom, a Democrat. The board set target spending growth rates of 3.5% in 2025 and 2026, 3.2% in 2027 and 2028, and 3.0% in 2029. OHCA will require payers regulated by the state and providers alike to meet the designated spending targets. Organizations that don't meet the spending targets will be subject to a state-overseen corrective action plan and possibly fines.

0 Comments
© 2024 MMIT

DOJ Probe of UnitedHealth Could Spawn Optum Spinoffs, SEC Review of Stock Sales

A group of lawmakers is urging federal regulators to investigate UnitedHealth executives’ sale of company stock right after learning that the health care firm was the target of a Dept. of Justice (DOJ) investigation concerning its provider-acquisition spree. As for the investigation itself, one antitrust lawyer says it could take years before the DOJ files a case — but if it does, regulators could try to force the health care giant to spin off all or part of its Optum division.

Meanwhile, the DOJ’s antitrust division on May 9 announced a new Task Force on Health Care Monopolies and Collusion, which it said will “guide the division’s enforcement strategy and policy approach in health care, including by facilitating policy advocacy, investigations and, where warranted, civil and criminal enforcement in health care markets.” Some of the competition concerns the task force will examine include “issues regarding payer-provider consolidation” and “serial acquisitions.”

0 Comments
© 2024 MMIT

News Briefs: Walmart Cites Reimbursement Woes in Closing Clinics, Virtual Care

Walmart Inc. announced on April 30 that it is closing its 51 health centers in five states as well as its virtual care offering. The company said in a press release that it had determined “there is not a sustainable business model for us to continue” with its Walmart Health and Walmart Health Virtual Care centers and added that “the challenging reimbursement environment and escalating operating costs create a lack of profitability that makes the care business unsustainable for us at this time.” Walmart launched the clinics in 2019. The company will continue to operate its nearly 4,600 pharmacies and more than 3,000 vision centers.

UnitedHealth Group CEO Andrew Witty testified before the Senate Finance Committee and House Energy & Commerce Committe on May 1 about the cyberattack on Change Healthcare, a UnitedHealth subsidiary. Fierce Healthcare reported that Witty said much of Change’s data was stored in data centers rather than on the cloud and that hackers accessed a server that did not have two-factor authentication. Fierce also noted that several politicians criticized UnitedHealth for its massive vertical integration, noting it owns a PBM and is a major player in health care delivery. Axios reported that UnitedHealth “could face more regulation or even calls to divest some of its businesses in the fallout from the hack.” Last month, a bipartisan group of politicians wrote a letter to Witty seeking information about the cyberattack and 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.

0 Comments
© 2024 MMIT

News Briefs: Kaiser Reports Data Breach Affecting 1.34M

Kaiser Foundation Health Plan, Inc. is notifying millions of current and former customers that their information may have been shared with third parties included Google, Microsoft and the social medial platform X. Kaiser reported the breach to the HHS Office for Civil Rights on April 12, according to an OCR filing, which stated that the number of individuals affected was 1.34 million. In a statement to the news outlet TechCrunch, Kaiser said that “certain online technologies, previously installed on its websites and mobile applications, may have transmitted personal information to third-party vendors.” Compromised data includes member names and IP addresses, as well as information about how members “interacted with and navigated through the [Kaiser Permanente] website and mobile applications, and search terms used in the health encyclopedia,” according to the article.

0 Comments
© 2024 MMIT

Employer Group Fires First Shot in Fight Over Mental Health Parity Regs

The ERISA Industry Committee (ERIC), a benefits trade group for large employers, launched an ad campaign attacking the Biden administration’s mental health parity policies — a notable escalation in plan sponsors’ intensifying opposition to the administration’s approach to mental health care access, which could ultimately lead to litigation.

In a press release, ERIC said it hopes to influence upcoming mental health parity regulation, noting that “departments of President Biden’s administration, including the U.S. Departments of Health and Human Services (HHS), Labor (DOL) and the Treasury are finalizing proposed rule changes regarding mental health and substance use disorder parity.” The expected rule would be a finalized version of a regulation released in September 2023, which calls for much stricter network adequacy standards than were required in previous parity rulemaking.

0 Comments
© 2024 MMIT

News Briefs: CarelonRx Launches New Specialty Offering

CarelonRx, the PBM arm of Elevance Health, Inc., has a new “comprehensive approach to specialty medication savings across pharmacy and medical benefits,” according to an April 22 press release. The new product will use “advanced analytics” to “identify members whose health is at the greatest risk,” which will prompt “a thorough review of a member’s clinical diagnoses, medications, whole-health integrated support, and a review of their site of care options.” At that point, identified members will receive “proactive pharmacist-led outreach to address any barriers to care, and to further coordinate integrated care with their whole health team, including medical and behavioral health professionals.” Elevance recently announced a pending deal to acquire Kroger Inc.’s specialty pharmacy division as it grows its Carelon health services division.

Sen. Bernie Sanders (I-Vt.) said on April 24 that he has launched an investigation into the “outrageously high prices” that Novo Nordisk is charging for its popular treatments for weight loss and Type 2 diabetes, Wegovy and Ozempic. In a letter to the Danish drugmaker’s CEO, Sanders — who chairs the Senate’s Health, Education, Labor and Pensions Committee — noted that the list prices for Wegovy and Ozempic ($1,349 and $969 per month, respectively) are far higher than what the drugs can be purchased for in countries like Canada and Germany. In his letter, Sanders requested information about how Novo Nordisk determined the prices for Ozempic and Wegovy, what it spent on research and development, and more.

0 Comments
© 2024 MMIT

AMCP Panel, GAO Report Sharpen Focus on State PBM Regulation

Although PBM-targeted legislation has stalled at the federal level, states are forging ahead in their efforts to rein in the highly scrutinized industry. In fact, the volume of state measures aimed at PBMs recently led the Government Accountability Office (GAO) to publish a review that zeroed in on five states that have taken a variety of approaches. Meanwhile, speakers at the Academy of Managed Care Pharmacy (AMCP) annual meeting told attendees about pending measures in states like California that industry stakeholders should be closely watching.

“We talk about states as the laboratories of democracy a lot,” Adam Colborn, director of government affairs at AMCP, said during an April 17 session at the conference, which was held in New Orleans. “There are a lot of experiments; I don’t know that they’re all successful experiments, but a lot of policies — particularly in the health care space — that are first enacted at the state level are then later implemented at the federal level.”

0 Comments
© 2024 MMIT

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