Latest / Becker’s Payer Issues Podcast / CMS pitches major MA changes + more

Transcript

CMS pitches major MA changes + more · Becker’s Payer Issues Podcast

• 0:00
  This is Jacob Emerson with the Becker's payer
• 0:02
  issues podcast. Here's your biweekly industry news briefing
• 0:06
  for December 2nd.
• 0:08
  CMS has proposed major reforms for the Medicare
• 0:10
  Advantage and Part D programs in its final
• 0:13
  rule for 2026,
• 0:15
  including changes to prior authorization and weight loss
• 0:18
  drug coverage.
• 0:19
  The agency is also looking for public feedback
• 0:22
  on how Medicare Advantage medical loss ratios are
• 0:25
  calculated in order to address concerns surrounding vertical
• 0:28
  integration across the industry.
• 0:30
  As part of its proposal for contract year
• 0:32
  26, the agency is proposing that Part d
• 0:35
  plans and Medicaid programs provide coverage of GLP
• 0:38
  ones for obesity after previously being excluded, unless
• 0:42
  those drugs were being used to treat
• 0:44
  conditions such as diabetes.
• 0:45
  CMS is also looking to address concerns about
• 0:48
  the overuse of prior authorization
• 0:50
  by introducing clearer definitions for internal coverage criteria,
• 0:54
  stricter transparency requirements for insurers,
• 0:57
  ensuring enrollees are informed about their appeal rights,
• 1:00
  and collecting more data on initial coverage decisions
• 1:03
  and appeals.
• 1:04
  CMS is also proposing new standards for MA
• 1:06
  medical loss ratios reporting to better align with
• 1:10
  Medicaid and commercial requirements.
• 1:13
  The agency is issuing a request for information
• 1:15
  on potential policies that it could adopt regarding
• 1:18
  how the MA and Part D MLRs are
• 1:20
  calculated in order to enable policymakers to address
• 1:23
  concerns surrounding vertical immigration across the industry.
• 1:27
  The agency is also proposing to expand the
• 1:29
  definition of marketing to cover more materials and
• 1:31
  activities related to MA and Part D plans,
• 1:34
  requiring more advertisements and communications to be reviewed
• 1:37
  by the agency
• 1:38
  before being shared with the public. The new
• 1:40
  rule also focuses on improving consumer tools on
• 1:43
  medicare.gov,
• 1:44
  and brokers are it's proposed that brokers must
• 1:47
  discuss additional topics with enrollees such as Medigap
• 1:50
  rights and low income subsidy eligibility.
• 1:53
  On the topic of artificial
• 1:55
  intelligence, CMS said it aims to enforce equitable
• 1:57
  access to care regardless of delivery by humans
• 2:00
  or AI tools.
• 2:01
  MA plans
• 2:03
  using AI must comply with anti discrimination laws
• 2:06
  and provide fair, unbiased access to services.
• 2:10
  On Becker's website, there's a full analysis of
• 2:12
  the full proposed rule for contract year 2026.
• 2:17
  UnitedHealthcare
• 2:18
  has prevailed in its lawsuit against CMS regarding
• 2:20
  the methodology used to calculate its 2025
• 2:23
  Medicare Advantage Star ratings.
• 2:26
  That lawsuit was filed at the end of
• 2:28
  September in a federal court in Texas, and
• 2:30
  it revolved around the inclusion of a single
• 2:32
  disputed customer service phone call in the agency's
• 2:35
  calculation.
• 2:36
  The judge ruled that CMS must recalculate
• 2:39
  United's 2025 star ratings without consideration of the
• 2:42
  disputed call and immediately republish those recalculated
• 2:45
  star ratings online.
• 2:47
  The courts found that CMS had acted contrary
• 2:49
  to its own guidelines when evaluating that phone
• 2:52
  call, which was marked as unsuccessful
• 2:54
  despite evidence showing it lasted over 8 minutes
• 2:57
  and connected to a call center representative.
• 2:59
  United's lawsuit is one of several filed by
• 3:02
  insurers this year challenging the agency's 2025
• 3:06
  MA star ratings.
• 3:07
  The agency reported a significant drop in 5
• 3:09
  star plans for this year with only 7
• 3:12
  achieving the top rating compared to 38
• 3:14
  last year. Humana, Centene, Elevance, and Blue Cross
• 3:17
  Blue Shield of Louisiana have all raised legal
• 3:20
  challenges about the methodology CMS employed for the
• 3:23
  2025 ratings.
• 3:24
  Some of those challenges have centered on the
• 3:26
  agency's use of secret shopper phone calls to
• 3:29
  assess customer service metrics.
• 3:32
  In November, the deputy CMS administrator doctor Mina
• 3:35
  Seshamani announced that call center measures will carry
• 3:38
  less weight in future MA star ratings starting
• 3:41
  in 2026.
• 3:44
  Well, Humana
• 3:45
  misrepresented the providers its Medicare Advantage Plans will
• 3:48
  be in network with in 2025.
• 3:50
  That's according to Minnesota's attorney general, Keith Ellison.
• 3:54
  Mister Ellison sent a letter to Humana CEO
• 3:56
  Jim Rechten on November 22nd
• 3:59
  expressing concern that the insurer listed Essentia Health
• 4:02
  and other health systems
• 4:03
  as in network for its for its 2025
• 4:07
  Medicare Advantage plans on its website.
• 4:09
  Accenture has said it will be out of
• 4:11
  network with Humana MA plans in 2025.
• 4:14
  Mister Ellison alleged that Humana also listed Avera
• 4:17
  Health, North Memorial Health, and Sanford Health as
• 4:20
  in network in Minnesota for 2025,
• 4:22
  though all three systems have said they intend
• 4:24
  to exit Humana's m a MA network in
• 4:26
  the state at the end of 2025.
• 4:32
  Well, at least 8 health systems are getting
• 4:34
  out of the insurance business.
• 4:36
  Earlier this year, Baystate Health in Massachusetts
• 4:40
  reached a deal to sell Health New England
• 4:42
  to 0.32 Health for a $165,000,000.
• 4:45
  Massachusetts regulators approved that deal on November 26th.
• 4:50
  Baystate has around a 180,000 members across Medicare,
• 4:54
  Medicaid, and commercial plans.
• 4:56
  Point 32 Health has more than 1,000,000 members.
• 4:59
  Also, in November, Astana Health entered into a
• 5:02
  definitive agreement to acquire certain assets from Prospect
• 5:05
  Health System in Los Angeles, including Prospect's health
• 5:08
  plan. In September, Indiana University Health said it
• 5:11
  plans to sell its insurance business to Anthem
• 5:14
  Blue Cross and Blue Shield for an undisclosed
• 5:16
  amount.
• 5:17
  In May, ProMedica in Toledo, Ohio sold its
• 5:19
  insurance subsidiary, Paramount Health, to the insurer, Medical
• 5:20
  Mutual of Ohio.
• 5:21
  Subsidiary, Paramount Health, to the insurer, Medical Mutual
• 5:24
  of Ohio.
• 5:27
  And back in 2023, Ascension Wisconsin finalized a
• 5:30
  deal to sell all of its stake in
• 5:32
  the insurer, Network Health, to Froedtert Health. The
• 5:35
  Milwaukee system freighter is now the sole owner
• 5:38
  of network health, which offers health plans in
• 5:41
  23 Wisconsin counties.
• 5:43
  And other health systems have chosen to close
• 5:45
  rather than sell their health plans. Southwestern Health
• 5:48
  Resources out of Farmers Branch, Texas is shutting
• 5:51
  down Care and Care, its Medicare Advantage Business
• 5:53
  at the end of this year.
• 5:55
  And Michigan Medicine out of Ann Arbor said
• 5:57
  in November it plans to discontinue its health
• 5:59
  plan at the end of 2025
• 6:01
  after experiencing significant financial losses over the last
• 6:05
  few years. And finally, Mary Washington Healthcare in
• 6:08
  Fredericksburg, Virginia closed its MA plan at the
• 6:11
  beginning of 2024.
• 6:15
  Well, CVS Health is laying off an additional
• 6:17
  42 employees at Aetna's headquarters in Hartford, Connecticut
• 6:20
  after laying off 100 of employees at the
• 6:22
  insurer earlier this year.
• 6:24
  Those layoffs will take place between January 25th
• 6:27
  February 7, 2025.
• 6:30
  Though all of the infect affected employees report
• 6:32
  to Aetna's Hartford headquarters,
• 6:34
  just 12 reside within the state. Back in
• 6:37
  October, Aetna reported that it would lay off
• 6:39
  more than 400 employees at Aetna. The layoffs
• 6:41
  are part of an initiative to cut more
• 6:43
  than $2,000,000,000
• 6:44
  in costs at CVS.
• 6:46
  Across the company, CVS is laying off more
• 6:48
  than 29100
• 6:49
  employees as part of its efforts to cut
• 6:51
  costs, though that accounts for less than 1%
• 6:54
  of the company's workforce, and most of those
• 6:56
  jobs are in corporate roles.
• 7:01
  Also at Aetna, a former employee with the
• 7:03
  company has been sentenced to 5 years in
• 7:05
  prison in Ohio over his involvement in several
• 7:08
  fraudulent claims schemes. The in individual
• 7:12
  pleaded guilty to 13 felony counts of insurance
• 7:14
  fraud, telecommunications
• 7:16
  fraud, tampering with records, identity fraud, forgery, and
• 7:20
  attempted theft,
• 7:22
  according to a November 26 news release from
• 7:25
  the Ohio Department of Insurance.
• 7:27
  He's also been ordered to pay $229,000
• 7:31
  in restitution.
• 7:32
  That sentencing in Ohio comes shortly after 2
• 7:35
  other Aetna employees were arrested in Florida in
• 7:37
  November
• 7:38
  for allegedly orchestrating a $1,100,000
• 7:41
  fraud scheme involving the submission of 42 false
• 7:44
  claims between 2019 and 2023.
• 7:47
  In Ohio, an investigation uncovered the individual's pattern
• 7:51
  of submitting altered documents, falsified claims, and identity
• 7:54
  theft to fraudulently secure payouts from multiple insurers,
• 7:58
  including Aetna.
• 7:59
  Between November 2022 October 2023,
• 8:02
  the individual filed 21 fraudulent claims while employed
• 8:06
  at Aetna, receiving more than a $162,000
• 8:09
  for false hospitalizations,
• 8:11
  accidents, and a fabricated cancer diagnosis.
• 8:14
  Additionally, he submitted fraudulent claims totaling over $67,000
• 8:18
  to property and pet insurers.
• 8:20
  Aetna told Becker's in a statement that the
• 8:22
  company is committed to maintaining the highest standards
• 8:24
  within its business practices
• 8:26
  and that it takes legal allegations seriously and
• 8:28
  cooperated fully with the Ohio Department of Insurance's
• 8:32
  investigation.
• 8:34
  If you'd like to receive
• 8:36
  more health care insurance
• 8:38
  news directly to your inbox every morning, subscribe
• 8:40
  to the Becker's Payer Issues e newsletter on
• 8:43
  our website at beckerspayer.com.