Health Plan Weekly

  • News Briefs: CMS Says 30 States Pause Medicaid Disenrollments

    CMS will reinstate coverage for approximately 500,000 Medicaid and CHIP enrollees, mainly children, after they were improperly disenrolled from the safety net insurance programs. According to CMS, on Aug. 30 the agency sent a letter to all states, the District of Columbia, Puerto Rico and the U.S. Virgin Islands “requiring them to determine and report whether they have a systems issue that inappropriately disenrolls children and families, even when the state had information indicating that they remained eligible for Medicaid and CHIP coverage.” The agency said 30 states have reported that they are working through the “systems issue” behind the improper disenrollments and have paused procedural disenrollments for affected beneficiaries. Every state Medicaid program is working through the resumption of Medicaid eligibility redeterminations, which were paused for over two years as part of the federal response to the COVID-19 pandemic. 
  • House Inches Closer to Passing Hospital-Feared, Payer-Loved ‘Site-Neutral’ Reforms

    The House is reportedly poised to vote soon on legislation that consolidates a host of previously introduced health care measures — including a step toward site-neutral payment reform. Aimed at stopping “price gouging” by hospital outpatient departments (HOPDs), those provisions are enthusiastically supported by payers but opposed by the hospital industry, which argues that they would result in payment reductions. 

    The legislation also would codify existing regulations that lay out new price transparency requirements for health plans and hospitals, and it would implement modest PBM reforms.  

  • BCBS of Michigan Becomes Latest Insurer to Reduce Prior Authorizations

    Blue Cross Blue Shield of Michigan announced on Sept. 7 that it plans to reduce the use of prior authorization (PA) by 20%, becoming the latest payer to cut its PA requirements. While the moves make care delivery less burdensome for providers and patients, health insurers should also benefit from not relying as much on PA, according to health policy experts who spoke with AIS Health, a division of MMIT. 

    Michael Lutz, a senior consultant at Avalere Health, says that insurers can lower their administrative burden and focus on services where PAs are essential such as costly or high-volume procedures. He adds that plans announce their PA reductions as a marketing tool, too.  

  • CVS, Cigna CEOs Pan Blue Shield of California PBM Deals

    The CEOs of CVS Health Corp. and The Cigna Group on Sept. 12 downplayed the potential for PBM market disruption that could result from Blue Shield of California’s recent deal to unbundle its pharmacy benefit contracts. But both executives hedged by emphasizing their PBMs’ flexibility, and Cigna’s boss suggested that its Express Scripts subsidiary has an a la carte PBM menu. 

    CVS and Cigna leaders also said, during presentations at the Morgan Stanley Health Care Conference, that they are confident that their Medicare Advantage Star Ratings will improve, and they promised further MA growth. Both firms assured investors that their recent, multibillion-dollar provider transactions will lead to future growth. And both firms, which own two of the “Big Three” PBMs, said that biosimilars will be a boon to payers — with CVS promising as much as 80% savings on its forthcoming Humira (adalimumab) biosimilar line. 

  • One in Three HHS Appointees Exit for Industry Jobs

    One-third of political appointees to HHS between 2004 and 2020 later exited to work for the private sector, according to a recent study published in Health Affairs.

    Based on an analysis of employment histories for 766 appointees, the researchers found that more than half of appointees at the Centers for Disease Control and Prevention, CMS and the Office of the Deputy Secretary at HHS went straight to private industry after their government employment.

    Meanwhile, about 15% of people appointed to HHS during the study period were employed in the private sector immediately before joining the government. A greater share of people appointed by a Republican president came from the industry compared with a Democratic president, yet net rates of exit to industry remained similar.

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