Health Plan Weekly

Most state Medicaid programs require managed care plans to cover some common treatments and medications for substance use disorder (SUD), according to a study published this month in Health Affairs. However, Lauren A. Peterson, one of the study’s authors, tells AIS Health, a division of MMIT, it is “concerning” that only half of the states that contract with managed care plans require coverage of all treatments and services recommended by the American Society of Addiction Medicine (ASAM). 

While Peterson, a Ph.D. candidate at the University of Chicago, acknowledges that “states are really making a commitment to cover [SUD treatments],” she says she and her co-authors agree with ASAM that all SUD treatments should be available.  

CMS’s recent revision of Medicare Advantage Star Ratings made some health insurers, especially CVS Health Corp.’s Aetna, big winners in the eyes of Wall Street. A number of insurers received higher bonus payments from CMS for the 2024 plan year after the revision, and others were able to resubmit their bids for the 2025 plan year on more favorable terms. 

The changes are the result of the rulings in lawsuits brought by SCAN Health Plan and Elevance Health, Inc. against CMS. In the SCAN lawsuit, the U.S. District Court for the District of Columbia found that CMS’s failure “to follow its own regulation” resulted in the not-for-profit MA insurer receiving an incorrect 2024 Star Rating, which cost the plan nearly $250 million in quality bonus payments (QBPs) for 2025. That same court also ruled separately that CMS must recalculate Elevance subsidiary Anthem Blue Cross and Blue Shield of Georgia’s Star Ratings. 

As states resumed their Medicaid eligibility redeterminations last spring, some experts suggested that states should prioritize enrolling Medicaid managed care (MMC) enrollees who were losing coverage with the same carrier in the Affordable Care Act (ACA) individual marketplace. Private insurers like Centene Corp. have also emphasized this strategy, with the goal of stemming member attrition. However, a new study from Health Affairs suggests that “a within-carrier transition is likely to be possible only for roughly half of Medicaid managed care enrollees.”

By examining Clarivate’s InterStudy enrollment data from 2021, researchers found that in 2021, 52.1% of MMC members were enrolled by a carrier that also had a plan on the ACA marketplace in the same county. Among all MMC enrollees, 24.5% were in counties where the largest insurer was the same in both Medicaid and the ACA marketplace. In 10.3% of the 2,625 counties with MMC, all MMC enrollees were in a plan offered by an insurer that also had a marketplace plan.

Doctors are increasingly turning to artificial intelligence (AI) chatbots to fight back against health insurers’ claim denials and prior authorization requests, The New York Times reported. Tools like ChatGPT and the HIPAA-compliant Doximity GPT are helping justify treatments they say patients need by drafting letters in seconds that cite scientific studies to back up their arguments. One doctor told the publication that Doximity GPT cut the time he spent on prior authorization requests in half. Major insurers, meanwhile, are facing increasing scrutiny — and a spate of lawsuits –— over their use of AI for tasks like denying large batches of claims or determining the length of patients’ post-acute rehabilitation stays. An AHIP spokesperson told the Times that the insurer trade group welcomes efforts to streamline the prior authorization process, including those that involve the “appropriate use” of AI. 

On June 28, the U.S. Supreme Court in two rulings eliminated a longstanding legal precedent that has protected regulations issued by federal agencies from a broad swath of legal challenges. Attorneys say rulemaking in health care will become more unpredictable as regulations are challenged — which could cost health plans, providers, and patients.

In their rulings in Relentless v. Department of Commerce and Loper Bright Enterprises v. Raimondo, the Supreme Court did away with “Chevron deference,” a legal concept that is over 40 years old. Chevron deference granted agencies the legal benefit of the doubt when they issued regulations that clarified parts of statute that Congress had left ambiguous. The premise behind the concept was that agency staff have subject matter expertise that Congress is unlikely to share, and that Congress couldn’t be expected to continually update statutes in order to address every emerging issue of importance to a specific sector of the economy.