Health Plan Weekly

The number of prior authorization (PA) determinations made by Medicare Advantage insurers has risen steadily in recent years as enrollment in MA has grown, according to a new KFF analysis.

In 2021, there were 37 million PA determinations, followed by 46 million in 2022 and nearly 50 million in 2023. The increase corresponds to the growing enrollment in MA plans, from 22 million in 2019 to 31 million in 2023.

The Trump administration plans to continue with the Inflation Reduction Act’s Medicare Drug Price Negotiation Program as well as a model to help state Medicaid agencies pay for expensive cell and gene therapies. CMS said in a Jan. 29 statement that the agency “is committed to incorporating lessons learned to date” from the price negotiation program, and CMS will consider “opportunities to bring greater transparency” into the program. On Jan. 17, three days before Trump’s inauguration, CMS released the list of 15 drugs selected for the second cycle of the program. Meanwhile, an HHS spokesperson told STAT that the administration will continue with the Cell and Gene Therapy (CGT) Access Model, which CMS introduced in 2023 and is set to go into effect later this year. Trump’s recent recission of former President Joe Biden’s executive order that led to the creation of the model caused confusion about whether the CGT Access Model would continue during his administration. CMS last month announced the manufacturers of two high-cost sickle cell gene therapies will participate in the model.  

With chatter in the Capitol heating up about revamping the Medicaid program, some interest groups are already kicking off their efforts to sway lawmakers away from proposals like per capita funding caps, work requirements and changes to the federal funding match rate. Yet at least one health insurer trade group says that it’s focusing more on nearer term threats such as inadequate capitation rates and the cost of covering GLP-1 drugs. 

“The broader discussion on any kind of newer approach to Medicaid is an excellent conversation to have, but we’re not at that point yet,” says Ceci Connolly, president and CEO of the Alliance of Community Health Plans (ACHP). “Nobody is really providing any specific detail about what they mean by work requirements, for instance, or by block grants. They’re just kind of slogans right now.” 

With Donald Trump now sworn in as the 47th president and Republicans controlling both chambers of Congress, the future of Medicaid is uncertain.  

During his campaign, Trump promised to slash federal spending. And according to a document now circulating on Capitol Hill, House Republicans are considering several Medicaid policy changes that could reduce federal spending by $2.3 trillion, including imposing a per capita cap on federal Medicaid funding, reducing the funding match rate for the Medicaid expansion population, and lowering the federal medical assistance percentage (FMAP) floor from the current 50% level. 

Elevance Health, Inc.’s fourth-quarter 2024 earnings report was better than many analysts expected after its third-quarter report included a full-year 2024 earnings outlook cut that sent the insurer’s stock tumbling 12%. 

Elevance reported adjusted diluted earnings per share (EPS) of $3.84 for the fourth quarter, beating the Wall Street consensus estimate of $3.77. The insurer also posted a medical loss ratio (MLR) of 92.4%, narrowly beating the consensus of 92.6%. Fourth-quarter operating revenue was $45 billion, a 6% year-over-year increase. Total 2024 operating revenue was $175.2 billion, up 3% from 2023. This increase was largely driven by higher premium yields in the insurer’s Health Benefits segment, which includes individual plans, employer group plans, Medicare and Medicaid.