Health Plan Weekly
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Here’s Why States, Pharmacists Want SCOTUS to Weigh Another PBM Case
Although the Supreme Court has already weighed in on one case regarding states’ ability to regulate PBMs, the top law enforcement officials in more than 30 states are asking the high court to review another case that they claim will remove lingering uncertainty about the limits of states’ authority.
In PCMA v. Mulready, the current case, the Pharmaceutical Care Management Association is challenging an Oklahoma law — the Patient’s Right to Pharmacy Choice Act — which sets geography-based access standards for pharmacy networks. Among other provisions, it also bans PBMs from using discounts or cost-sharing differences to push plan members to certain in-network pharmacies, particularly those owned by that same PBM’s parent company.
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Health Care Coverage, Spending Trends Diverge Among Payers as COVID-Related Policies Expire
The share of people without health insurance coverage reached an all-time low of 7.2% in 2023 but is projected to rise to 8.9% in 2034, according to the Congressional Budget Office.
The increase in the uninsured rate was largely due to the end of Medicaid’s continuous eligibility provisions in 2023 and 2024, the expiration of enhanced subsidies available through the Affordable Care Act (ACA) marketplaces after 2025 and a surge in immigration that began in 2022, observed the CBO in a report posted June 18.
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News Briefs: Texas Court Ruling Delays New Agent and Broker Restrictions in MA
Just days after the Supreme Court issued rulings overturning a longstanding legal framework that gives federal agencies the benefit of the doubt when interpreting ambiguous legislation, the U.S. District Court for the Northern District of Texas granted plaintiffs’ request for a stay to prevent CMS from implementing new agent and broker provisions in Medicare Advantage this fall. Since CMS finalized the 2025 MA and Part D rule that included new caps on administrative payments to agents and brokers by MA organizations and a ban on anticompetitive terms in MAO contracts with agents, brokers and third-party marketing organizations, at least three complaints have been filed challenging CMS’s implementation of the new provisions that take effect Oct. 1. According to a July 3 opinion signed by U.S. District Judge Reed O’Connor, the court agreed to stay the effective date of the fixed-fee and contract-terms restriction in the final rule until the issues can be fully briefed and heard by the court. The parties must submit a joint schedule for summary judgment briefing by no later than July 17. “Of note, the Court declined to grant a stay with respect to the regulatory changes on the sharing of beneficiary information,” Helaine Fingold, partner at the law firm Epstein Becker & Green, P.C., tells AIS Health, a division of MMIT. “Keep in mind that this does not mean that the plaintiffs will definitely win (or definitely lose, as to the sharing of beneficiary information provision) upon the Court’s full consideration of the issues. It does, however, indicate that the plaintiffs were able to convince the Court that they are likely to prevail (or not) on the merits.”
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Appeals Court Leaves Preventive Services Coverage Mandate in Limbo — What’s Next?
Legal odds are growing long for the Affordable Care Act’s preventive services coverage mandate after a June 21 appeals court decision, which didn’t resolve a lawsuit that could undermine the legal authority of federal preventive services experts to recommend those services be covered free of charge by health plans. The next stage of the Braidwood v. Becerra suit will be decided by either the conservative Supreme Court or a federal judge who has issued a series of rulings undermining the ACA.
The U.S. Court of Appeals for the Fifth Circuit found that the federal government can still require health plans to provide some preventive services to plan members free of charge under the Affordable Care Act — for now. The ruling still leaves open the possibility that, in the end, Braidwood could upend the preventive services coverage regime set up by the ACA. In the next step of Braidwood, the Biden administration must decide whether to petition the Supreme Court for an appeal, or let the case be decided by Texas District Court Judge Reed O'Connor, who has repeatedly ruled against provisions of the ACA.
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UnitedHealthcare to Offer Risk-Sharing in Type 2 Diabetes Program
More and more plan sponsors are interested in introducing risk-based reimbursement in their contracts with health insurers. That interest has grown into a range of plan designs: On the extreme end, plan sponsors like CalPERS are introducing upside and downside risk to entire third-party administrator contracts. A more incremental approach sees health insurers offering upside risk to plan sponsors based on the health insurer’s ability to control costs for a specific condition.
UnitedHealthcare on June 26 launched such an offering, called the Level2 Assured Value Program. It’s a new payment model for an existing Type 2 diabetes management benefit design called Level2.
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