Radar on Medicare Advantage
-
As MA Prior Authorization Requests Soar, Are Reform Efforts Falling Short?
As CMS firms up plans to collect more granular information from Medicare Advantage organizations on service coverage denials, a timely analysis from KFF finds that their use of prior authorization (PA) surged to over 46 million requests in 2022. This marks a notable increase from the 37 million requests recorded in 2019, reflecting both the growing enrollment in MA plans and the expanding scope of services requiring prior approval. And while several insurers this year have publicized their efforts to eliminate PA requirements, providers say they’re still feeling the burden, and at least one major MA insurer is adding new PA restrictions.
While PA helps control costs and prevent unnecessary utilization, it can introduce potential barriers to timely care and frustrations for providers. Nearly all MA enrollees (99%) are subject to prior authorization for some services, particularly high-cost ones like inpatient hospital stays, skilled nursing facility stays and chemotherapy.
-
News Briefs: Humana Talks Scaled-Back MA Presence, Products at Wells Fargo
A Humana Inc. executive speaking at the Wells Fargo Healthcare Conference on Sept. 4 said the Medicare Advantage-focused insurer will exit 13 counties where membership was “insignificant” and reduce its plan offerings in other counties, impacting an estimated 560,000 MA members next year. The selected counties will leave Humana’s footprint largely intact, while impacted members in other counties will have Humana plans to choose from, Chief Financial Officer Susan Diamond told Wells Fargo analyst Stephen Baxter. “The exit itself is positive in the sense that those plans were not contributing,” said Diamond. And in the other counties, if Humana can “ultimately retain more of those members, that’s incrementally positive because the plan choices left behind are priced in such a way that they will be positively contributing.” Despite seeing elevated utilization and medical cost pressure in the first half of the year, the insurer on Sept. 3 reaffirmed its full-year guidance of approximately $16.00 adjusted earnings per share. Diamond during the conference added that Humana is seeing more prior authorization decision appeals than it has seen historically. She also disclosed that Humana anticipates greater utilization of supplemental benefits such as over-the-counter cards and dental services in the fourth quarter, "just recognizing the benefit changes we've made for 2025."
-
Cycle of Protests Dictates Playbook for Medicaid MCOs, Says Industry Expert
As evidenced by hotly contested Medicaid contract awards in Florida, Kansas and Texas this year, local and regional health plans are increasingly being shut out of opportunities to serve enrollees in their communities. And though a recent administrative law judge decision in Arizona suggests the winds could be changing, community plans need to become more strategic about their approach to procurements, says one industry expert.
Beyond the headlines, “so much more has happened in the Medicaid space than the eligibility redetermination process,” says Clay Farris, founder and practice lead of client solutions at Mostly Medicaid, which offers advisory services to community plans and other stakeholders across the Medicaid continuum. He is referring to the so-called unwinding of policies that were in place during the COVID-19 public health emergency, when a yearslong pause on routine eligibility checks led Medicaid and Children’s Health Insurance Program (CHIP) enrollment to hit an unprecedented 94 million in March 2023. As of Aug. 1, at least 24.8 million people had been disenrolled from Medicaid because of redeterminations, KFF reports.
-
Part D Plans Muster Readiness for Potentially ‘Transformative’ M3P Program
Along with other major changes to the Medicare Part D benefit, beneficiaries starting next year will have a $2,000 limit on their annual out-of-pocket (OOP) prescription drug costs, thanks to the Inflation Reduction Act (IRA). If seniors find themselves uncomfortably close to that threshold, they also can smooth those OOP costs over the course of the 2025 plan year through the IRA-established Medicare Payment Prescription Plan (M3P) program. While sources agree the program has the potential to improve access to prescription drugs, they say its success is also largely dependent on how well plans inform patients that the option is available.
-
CMS Flexes Reporting Muscle With Proposed Service-Level Data Collection
In a Paperwork Reduction Act (PRA) notice issued on Aug. 9, CMS informed Medicare Advantage organizations of its plans to collect more granular information on service-level decisions, including both initial determinations and appeals. Sources say this approach aligns with CMS’s continued focus on health equity and transparency, and it could lead to greater oversight of prior authorization decisions.
To plan sponsors, the transmittal should not have come as a surprise, given that the 2024 MA and Part D rule finalized in April affirmed CMS’s authority to collect detailed information from MA organizations and Part D plan sponsors. “An example of increased data collection could be service level data for all initial coverage decisions and plan level appeals, such as decision rationales for items, services, or diagnosis codes to have better line of sight on utilization management and prior authorization practices, among many other issues,” CMS stated in that rule.
The Latest
Complimentary Publications
Premium Categories
Premium Categories
