The notion that a Republican administration would be inherently favorable to Medicare Advantage (MA) is being tested. From CMS’ decision to hold MA rates flat for next year, to the DOJ's continued enforcement actions related to MA billing and the OIG's heightened scrutiny of upcoding practices, MA stakeholders are preparing for a bumpy...
The Center for Medicare & Medicaid Services on Monday released a proposed rule that would formalize the most sweeping changes to the Medicare Part D benefit since its launch in 2006. According to CMS, the rule would codify key Inflation Reduction Act (IRA) reforms for 2027 and beyond, lowering out-of-pocket drug spending while aiming...White Papers, E books, Reports and more
A new study published in the JAMA Health Forum suggests that changes to the risk adjustment formulas used in Medicare's payment system could ensure health plans are fairly compensated for taking on sicker patients from disadvantaged populations.
The JAMA study looked at health and payment data from 4.4 million Medicare beneficiaries...National News
Centene threw out its earnings guidance for the year after projections showed that the company will make $1.8 billion less than expected through the exchange risk-adjustment program.
In a news release on Tuesday, Centene announced that a report by the independent actuarial firm Wakely found that 22 of the company's 29 Marketplace...National News
This week, America's Health Insurance Plans (AHIP), the American Medical Association (AMA), and the National Association of ACOs (NAACOS) released a playbook on voluntary best practices as part of their efforts together to advance the adoption of value-based care arrangements in the private sector to improve the quality, equity, and...
The Alliance of Community Health Plans (ACHP) demanded a major overhaul of Medicare Advantage and is asking the Centers for Medicare and Medicaid Services (CMS) and Congress to change the program's regulatory aspects.
ACHP calls the new plan MA for Tomorrow, and will break down policies into five areas: improving quality, streamlining...
Lawmakers and stakeholders are still very upset with the U.S. Department of Health and Human Services' (HHS) plan to cut payments to the Medicare Advantage (MA) program and to enforce regulations against MA plans that have benefitted financially from improper overpayments. This week, HHS Secretary Xavier Becerra defended the rule in two...
Medicare Advantage (MA) is a tremendously popular program among not only beneficiaries but the policymakers and stakeholders who want to see the program work out. As an alternative to Traditional Medicare, hundreds of billions of dollars flow through MA plans, leaving a lot of room for fraud.
One major source of overcharging the...National News
Last week, the Biden administration issued a proposed rule aimed toward making it easier for consumers to find affordable, comprehensive health coverage in 2023. The Centers for Medicare and Medicaid (CMS) have released the details of the proposed rule, which includes reversals of several Trump-era policies.
Benefits Pro reports...National News
Insurers claim the Trump administration's decision to withhold billions of dollars in risk adjustment payments could result in higher premiums for millions.
It was confirmed Saturday that $10.4 billion in payments to insurers under Obamacare is suspended due to a court's ruling over the risk adjustment program in New Mexico....
The 21st Century Cures Act requires changes to the risk adjustment model for aged and disabled beneficiaries enrolled in Medicare Advantage Part C plans beginning in calendar year 2019.
For 2019, the agency proposes adding mental health, substance use disorder and chronic kidney disease conditions to the risk adjustment model and...
CMS and Mark Farrah Associates looked at the impact of the different programs the ACA put in place to mitigate adverse selection and stabilize premiums.
Risk corridors, reinsurance and risk adjustment were the "Three R's" of the ACA. Only the risk adjustment program is permanent. It deters insurers from manipulating risk selection...National News
The ACA created the permanent risk adjustment program to redistribute funds from plans with lower-risk policyholders to plans with higher-risk policyholders.
The CMS report, released June 30 made a number of findings to put the program in perspective. Read "Five Things to Know" in Becker's Hospital Review.
Read the 54 page report...
