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HealthPayerIntelligence News

Nearly 20% of Employees Have Inpatient Out-of-Network Claims

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Approximately twenty percent of employees with insurance had at least one out-of-network claim for inpatient care, according to a Peterson-Kaiser Tracker analysis. Employees with out-of-network provider bills may experience increased...

Managed Care Accounted for 38% of Medicaid Spending in 2012

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Medicaid managed care accounted for 38 percent of total Medicaid spending in 2012, according to a Congressional Budget Office analysis. The report found that the majority of states in the US have implemented some form of a managed care...

CMS Proposed Rule Aims to Secure 2018 Risk Adjustment Payments

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CMS has proposed a new rule that aims to resolve legal issues over the risk adjustment program’s payment methodology.  The rule would ensure that payers will receive appropriate risk adjustment payments for plan year 2018. The...

Medicare Advantage Part B Plans Can Use Drug Step Therapy

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CMS is allowing Medicare Advantage (MA) health plans to implement step therapy protocols in order to decrease prescription drug spending. On January 1, 2019, MA health plans can apply step therapy guidelines for physician-administered...

AMA: CVS-Aetna Merger Would Reduce PBM Competition, Raise Prices

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The American Medical Association is urging the Department of Justice to squash the proposed merger between CVS Health and Aetna.  The combined entity would drastically reduce competition in many pharmacy benefit management (PBM)...

Only 22% of Medicare Advantage Customers Aware of Star Ratings

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Only 22 percent of Medicare Advantage (MA) beneficiaries are familiar with how star ratings work and increasing consumer awareness about star ratings would help beneficiaries choose high quality plans, according to a new Healthmine...

Provider Market Concentration Outweighs Payer Concentration

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Healthcare provider systems tend to be bigger, more consolidated, and have more market share than payers in the same metropolitan areas, leaving some payers with less power to negotiate pricing and other contracts, according to the...

Medicare Part D Premiums Expected to Decline in 2019

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CMS has announced that monthly Medicare Part D premiums are expected to fall from $33.59 in 2018 to $32.50 in 2019 as new policies to reduce Medicare’s drug costs take effect. Earlier in 2018, CMS issued a final rule that made...

CMS Final Rule Extends Short-Term Health Insurance to 3 Year Max

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CMS has issued a final rule that triples the length of time a beneficiary can keep short-term health insurance. The rule allows individuals to purchase a new short-term, limited benefit health plan that lasts for 12 months, or extend...

Insurance Coverage Rates Dip by 12% Due to High Premium Costs

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Individual health plan enrollment between 2017 and 2018 fell by 12 percent as high premiums and a scarcity of subsidy assistance force consumers out of the market, according to an analysis from the Kaiser Family Foundation (KFF). Health...

How to Improve Cost Sharing to Enhance Chronic Disease Management

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A tailored cost sharing program that helps beneficiaries pay for chronic disease care can reduce wasteful spending and increase access to chronic disease management services. However, relying on one-size-fits all cost-sharing plans can...

Centene, Ascension Partner for Medicare Advantage Offering

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Centene and Ascension have partnered to offer a Medicare Advantage plan across multiple geographic markets in 2020.   Centene Chairman and CEO Michael F. Neidorff believes that the partnership will showcase effective strategies to...

CMS Approves Wisconsin State Reinsurance Program

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CMS has approved Wisconsin’s plan to launch a state reinsurance program from 2019 to 2023 to help reduce individual state premiums and control the growth of state healthcare spending. The program, called the Wisconsin Healthcare...

12 Attorneys General File Lawsuit Over Association Health Plans

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A dozen state attorneys general are suing the Department of Labor (DOL) over the expansion of association health plan (AHPs).   In the suit, which was filed in the DC District Court of Appeals, the officials argue that broad...

CAQH CORE Urges Industry Collaboration on Prior Authorizations

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CAQH CORE is urging healthcare payers, providers, and other stakeholders to promote industry-wide collaboration on how to improve prior authorizations. Leading provider and payer organizations, including AHIP, AHA, the BlueCross...

How to Address Medicare Advantage Beneficiary Disenrollment

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Medicare Advantage is a growing market and an attractive opportunity for payers to offer quality plans to older beneficiaries.  Competition is increasing in the MA environment, and beneficiaries have more options than ever to meet...

CMS Proposes Site-Neutral Payments, Drug Price Negotiation

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CMS has proposed a rule that would expand the use of site-neutral payments and improve the drug price negotiation process with manufacturers in order to reduce Medicare’s overall spending. The new rule would allow Medicare to...

10% of Medicare Advantage Members Receive Chronic Care Reminders

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Only 10 percent of Medicare Advantage (MA) and Medigap plan members receive chronic care management reminders,, according to a new survey from Healthmine. The CDC estimates that 70 percent of all Medicare beneficiaries have at least one...

CMS: We Will Make $10.4B in 2017 Risk-Adjustment Payments

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CMS has issued a final rule that will allow the agency to disburse $10 billion in 2017 risk adjustment payments that had been in doubt due to a court ruling.   To comply with the initial outcome of a New Mexico lawsuit contending the...

Generic Drugs Could Have Saved $3B for Medicare Part D Program

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Using generic drugs instead of their brand-name equivalents could have saved the Medicare Part D program approximately $3 billion in 2016 alone, according to new data from HHS. A relatively small number of brand-name therapies is...

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