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Poor Data Quality in CA Medicaid Drives $4B in Improper Payments

November 6, 2018 - California's Medicaid program, Medi-Cal, made over $4 billion in improper payments to cover benefits for ineligible beneficiaries because of poor data quality and insufficient oversight, according to a new report from state auditors. The majority of the improper payments, totaling $3 billion from 2014 to 2017, were made by the state’s Department of Health Care Services to...


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PBMs, Specialized Formularies Reduce Managed Care Prescription Costs

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Pharmacy benefit managers (PBMs) with specialized drug formularies can help managed care payers significantly reduce prescription drug costs, according to new research published in the Journal of Managed Care and Speciality Pharmacy. The...

Administrative Plan Costs for Managed Care Payers Jumped 5.7% in 2017

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Managed care payers experienced a 5.7 percent increase in administrative plan costs in 2017, for items such as staffing and customer service support, according to an analysis from the Sherlock Company. Spikes in Medicaid enrollment...

Medicare Diabetes Prevention Program May Have Cost Concerns

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The Medicare Diabetes Prevention Program (MDPP) may not fully cover provider costs needed to administer classes and other programs to prevent diabetes among Medicare members, says a new report from the University of Colorado (UC) School of...

CMS Proposes Drug Price Transparency in Television Ads

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CMS has proposed a new rule that would enhance drug price transparency by requiring drug manufacturers to publish wholesale prices of Medicaid and Medicare prescription drugs during television ads. The proposed rule would require...

Medicare Deductibles, Premiums to Increase Slightly in 2019

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CMS has announced that Medicare Part A and Part B premiums and deductibles are expected to increase slightly for the 2019 plan year. Part B members will see small increases in both their premiums and their deductibles, while Part A...

Medicaid Beneficiaries Face Significant Food Insecurity Challenges

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Medicaid beneficiaries face significant food insecurity challenges and may require additional healthcare programs to reduce food insecurity risks, according to new research from the Root Cause Coalition. Many Medicaid beneficiaries...

Managed Care Payers Struggle to Staff Long Term Support Services

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Managed care payers and state Medicaid agencies are finding it difficult to find personnel to administer long-term support services (LTSS) within home and community-based settings (HCBS), says a new GAO report. Currently, Medicaid spends...

DaVita Medical to Pay $270M for Improper Medicare Advantage Payments

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DaVita Medical Group has agreed to pay $270 million to the Medicare program after identifying suspect billing practices that incorrectly raised its Medicare Advantage payments, says the Department of Justice (DOJ). The improper MA...

Next Generation ACO Model Saved Medicare $62M in 2016

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Next Generation Accountable Care Organizations (ACO) saved the Medicare program $62 million during their first year of operation in 2016, encouraging CMS to expand downside risk models across Medicare. Next Generation ACOs accept the...

CMS Processes State Medicaid Requests, Approvals 23% Faster

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CMS has announced that an agency initiative to streamline state Medicaid approvals and state plan amendments (SPAs) has increased approval processing speed by 23 percent. In 2017, CMS sent a bulletin to state Medicaid programs informing...

OH Medicaid Adopts Pass-Through Model for Managed Care Drugs

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Ohio’s Medicaid program has issued a mandate that requires managed care health plans to re-negotiate pharmacy benefit manager (PBM) contracts to transition from a spread-pricing drug purchasing model to a pass-through model. The...

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...

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...

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...

CMS Proposed Rule Cuts State Authority to Divert Medicaid Payments

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CMS has proposed a new rule that would eliminate a state’s authority to divert Medicaid payments away from providers. The rule is intended to ensure beneficiaries have adequate access to healthcare services through direct...

Medicare, Medicaid Home Health Benefits Stabilize Care Costs

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Providing extended home health benefits for Medicare beneficiaries is likely to stabilize care costs for public payer programs, according to a new analysis from the Commonwealth Fund. Researchers from the Hilltop Institute and Johns...

Aetna Takes Amerigroup Spot in Kansas Managed Medicaid Contract

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Aetna has received a Managed Medicaid contract from the state of Kansas for plan year 2019 and will replace Amerigroup as one of the state’s three managed care payers. The state received six bids from commercial payers and...

How to Drive Enrollment in the ACA Health Plan Marketplaces

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Payers and states wishing to increase enrollment in the ACA health plan marketplaces should  create targeted advertisements, benchmark silver-tier plans as their primary exchange plan, and help consumers navigate health plan...

MedPAC: Value-Based Payment, Post-Acute Care Boost Medicare Savings

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MedPAC has advised Congress that value-based payment reform and encouraging the use of post-acute care can help the Medicare program increase savings and improve beneficiary outcomes, the group said in a new report. Revisions to payment...

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