Below is a roundup of payer-centric news headlines you may have missed during the month of October 2024.
Updated: Wednesday, Oct. 30 at 4:30 p.m.
Leading stories
New York City ends GLP-1 coverage, met with backlash
Workers in New York City will no longer have coverage to weight-loss drugs after the city’s health plan changed its policy.
It turns out the drugs were only added to a list of covered medications in error, a spokesperson for the city told the Gothamist. The city will continue to cover GLP-1 drugs for diabetes.
Covering GLP-1s for diabetes but not weight loss is increasingly common among health plans across the country due to rising costs on the healthcare system.
Michigan files PBM opioid lawsuit
Optum Rx and Express Scripts are facing a new lawsuit, this time from the state of Michigan.
The state claims the PBMs colluded with opioid manufacturers, receiving kickbacks in exchange for better placement on drug formularies.
“Pharmacies, manufacturers and PBMs have reaped huge profits during the opioid epidemic, lining their pockets at the expense of Michiganders struggling with substance use disorder,” said Michigan AG Dana Nessel in a statement. “I am committed to holding companies accountable for their role in this crisis and ensuring that the well-being of Michigan residents always takes precedence over corporate profits.”
Michigan is just the latest state to attack PBMs from the angle of exploiting the opioid crisis. In June, Arkansas filed a similar lawsuit.
More plan previews for 2025
Health plans are giving insight into their Medicare Advantage (MA) offerings for 2025.
SCAN Health Plan is launching a new plan for older Asian adults in Los Angeles, San Francisco and San Mateo counties called SCAN Allied. It will feature $0 premiums, unlimited acupuncture, a supplemental benefit allowance and a network of “culturally aligned” providers.
It is also ensuring its members can purchase more than 10,000 products at CVS retail stores with a preloaded debit card, providing a new grocery allowance with Instacart for “culturally-tailored” food options and offering $0 preventive and diagnostic dental services.
Alignment Healthcare’s plans will now be available to 8.1 million adults. The insurer is offering 18 chronic condition and dual-eligible special needs plans, a 29% increase from 2024. Condition-specific plans for bipolar disorder and major depressive disorder will be introduced for the first time.
A Dual Select+ plan is available for Texas-based dually eligible members. It will have a $125 monthly OTC allowance and $0 copay on Part D drugs.
Devoted Health revealed the company is expanding its reach to 99 counties across 13 states.
Ambetter Health, a Centene subsidiary, is expanding into Iowa and adding 60 counties to its footprint across 10 states. Members in four states will receive a 20% discount on certain OTC products at Walgreens.
Individual coverage health reimbursement arrangement plans will be available to Ambetter members in six states.
Sonder Health said it is expanding more than any time in the company’s history, increasing its footprint from 12 to 84 counties in Georgia.
MVP Health Care and the University of Vermont Health Network's co-created MA plan is no longer available to Vermont residents, though it will still be offered in five New York counties. The companies said MA isn't feasible in Vermont due to care utilization spikes and regulatory pressures.
Premera Blue Cross in Washington is also exiting MA, citing “changing” marketing conditions and financial pressures.
Essence Healthcare will begin providing health plans in Chicago for the first time.
Major payers including Aetna, Cigna, Elevance Health, Humana, UnitedHealthcare and Wellcare also released their MA offerings for 2025, as previously reported by Fierce Healthcare.
Harris wants Medicare to cover home care for seniors
Vice President Kamala Harris will push for a home care benefit in Medicare if elected, she told the hosts of "The View."
Addressing the "sandwich generation," or the population of people that is responsible for caring for their children and parents simultaneously, Harris’ proposal could cover in-home health aides and help families avoid costs associated with nursing home facilities.
“Basically what we will do, is we will allow Medicare to cover in-home healthcare,” she said. "For the family to send them to a residential care facility, to hire somebody, is so expensive.”
She said the program would be paid for through continued cost savings from the drug price negotiation program.
Legislation
Delaware signs mammogram screening laws
Delaware is expanding women’s health insurance protections with two new bills signed into law.
The state is requiring private health insurers and the state’s employee health plan and Medicaid program to cover annual mammograms for women older than 40, reported Delaware NPR’s affiliate.
A bill also codified insurance coverage requirements for ovarian cancer monitoring.
New York signs several health insurance bills
New York Gov. Kathy Hochul signed a spree of healthcare bills into law this month.
The legislation allows pregnant women to enroll in health insurance at any time without penalty and prohibits HMOs from imposing fees for special enrollment.
"We've taken another significant step towards ensuring that every expectant mother in our state has access to healthcare without barriers or delays,” Hochul said in a statement.
Other signed bills mandate health insurers to cover prenatal vitamins if prescribed by a healthcare practitioner and broaden insurance coverage for human donor milk in outpatient settings.
Legal
Aetna loses KanCare lawsuit
The state of Kansas’ Medicaid contracts will go into effect without delay, reported The Topeka Capital-Journal.
Aetna’s petition for the state to review its Medicaid contract decisions was rejected. The contracts are worth an estimated $4 billion.
Aetna submitted a protest over the state’s decision not to award the insurer a Medicaid contract, Fierce Healthcare previously reported.
Industry
BCBS Texas ends contracts with MD Anderson Cancer Center
Blue Cross Blue Shield of Texas is ending its relationship to cover Medicare Advantage and managed Medicaid services to MD Anderson Cancer Center, effective Nov. 1.
The changes do not apply to the Texas A&M retirees.
“While MD Anderson welcomes the opportunity to remain in-network for BCBS Medicare Advantage and Texas Managed Medicaid services, our goal is to ensure continuity of care for those in active treatments,” MD Anderson said in a statement on its website.
UnitedHealthcare partnering with Calm Health
More than 13 million UnitedHealthcare members will now have access to digital health tool Calm Health.
Calm Health is an app designed to help enrollees with their mental health through screenings, coaching and therapy referrals and personalized content.
“UnitedHealthcare’s adoption of Calm Health marks a pivotal step in helping make mental health care and resources as accessible and essential as physical health care,” said Calm Health CEO David Ko in a statement.
HealthSherpa rolls out ICHRA Marketplace
A new marketplace to help brokers, third-party administrators and insurers enroll employees in individual coverage health reimbursement arrangements, or ICHRAs, has been created by health exchange HealthSherpa.
The marketplace is integrated with UnitedHealthcare, Cigna, Blue Cross plans, Centene subsidiaries and Molina Healthcare. It will go live in early 2025.
Elevance Health sells Florida-based medical centers
Two medical centers in South Florida owned by Elevance Health were sold to Las Mercedes Medical Centers.
The acquisition expands Las Mercedes’ reach to more than 22,000 senior members. Elevance Health is reportedly buying home health company CareBridge in a $2.7 billion deal.
Claimable unveils AI prior authorization platform
Health tech company Claimable is launching its new AI-powered appeals platform, the company announced.
It is designed to evaluate research, policy details, appeals data and patient-specific information to submit appeals quicker and easier. Right now, the platform supports 60 treatments but plans to expand to more than 100 treatments next year.
The company said its pilot program has an appeal success at 1.6 times the industry average and most cases are resolved three times faster. It has led to $3 million in claim recoveries for patients.
Studies
Drug price negotiation program is a success—with caveats
The first round of CMS’ drug price negotiation program resulted in critical savings for beneficiaries though savings vary per drug, a new study in the New England Journal of Medicine argues.
CMS predicts the government would have saved $6 billion, or a 22% reduction in spending, if it could negotiate prices for the 10 selected drugs in 2023. However, that figure is likely overestimated as some of these drugs will face generic or biosimilar competition.
“This issue was predictable because some drugs selected for price negotiation have been on the market for long periods,” the study explained.
Some drugs, like Eliquis, will still cost more money in the U.S. than other countries, despite the drug costing less than before.
IRA Part D redesign to cost $10B to $20B more: CBO
The Congressional Budget Office anticipates changes to Medicare Part D under the Inflation Reduction Act (IRA) will cost up to $10 billion to 20 billion more (PDF) than previously anticipated.
Temporary subsidies imposed by the Centers for Medicare & Medicaid Services (CMS) through the agency’s new premium stabilization program will increase spending by $5 billion in 2025.
Changes to the IRA include capping out-of-pocket costs and limiting premium increases. This caused the national average monthly bid amount to increase from $64.28 in 2024 to $179.45 in 2025.
In August, leading Republicans asked the Government Accountability Office to determine whether CMS’ premium stabilization program was legal. They viewed the program as a short-term solution to prevent soaring premiums in an election year, all caused by poorly developed provisions in the IRA.
Uninsured emergency visits ticking up
Since the end of the COVID-19 public health emergency and the beginning of Medicaid redeterminations, emergency room patients are self-paying at a higher rate.
While the increase in uninsured visits has returned to pre-pandemic levels for most age groups, children under 18 years old have had a 60% increase, a study from Epic Research found.
Nearly half of all Medicaid and Children’s Health Insurance Plan enrollees are under the age of 18.
Quick Hits
- Until more data is available showing how enrollees utilize supplemental benefits, it’s unclear how much value is extracted from the $83 billion in rebates Medicare pays private insurers, Medicare Payment Advisory Commission (MedPAC) staff said during a recent meeting.
- L.A. Care Health Plan agreed to pay $55 million across two settlements with the state of California. The arrangement requires the plan to make “improvements to their operations that ensure timely access to medically necessary healthcare services.”
- Approximately one-third of private psychotherapists do not accept insurance, a study in Health Affairs found after reviewing a consumer-facing directory of 175,000 providers.