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All News > Medicare

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Mental Health Care Coverage Is Coming for Medicare Recipients in 2024
Kiplinger Link to more items from this source
Dec. 28, 2023

"Medicare is set to expand its coverage to include marriage and family therapists as well as mental health counselors beginning in January 2024 ... The move ... is a big change for Medicare that has for decades limited mental health care coverage to services provided by psychiatrists, psychologists, licensed clinical social workers and psychiatric nurses[.]"

Tags: Health Plan Design  •  Medicare

Changes in Hospital Adverse Events and Patient Outcomes Associated with Private Equity Acquisition
JAMA Health Forum Link to more items from this source
Dec. 27, 2023

"Private equity acquisition was associated with increased hospital-acquired adverse events, including falls and central line-associated bloodstream infections, along with a larger but less statistically precise increase in surgical site infections.... These findings heighten concerns about the implications of private equity on health care delivery."

Tags: Health Plan Costs  •  Medicare

2024 Income Related Monthly Adjustment Amount (IRMAA) for Medicare Part B and Part D Premiums
Kiplinger Link to more items from this source
Dec. 27, 2023

"The IRMAA is calculated on a sliding scale with five income brackets topping out at $500,000 and $750,000 for individual and joint filing, respectively. These figures change annually with inflation.... Whether you pay an IRMAA in 2024 depends on your 2022 tax returns."

Tags: Health Plan Costs  •  Medicare

Employer-Sponsored Insurance Pays Nearly Three Times Medicare Rates for Hospital Outpatient Services
Health Care Cost Institute Link to more items from this source
Dec. 15, 2023

"Among the 10 most commonly used health services, 8 had ESI reimbursement that was more than double Medicare reimbursement. These included general laboratory tests, x-rays, and ultrasounds. Among the 10 services that that make up the most ESI spending, 5 had ESI reimbursement that was more than double Medicare reimbursement.... Total ESI outpatient spending would have been $76 billion lower in 2021 if outpatient services were reimbursed at average Medicare rates."

Tags: Health Plan Costs  •  Medicare

Text of CMS Revised Guidance on Medicare Part D Drug Inflation Rebates Paid by Manufacturers (PDF)
Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS] Link to more items from this source
[Official Guidance]
Dec. 14, 2023

78 pages. "This memorandum provides interested parties with the revised Medicare Part D Drug Inflation Rebate guidance for 2022, 2023, and 2024. This memorandum includes ... [1] A summary of changes and clarifications to the initial memorandum, the Medicare Part D Drug Inflation Rebates Paid by Manufacturers: Initial Memorandum, released on February 9, 2023 ... [2] A summary of the public comments received in response to the initial memorandum, and [CMS'] responses ... [3] Revised guidance that establishes final policies for the Medicare Part D Drug Inflation Rebate Program[.]" [Also available: Fact Sheet and CMS Letter to Plans and PBMs]

Tags: Medicare  •  Prescription Drug Costs

Lawsuit Claims Humana Used Algorithm to Deny Care
HealthcareDIVE Link to more items from this source
Dec. 14, 2023

"Humana is the latest insurer to be sued over its use of artificial intelligence in claims processing, with a lawsuit alleging the payer used AI model nH Predict to improperly deny care ... [P]laintiffs argued the payer prematurely cut payments for MA beneficiaries' rehabilitation care. According to the suit, Humana based the cuts on the AI model's 'rigid and unrealistic predictions for recovery' -- not doctors' recommendations -- despite knowing the model's estimations were often 'highly inaccurate.' " [Barrows v. Humana, Inc., No. 23-0654 (W.D. Ky. complaint filed Dec. 12, 2023)]

Tags: Health Plan Administration  •  Medicare

Inflation Reduction Act Research Series: Medicare Part B Inflation Rebates in 2023 (PDF)
Assistant Secretary for Planning and Evaluation [ASPE], U.S. Department of Health and Human Services [HHS] Link to more items from this source
Dec. 14, 2023

"The Inflation Reduction Act (IRA) includes provisions to increase accessibility and affordability of prescription drugs for the 65 million Medicare beneficiaries, reduce the rate of growth in Medicare drug spending, and improve the financial sustainability of the Medicare program. These IRA provisions include a rebate on certain Part B and D drug prices if prices rise faster than inflation. This fact sheet focuses on ... the Medicare Part B inflation rebate, and its impact on the drugs that meet the law's criteria in calendar year 2023."

Tags: Medicare  •  Prescription Drug Costs

Understanding and Preparing for Value-Based Care: A Primer for Behavioral Health Providers
RAND Corporation Link to more items from this source
Dec. 12, 2023

"Insurance companies and [CMS] are shifting from reimbursing health providers a fixed amount for a service to reimbursement based in part on patients' outcomes. This approach is called value-based care (VBC) and includes a wide range of programs. Although the behavioral health providers that have been impacted by VBC to date are primarily those in larger health systems, use of VBC is expanding as payors seek to combat rising health care costs and increase transparency and accountability for health services. Thus, behavioral health providers need to know about VBC models and their impact as well as steps they can take to be better prepared for this shift."

Tags: Health Plan Costs  •  Health Plan Design  •  Medicare

CRS Report on Medicare Drug Price Negotiation Under the Inflation Reduction Act: Industry Responses and Potential Effects (PDF)
Congressional Research Service [CRS] Link to more items from this source
Dec. 11, 2023

"This report provides information related to several topics of recent congressional interest with respect to the implementation of the IRA, including litigation surrounding the Program; concerns about its impact on future drug innovation, research, and development; and questions about its interaction with patents and other federal marketing protections for pharmaceuticals." [R47872 Dec. 8, 2023]

Tags: Medicare  •  Prescription Drug Costs

2025 Medicare Advantage and Part D Proposed Rule: What's New for 2025?
Groom Law Group Link to more items from this source
[Guidance Overview]
Nov. 30, 2023

"The Proposed Rule previews potential substantive and technical changes to MA and Part D including coverage for expanded access to behavioral health provider types, changes to the risk adjustment data validation (RADV) appeals process, ... and stricter controls around agent and broker compensation. The Proposed Rule continues this Administration's focus on health equity[.]"

Tags: Health Plan Design  •  Medicare

Text of CMS Corrections to Final Regs: Medicare Secondary Payer and Certain Civil Money Penalties
Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS] Link to more items from this source
[Official Guidance]
Nov. 27, 2023

"This correcting document identifies and corrects errors in [final regs] of October 11, 2023.... [T]he corrections are effective December 11, 2023.... [CMS] made technical errors in the amendatory instructions as well as the headings, entries, and table notes in the civil monetary penalty adjustment table[.]"

Tags: Health Plan Administration  •  Medicare

Incorporating Information on Therapeutic Alternatives Into the IRA Prescription Drug Negotiations
The Brookings Institution Link to more items from this source
Nov. 22, 2023

"To consider the relative importance of a given drug in patient care, [CMS] will need to identify therapeutic alternatives, determine their comparative therapeutic advantage for patients, and incorporate that comparative information into its initial proposed price that will serve as the starting point for negotiation. This commentary discusses at a high level the issues CMS will need to consider in pursuing each of these three steps along with the necessary data sources to support each step."

Tags: Medicare  •  Prescription Drug Costs

CMS Fact Sheet: Fiscal Year 2023 Improper Payments
Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS] Link to more items from this source
Nov. 17, 2023

"The Medicare Fee-for-Service (FFS) estimated improper payment rate was 7.38%, or $31.2 billion ... The Medicare Part C estimated improper payment rate was 6.01%, or $16.6 billion.... The Medicare Part D estimated improper payment rate was 3.72%, or $3.4 billion.... The 2023 improper payment rate for the Advance payment of the Premium Tax Credit (APTC) program ... for Benefit Year 2021 was 0.58% or $272 million."

Tags: Health Plan Costs  •  Medicare

Lawsuit Accuses UnitedHealth Group of Using Faulty AI to Deny Claims
StarTribune Link to more items from this source
Nov. 16, 2023

"A class-action lawsuit ... [alleges] UnitedHealth Group is using a faulty artificial intelligence algorithm to wrongly deny coverage for Medicare patients who need rehabilitation care following hospitalizations.... The litigation comes amid signs of growing consumer and government suspicion that health insurers are frequently denying payment for medically necessary services." [Estate of Lokeken v. UnitedHealth Group, Inc., No. 23-03514 (D. Minn. complaint filed Nov. 14, 2023)]

Tags: Health Plan Administration  •  Medicare

CRS Report: Medicare Part D Prescription Drug Benefit
Congressional Research Service [CRS] Link to more items from this source
[Guidance Overview]
Nov. 15, 2023

67 pages. "Of the 65 million Medicare beneficiaries in 2022 who were eligible for Part D, 49.8 million (about 77%) were enrolled in a Part D plan and another 1.3 million (about 2%) had prescription drug coverage through a former employer that received a Part D subsidy for a portion of the coverage.... The 2022 IRA phases in a number of significant Part D changes from 2023 to 2025, including an annual out-of-pocket cap on Part D enrollee cost sharing, enhanced low-income subsidies, a $35 monthly cap on insulin cost sharing, and an annual limit on premium increases from 2024 to 2029." [R40611 updated Nov. 14, 2023]

Tags: Medicare  •  Prescription Drug Costs

Text of CMS Memo: Application of Pharmacy Price Concessions to the Negotiated Price at the Point of Sale Beginning January 1, 2024 (PDF)
Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS] Link to more items from this source
[Official Guidance]
Nov. 14, 2023

"[CMS] is issuing this memorandum to highlight upcoming requirements regarding pharmacy price concessions effective January 1, 2024. [CMS reminds] Part D plan sponsors and/or their pharmacy benefit managers (PBMs) that CMS strongly encourages them to make necessary cash flow arrangements with network pharmacies in preparation for these upcoming changes."

Tags: Health Plan Administration  •  Medicare  •  Prescription Drug Costs

CMS FAQs Address Imposition of Penalties for MSP Reporting Violations (PDF)
Thomson Reuters / EBIA Link to more items from this source
[Guidance Overview]
Nov. 9, 2023

"The FAQs confirm that the regulations do not alter the reporting requirements in any way. According to the FAQs, the regulations will apply beginning October 11, 2024, meaning that the earliest a penalty may be imposed is October 2025. "

Tags: Health Plan Administration  •  Medicare

Updates on the Financial Status of Social Security and Proposals (PDF)
Office of the Chief Actuary, U.S. Social Security Administration [SSA] Link to more items from this source
Nov. 9, 2023

31 slides from presentation to 2023 SOA Annual Conference. "[1] What's new in the 2023 Trustees Report (released March 31) regarding Social Security's actuarial status? [2] What options can be considered for closing the financing gap? [3] How do Social Security and Medicare ('entitlements') figure in the fiscal status of the federal government and the economy?"

Tags: Medicare  •  Social Security

Senate Votes to Reform PBMs
FierceHealthcare Link to more items from this source
Nov. 9, 2023

"[The] Better Mental Health Care, Lower-Cost Drugs and Extenders Act, when included with provisions from the Modernizing and Ensuring PBM Accountability (MEPA) Act from earlier this year, would introduce more transparency and regulation surrounding PBMs."

Tags: Health Plan Costs  •  Medicare  •  Prescription Drug Costs

CMS Announces 2024 Medicare Parts A and B Premiums and Deductibles
Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS] Link to more items from this source
[Guidance Overview]
Oct. 13, 2023

"The standard monthly premium for Medicare Part B enrollees will be $174.70 for 2024, an increase of $9.80 from $164.90 in 2023. The annual deductible for all Medicare Part B beneficiaries will be $240 in 2024, an increase of $14 from the annual deductible of $226 in 2023.... The 2024 Part B total premiums for high-income beneficiaries with full Part B coverage are shown in [a] table."

Tags: Medicare

CMS Finalizes Regs Addressing Penalties for MSP Reporting Violations (PDF)
Thomson Reuters / EBIA Link to more items from this source
[Guidance Overview]
Oct. 12, 2023

"[F]or group health plans, responsible reporting entities (RREs) -- typically insurers or third-party administrators (TPAs) -- are required to report information to CMS about individuals who are both entitled to Medicare and covered under a group health plan.... While relatively few employers are RREs, employers that are group health plan sponsors may be asked to assist their insurers or TPAs in compiling information about participants in their plans. With enforcement activity on the rise and soon to be enhanced by penalty imposition, employers' cooperation will be vital in ensuring RRE compliance."

Tags: Health Plan Administration  •  Medicare

October 14 Is Deadline for Medicare Part D Notice of Creditable (Or Non-Creditable) Coverage
Fraser Trebilcock Link to more items from this source
[Guidance Overview]
Oct. 12, 2023

"[T]here are five instances in which such notice must be provided: [1] Prior to an individual's initial enrollment period for Part D; [2] Prior to the effective date of enrollment in your company's prescription drug coverage; [3] Upon any change in your plan's creditable status; [4] Prior to the annual election period for Part D (which begins each October 15); and [5]Upon the individual's request."

Tags: Health Plan Administration  •  Medicare

Text of CMS Final Regs: Medicare Secondary Payer and Certain Civil Money Penalties
Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS] Link to more items from this source
[Official Guidance]
Oct. 10, 2023

37 pages. "This final rule will specify how and when CMS must calculate and impose civil money penalties (CMPs) when group health plan (GHP) and non-group health plan (NGHP) responsible reporting entities (RREs) fail to meet their Medicare Secondary Payer (MSP) reporting obligations by failing to register and report as required by MSP reporting requirements. This final rule will also establish CMP amounts and circumstances under which CMPs will and will not be imposed."

Tags: Health Plan Administration  •  Health Plan Design  •  Medicare

HHS Moves Forward with Medicare Drug Price Negotiations
U.S. Department of Health and Human Services [HHS] Link to more items from this source
Oct. 3, 2023

"[A]ll 10 drug companies whose drugs were selected for price negotiation with Medicare for the first cycle of the program have decided to participate in those negotiations.... These selected drugs accounted for $50.5 billion in total Part D gross covered prescription drug costs, or about 20%, of total Part D gross covered prescription drug costs between June 1, 2022 and May 31, 2023 ... Medicare enrollees taking the 10 drugs covered under Part D selected for negotiation paid a total of $3.4 billion in out-of-pocket costs in 2022 for these drugs."

Tags: Medicare  •  Prescription Drug Costs

Medicare Part D Prescription Drug Rebates: Possible Impact of the Inflation Reduction Act
Milliman Link to more items from this source
[Guidance Overview]
Oct. 2, 2023

"In an effort to curb federal government and patient spending, several drug pricing reforms were included in the Inflation Reduction Act (IRA), which ... began taking effect in 2023 and include changes to the Part D benefit design as well as the introduction of a new drug price inflation control.... Together with contracted prices, rebates are a key factor in health insurers' choices about whether to include a specific prescription drug on a Part D formulary and in which tier. Therefore, rebates impact the finances of all stakeholders in the prescription drug distribution chain"

Tags: Medicare  •  Prescription Drug Costs

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