News That Helps Idaho Residents Stay Informed
The purpose of this article is to provide Idaho residents with one consolidated place to reference Medicare News and how it may help them make better decisions. Some of this material will not be found on the Medicare or CMS website and may be rotated off this site as its ‘information value’ decreases with time.
Title: “DOJ sues major insurers, brokers over alleged Medicare Advantage kickbacks”
Synopsis: “““Brokers repeatedly directed Medicare beneficiaries to the plans offered by insurers that paid them the most money, regardless of the quality or suitability of the insurers’ plans,” the complaint says. “They incentivized their agents to sell those plans; set up teams of agents who could sell only those plans; and at times ‘shut off,’ or refused to sell, plans of insurers who did not pay or did not pay enough in kickbacks. According to the lawsuit, one broker executive said about Aetna, for example, ‘more money will help drive more sales [be]cause your product is dog sh[*]t.’”
Read this article here.
Date: 5/6/2025
Title: “About 20% of patients who have a total knee arthroplasty are dissatisfied with the result, often due to residual pain.”
Synopsis: “This type of medial pain can be misdiagnosed as tendonitis or pes anserine bursitis. But it often turns out to be an infrapatellar saphenous nerve neuroma that is causing pain,” says Glenn G. Shi, M.D., an orthopedic surgeon at Mayo Clinic in Jacksonville, Florida. “Patients who have a misdiagnosis might be sent to pain clinics or physical therapy with no reasonable outcomes. That leads to a lot of frustration for patients and orthopedic surgeons alike.”
“Mayo Clinic is investigating strategies to treat infrapatellar saphenous nerve neuroma. One approach involves ultrasound-guided hydrodissection of the nerve from the adjacent interfascial planes, followed by a corticosteroid injection. A preliminary Mayo Clinic study found that this minimally invasive procedure significantly reduced medial knee pain for nine of 16 patients studied.
For patients whose pain persists after hydrodissection, Mayo Clinic is exploring options for surgical repair. “We are trying to use a less invasive incision to find the nerve end and place it in an area where it is protected from scar tissue,” Dr. Shi says. A prospective study is using a similar approach during total knee arthroplasty to prevent infrapatellar saphenous nerve neuroma from developing.
“This problem isn’t widely discussed among orthopedic surgeons, but it’s very impactful. Up to 3 million people are expected to have total knee arthroplasty by 2035,” Dr. Shi says. “Our goal is to bring attention to this problem, which we think contributes to patients’ dissatisfaction after total knee arthroplasty. A modified technique for the procedure can potentially avoid the development of neuroma and reduce pain.”
Read this article here.
Date published: 4/21/2025
Title: “White House eyes 30% HHS budget cut: 11 things to know.”
Synopsis: “The Trump administration is looking to cut the HHS budget by around one-third in an effort that would dramatically scale back federal health programs, The Washington Post reported April 16.
The new draft budget comes amid back-and-fourth regarding the recent dismissal of 10,000 HHS employees. In early April, HHS Secretary Robert F. Kennedy Jr. told CBS News that around 20% of affected employees might have their jobs reinstated.
Here are 11 things to know about the budget proposal:” ”
Read this article here.
Date published: 4/21/2025
Title: “Cancer-related hospitalizations rise: 5 notes
Synopsis: “The study, published April 18 in Nature Scientific Reports, analyzed National Inpatient Sample data between 2008 and 2019. They identified 371 million hospitalizations, 56 million of which were cancer-related.
Here are five findings:”
Read this article here.
Date published: 4/17/2025
Title: “Will the Trump Administration Fast Track the Privatization of Medicare?”
Synopsis: “According to MedPAC, an independent, non-partisan agency that advises Congress about Medicare payment, the federal government pays insurers 20% more for Medicare Advantage enrollees than it pays for similar people in traditional Medicare, at a cost of $84 billion in 2025. To put the $84 billion in context, that’s more than Medicare paid physicians under the physician fee schedule to treat traditional Medicare patients in 2024. The higher Medicare spending for Medicare Advantage enrollees results in $13 billion in higher Medicare Part B premiums paid by Medicare beneficiaries, including those who are not in Medicare Advantage.”
Read this article here.
Date published: 3/15/2025
Title: “25 health systems file ‘opt-out’ antitrust lawsuit against Blue Cross Blue Shield.”
Synopsis: “The lawsuit, filed March 4 in a federal court in Pennsylvania, comes after hospitals and other providers opted out of a $2.8 billion class-action settlement reached in October 2024 with BCBS. Physician groups, surgery centers and home health providers have also joined as plaintiffs in the new complaint.
The new lawsuit challenges the adequacy of the 2024 settlement, with hospitals arguing that BCBS’s anti-competitive practices are still happening and continue to harm providers financially. The plaintiffs, which include Temple University Health System, Penn Medicine, Geisinger Health, WellSpan Health, MedStar Health, and Northern Light Health, are seeking treble damages under federal antitrust law, meaning the court could award triple the amount of actual damages awarded to plaintiffs in the prior $2.8 billion settlement. The hospitals are also seeking injunctive relief to permanently ban BCBS companies from continuing their alleged collusive practices.”
Read this article here.
Date published: 3/6/2025
Title: “Mayo Arizona CEO details transformative $1.9B expansion.”
Synopsis: The centerpiece of our transform portion is the creation of Mayo Clinic Platform, which is a collaboration of nearly half of the top 11 healthcare organizations in the world, across four continents, to create a distributed data network that has the depth, breadth and heterogeneity of data on patients across socioeconomic class; urban versus rural; racial, ethnic categories, to ensure we can create and validate the most effective AI models to help anyone.
The rules of the road are that any values-aligned solution developer can leverage Mayo Clinic Platform data to create and validate algorithms, as long as those algorithms are then available on the platform for any healthcare organization that wishes to be part of the platform to take in to benefit their patients. So, that Mayo Clinic Platform piece is to benefit all of healthcare and all of society.”
Read this article here.
Date published: 3/3/2025
Title: “DOJ probes UnitedHealth’s Medicare Advantage billing practices: WSJ”
Synopsis: The Journal has previously published reports on insurers’ Medicare Advantage billing strategies, including UnitedHealth’s efforts to optimize government payments by increasing members’ documented sickness scores. According to one report, sickness scores for UnitedHealth patients transitioning from traditional Medicare rose by 55% in their first year in Medicare Advantage, compared to a 30% industry average, leading to higher reimbursements.
DOJ attorneys have interviewed healthcare providers named in these reports as recently as Jan. 31, the Journal noted, with interest in the software used by the insurer, diagnoses it promoted for employees to use with patients and incentive arrangements.
Read this article here.
Date published: 2/22/2025
Title: “Rural hospitals’ financial pressures mount as Medicare Advantage grows: 12 things to know Rural hospitals’ financial pressures mount as Medicare Advantage grows: 12 things to know.”
Synopsis: “6. Many seniors opt for MA plans due to supplemental benefits, such as vision and dental coverage, as well as cost-sharing protections. However, for rural hospitals, this shift has led to significant financial and operational challenges.
- Historically, traditional Medicare has reimbursed hospitals at rates below the cost of care, according to the AHA report, which found that MA plans pay even less, reimbursing rural hospitals at just 90.6% of traditional Medicare rates on average. For Medicare-dependent and low-volume hospitals, this rate drops to 85%, while critical access hospitals receive only 95% of their costs under MA plans.
- This payment disparity cost rural hospitals an estimated $1 billion in 2023 alone. Given that Medicare accounts for a larger share of rural hospital revenue than urban hospitals — 43% versus 37% — these lower rates have an outsized impact on rural providers.
- The AHA argues that the financial instability caused by MA policies is accelerating the closure and downsizing of rural hospitals. Over the past decade, more than 100 rural hospitals have closed or converted to other provider types. Additionally, 432 rural hospitals are at risk of closing, according to a Feb. 11 report from Chartis, a healthcare advisory services firm.”
Read this article here.
Date published: 2/21/2025
Title: “The Idaho Department of Health & Welfare’s contracts with Blue Cross of Idaho for Idaho Medicaid Plus (IMPlus) and the Medicare-Medicaid Coordinated Plan (MMCP) will end on June 2, 2025.”
Synopsis: “Dually eligible participants will have the choice to receive Medicaid coverage through Molina or fee-for-service Medicaid from June through December 2025. The Department of Administration’s Division of Purchasing issued an intent to award to United Healthcare and Molina for a service start date of January 1, 2026 for IMPlus and MMCP coverage to dually eligible participants..”
Read this article here.
Date published: 2/18/2025
Title: “Moody’s: Negative outlook for payers in 2025 amid rising costs.”
Synopsis: “Amid these challenges, Moody’s has assigned a positive outlook to only one major insurer, Elevance Health, reflecting its strong market position and operational performance. In contrast, Humana and Health Care Service Corp. have been given negative outlooks. Humana’s negative outlook is driven by its heavy reliance on Medicare Advantage. HCSC’s negative outlook reflects its exposure to Medicaid redeterminations and competitive pressures in its core commercial business.”
Read this article here.
Date published: 2/3/2025
Title: “Republicans target $880B in healthcare cuts; hospitals push back.”
Synopsis: “The budget resolution does not specify how the committee must cut costs by $880 billion, but Medicare and Medicaid are by far the largest programs under its oversight. The $880 billion makes up more than half of the $1.5 trillion total cost reductions Republican lawmakers aim to achieve over the 10-year period. ”
Read this article here.
Date published: 2/12/2025
Title: “Recognizing the Highest Level of Quality Care: Healthgrades Unveils America’s Best Hospitals for 2025.”
Synopsis: “Healthgrades’ clinically validated methodology focuses solely on what matters most–patient outcomes–empowering consumers to choose doctors who practice at high quality hospitals. To determine the top 250 U.S. hospitals, Healthgrades evaluated clinical performance for approximately 4,500 hospitals across more than 30 common procedures and conditions.”
Read this article here.
Date published: 2/10/2025
Title: “Drugmakers increase prices on 800 medications: 5 things to know.”
Synopsis: “The analysis found that while most price increases remained under 10%, certain medications saw significant hikes. For example, Amgen raised the price of its psoriasis treatment, Otezla, by 7%, pushing its monthly cost to about $5,325. ”
Read this article here.
Date published: 1/31/2025
Title: “Why NYU Langone is betting on molecular oncology.”
Synopsis: “Cancer is typically identified pathologically, looking at the biopsy under the microscope. As we’ve made more and more fundamental discoveries in cancer biology, we now know that most of these cancers are really made up of many different subgroups of diseases that could be defined at a molecular level.
What molecular oncology is really designed for is to provide access to cutting-edge molecular profiling. We’re focusing on a type of technology called a liquid biopsy that allows patients to have the most accurate diagnosis, matches them to the most appropriate standard therapies and the most applicable clinical trial, when relevant.
It’s basically a blood test, similar to physicians ordering a normal complete blood count. We use deep sequencing methods to detect pieces of cancer DNA within the blood sample.
The test allows us to diagnose cancers quickly, determine the molecular subtype of the cancer and what specific treatments will target the cancer most effectively. The test can also detect cancer recurrence, often before it is seen on a CAT scan.”
Read this article here.
Date published: 1/17/2025
Title: “Cancer burden shifts as incidence climbs: What to know.”
Synopsis: “In 2025, an estimated 618,120 people will die from cancer in the U.S. The figure represents about 30% of the estimated 2,041,910 new cancer cases the U.S. is expected to see in 2025.
As the cancer mortality rate continues to fall, incidence rates in the U.S. have increased at varying degrees across demographics and state lines, according to the American Cancer Society’s annual cancer statistics report published Jan. 16 in CA: A Cancer Journal for Clinicians.
Here are 10 key findings from the report:.”
Read this article here.
Date published: 1/17/2025
Title: “Customized implants for knee replacements.”
Synopsis: “The customized implants are designed for people who wish to remain active.”
“We use them in patients who want to do vigorous physical activity, such as tennis or downhill skiing. As with other knee prostheses, we don’t advise high-impact activities such as basketball or soccer afterward,” Dr. Clarke says.“
Read this article here.
Date published: 9/18/2018
Title: “Hospital Care, State by State”
Synopsis: “The sixth annual HealthGrades Hospital Quality in America Study shows the quality of healthcare at the nation’s hospitals varies greatly among states.
Researchers ranked each of the country’s nearly 5,000 hospitals on 26 common procedures and conditions and found better-performing hospitals tended to be in northern or sparsely populated states.
The quality chasm at American hospitals is real, and it is very alarming and concerning — despite evidence of process improvements,” says Samantha Collier, MD, HealthGrades’ vice president of medical affairs, in a news release.
Although there are exceptional hospitals in even the lowest-ranking states, researchers say that, on average, patients get better quality healthcare in the higher-ranking states.
For example, the report shows that a person has a 55% increased chance of dying if he or she had a balloon angioplasty or other similar heart procedure in Texas rather than in New York.
“In Mississippi, your chance of dying from a heart attack is 49% higher, on average, than if you were treated in Colorado,” says Collier.
Researchers say that the greatest differences at the state level were among certain heart procedures, such as balloon angioplasty, stenting, and others. For these procedures, New York was the best performing state and Alaska was the worst.”
Read this article here.
Date published: 1/7/2025
Title: “7 cancers linked to alcohol”
Synopsis: “Here are seven statistics to know from the surgeon general’s advisory:
- 96,730: The estimated number of alcohol-related cancer cases in 2019.
- 1 million: How many alcohol-related cancer cases have been preventable in the past decade.
- 44,180: The estimated number of alcohol-related breast cancer cases in women in 2019, representing 16.4% of all breast cancer cases in women.
- 741,300: The global burden of cancer cases related to alcohol use in 2020.
- 185,100: How many of those worldwide cases were related to about two or fewer drinks per day.
- 305,000: The annual total of years of potential life lost due to alcohol-related cancer deaths.
- 2: The number of daily drinks that would cause cancer in 5 in 100 women and 3 in 100 men, according to the estimated cumulative absolute risk. .”
Read this article here.
Title: “Molina Healthcare Awarded Dual Eligible Contracts”
Synopsis: “In Idaho, Molina’s health plan subsidiary, Molina Healthcare of Idaho, is set to administer the state’s Medicare Medicaid Coordinated Plan (MMCP) and Idaho Medicaid Plus Plan (IMPlus) for the dual eligible population. The initial term of these contracts is four years, with a potential one-year extension.
It is noteworthy that Molina Healthcare currently serves approximately 11,000 dual eligible members across Idaho.”
Read this article here.
Date published: 1/4/2025
Title: “An unimaginable year for UnitedHealth”.
Synopsis: “You see so much violence in hospitals and health systems often from people with behavioral health problems,” Scott Becker, founder and publisher of Becker’s Healthcare, said. “But I have not seen this, and it reminds me of the labor disputes in the early 1900s, where corporate CEOs were targeted by labor in a very aggressive way as those wars between unions and companies got very ugly. It’s been a long time since we’ve seen this type of activism and level of hostility. It’s a sad, sad situation.“
Read this article here.
Date published: 1/4/2025
Title: “32 health systems dropping Medicare Advantage plans | 2024”.
Synopsis: “Among the most commonly cited reasons are excessive prior authorization denial rates and slow payments from insurers.
Data on this topic is limited. In January, the Healthcare Financial Management Association and Eliciting Insights released a survey of 135 health system CFOs, which found that 16% of systems are planning to stop accepting one or more MA plans in the next two years. Another 45% said they are considering the same but have not made a final decision. The report also found that 62% of CFOs believe collecting from MA is “significantly more difficult” than it was two years ago.”
Read this article here.
Date published: 12/29/2024
Title: “BCBS antitrust settlement provider website goes live”.
Synopsis: “A website containing information for provider class settlement members in Blue Cross Blue Shield antitrust litigation has launched.
The website was launched after the Blue Cross Blue Shield Association, along with the 33 independent BCBS companies, agreed to pay $2.8 billion to settle antitrust claims from healthcare providers, marking the largest settlement of its kind in the healthcare industry. The settlement was reached in October. An Alabama court granted the agreement preliminary approval on Dec. 4.
The settlement class includes providers who currently provide or provided healthcare services, equipment or supplies to any patient who was insured by, or was a member or a beneficiary of, any plan administered by any settling individual Blues plan from July 24, 2008 to Oct. 4, 2024, according to the website.
The deadline to submit a claim is July 29, 2025..”
Read this article here.
Date published: 12/23/2024
Title: “Mark Cuban’s 2025 plans”.
Synopsis: “Nearly three years after its launch, Mark Cuban Cost Plus Drug Co. now manufactures injectables in shortage, works with thousands of healthcare facilities, including pharmacies, hospitals, long-term care sites and clinics, and offers more than 2,000 discounted generics and about a dozen branded medicines.
With its model of selling medicines at cost plus a 15% markup and $10 for shipping and pharmacy labor, several large pharmaceutical companies — including CVS and Express Scripts — have followed Cost Plus Drugs’ example.
In August, Mr. Cuban said Cost Plus Drugs would soon publish its own contracts to offer more transparency in an infamously opaque $4.3 trillion industry. He has also said the pharmaceutical industry has been his easiest industry to disrupt. As of June, the company was operating in a deficit.
The industry, on the care and pharmacy sides, have seen power consolidated in a few players. This is finally the year that can change. It is possible to align the incentives of providers, tax payers and patients, and I think we will finally see that start to happen.”
Read this article here.
Date published: 12/23/2024
Title: “Physicians slam Congress for failure to offset Medicare pay cuts”.
Synopsis: “Congress has signed a pared-down funding bill to prevent a government shutdown but failed to pass measures in a previously proposed bipartisan package that would have offset the 2.83% Medicare pay cut physicians face in 2025.
“The previously agreed-upon [continuing resolution], while not perfect, would have critically averted most of the 2.83% cut to physician reimbursement in Medicare beginning January 1,”
Anders Gilberg, senior vice president of government affairs, said in a statement. “Now physician practices head into the new year facing uncertainty and financial shortfalls that not only negatively impact the viability of their Medicare business, but their commercial contracts tied to Medicare rates, as well as Medicaid reimbursement in states that use Medicare as a benchmark.”
Physicians’ Medicare pay rates have dropped 33% over 20 years, and Congress has ignored inflation adjustments, prior authorization reforms and rising care costs, according to the American Medical Association. ”
Read this article here.
Date published: 12/23/2024
Title: “UnitedHealth Strategically Limits Access to Critical Treatment for Kids With Autism”.
Synopsis: “ProPublica has obtained what is effectively the company’s strategic playbook, developed by Optum, the division that manages mental health benefits for United. In internal reports, the company acknowledge that the therapy, called applied behavior analysis (ABA), is the “evidence-based gold standard treatment for those with medically necessary needs.” But the company’s costs have climbed as the number of children has ballooned; experts say greater awareness and improved have contributed to a fourfold increase in the past two decades — from 1 in 150 to 1 in 36.
So Optum is “pursuing market-specific action plans” to limit children’s access to the treatment, the reports said.
“Key opportunities” are bullets in the documents. While acknowledging some areas have “very long waitlists” for the therapy, the company said it aims to “prevent new providers from joining the network” and “terminate” existing ones, including “cost outliers.” If an insurer drops a provider from its network, patients may have to find a new clinician that accepts their insurance or pay up to tens of thousands of dollars a year out of pocket for the therapy. The company has calculated that, in some states, this reduction could impact more than two-fifths of its ABA therapy provider groups in network and up to 19% of its patients in therapy.”
Read this article here.
Date published: 12/23/2024
Title: “Higher Utilization, Regulatory Challenges Pressure Medicare Advantage Segment, prompting Some Carriers to Exit Market”.
Synopsis: “A contributing factor to the recent announcements of market exits by some participants include the Inflation Reduction Act of 2022 (IRA), which takes effect in 2025 and includes several provisions aimed at lowering prescription drug expenses for Medicare Part D beneficiaries, shifting a larger share of costs to insurers and drug manufacturers. A separate stabilization demonstration program was enacted earlier this year to support implementation of the redesigned Part D benefit by subsidizing the anticipated premium and cost increases; however, this is available to Medicare Part D-only insurers and does not apply to MA plans that include Part D. Another factor pressuring MA plans are the recent changes in the risk adjustment score calculation that are being phased in over three years starting with 2024; the new calculation drives down the score leading to lower reimbursement rates per member.”
Read this article here.
Date published: 11/7/2024
Title: “Why you should consider Proton Therapy for cancer treatment.”
Synopsis: “Proton therapy, or proton beam therapy, is a type of radiation treatment that uses a beam of protons to deliver radiation directly to the tumor.
Imagine a 196-ton, cancer-killing machine that can target a patient’s tumor with a sub-millimeter precision while sparing nearby healthy tissues and minimizing side effects. In its most simple terms, that’s proton therapy.
Pencil beam technology and IMPT build on the benefits of proton therapy. With a proton beam just millimeters wide, these advanced forms of proton therapy combine precision and effectiveness, offering unmatched ability to treat a patient’s tumor and minimizing the effect on a patient’s quality of life – during and after treatment. They rely on complex treatment planning systems and an intricate number of magnets to aim a narrow proton beam and essentially “paint” a radiation dose layer by layer.
Pencil beam is very effective in treating the most complex tumors, like those in the prostate, brain, eye, and cancers in children, while leaving healthy tissue and other critical areas unharmed. IMPT is best used to deliver a potent and precise dose of protons to complex or concave-shaped tumors that may be adjacent to the spinal cord or embedded head and neck or skull base, including nasal and sinus cavities, oral cavity, salivary gland, tongue, tonsils, and larynx.”
Read this article here and here.
Date published: 11/4/2024
Title: “BCBS reaches record antitrust settlement for $2.8B”.
Synopsis: “The Blue Cross Blue Shield Association, along with the 33 independent BCBS companies, have agreed to pay $2.8 billion to settle antitrust claims from healthcare providers, marking the largest settlement of its kind in the healthcare industry.
In addition to the cash settlement, the plaintiffs stated in an Oct. 14 filing in Alabama federal court that BCBS plans must implement significant operational changes across 16 categories. These changes include how BCBS processes claims, communicates, contracts with, and makes payments to providers.
The new operational requirements are expected to alleviate administrative burdens and inefficiencies experienced by providers, according to the plaintiffs’ counsel. The settlement applies to providers who treated BCBS members between July 2008 and October 2024..”
Read this article here. Read the comments section too.
Date published: 10/16/2024
Title: “UnitedHealth seeks ‘less abrasion’ with hospitals”.
Synopsis: “The executives’ comments come as hospital leaders allege UnitedHealth denies payments at a higher rate than other insurers. The insurer has had several public contract disputes with hospitals and health systems this year.
Craig Albanese, MD, CEO of Duke University Health System, told Becker’s UnitedHealthcare denies payments 40% more often than other insurers. The system and UnitedHealthcare face a Nov. 1 deadline to reach a new contract agreement.
Huntsville (Ala.) Hospital Health System is terminating its contract with UnitedHealthcare, alleging the insurer’s denial rate “is 75% higher than other like insurers.”
UnitedHealthcare said the health system asked for “an over 25% price hike in just one year, despite already being nearly 20% higher than the average cost of other hospitals in our network in northern Alabama.”
Read this article here. Read the comments section too.
Date published: 10/16/2024
Title: Early analysis: “How health plans fared in the 2025 Medicare Advantage star ratings.”
- Synopsis: “This year, 62% of membership is attributed to a 4+ star plan, down from 79% the year prior. Notably, only 1.8% of membership is now in a 5 star plan, down from nearly 8% the prior year and 27% in 2022.
- Enrollment in 5 star plans is now negligible. Only 1.8% of members are in this plan tier, down from its peak of 27% in 2022 and 8% in 2024.
- Enrollment in plans with less than 3 stars remained steady at approximately 1%. This is important because plans that score below this threshold in consecutive years cannot market for additional membership or file for new applications or service area expansions (SAEs). They also could be terminated if they are low scoring for 3 years in a row.”
Read this article here.
Date published: 10/14/2024
Title: Senator promises ‘dramatic’ Medicare Advantage investigation.
Synopsis: “Anybody following our hearings and public comments knows our findings will be very dramatic and powerful,” Mr. Blumenthal said. “What we have found is, essentially, there is no advantage for people in Medicare Advantage, all too often.”
Read this article here.
Date published: 10/7/2024
Title: The Great Disruption Coming for Medicare Advantage
Synopsis: Come mid-October, the Medicare Advantage program will enter its annual enrollment period, marked by significant changes for older adults.
Among these changes are increased government scrutiny, tighter CMS regulations, reduced base payments, and rising healthcare costs.
In response to these market shifts, MA carriers are prioritizing their margins over membership by reducing certain benefits and exiting unprofitable markets. As margins tighten and negotiations with providers become more strained, some health systems are choosing to no longer accept some or all MA plans.
Read this article here.
Date published: 9/9/2024
Title: “Feds Killed Plan to Curb Medicare Advantage Overbilling After Industry Opposition.”
Synopsis: The Justice Department alleged the giant health insurer cheated Medicare out of more than $2 billion by reviewing patients’ records to find additional diagnoses, adding revenue while ignoring overcharges that might reduce bills. The company “buried its head in the sand and did nothing but keep the money,” the DOJ said in a court filing.
Medicare pays health plans higher rates for sicker patients but requires that the plans bill only for conditions that are properly documented in a patient’s medical records.
In a court filing, UnitedHealth Group denied wrongdoing and argued it shouldn’t be penalized for “failing to follow a rule that CMS considered a decade ago but declined to adopt.”
Read this article here.
Date published: 9/6/2024
Title: Medicare Advantage: How Robust Are Plans’ Physician Networks?
Synopsis: For people on Medicare, one of the biggest trade-offs between Medicare Advantage and traditional Medicare is that Medicare Advantage plans have a more limited network of doctors and other providers. Medicare Advantage plans restrict the doctors, hospitals, and other providers from whom their enrollees can receive care, while traditional Medicare allows people to see any provider that accepts Medicare (overwhelming majority of providers). Seniors value having the ability to choose their own doctors as well as keep their existing doctors, and say that the doctors in the network are an important factor in their plan selections.1
Although Medicare Advantage enrollment is rising rapidly, with one in three beneficiaries now in a Medicare Advantage plan, relatively little is known about Medicare Advantage plans’ provider networks.2 The Centers for Medicare and Medicaid Services (CMS) requires Medicare Advantage plans to include a specified number of physicians for each of the 26 specialties, along with hospitals, and other providers within a particular driving time and distance of enrollees;3 however, little information is available about the extent to which plans go beyond these basic requirements. A prior analysis showed that Medicare Advantage hospital networks vary greatly in size and composition.4 The size and composition of a plan’s physician network can have important implications for Medicare Advantage enrollees, including whether or not they can see a given physician (for HMO enrollees) or how much more they would need to pay for out-of-network care (for PPO enrollees).
When forming their networks, insurers may choose to contract with some but not all physicians for a variety of reasons. For example, the insurer may want to have greater control over the cost or quality of care provided by a physician or they may prefer to limit the number of physicians included in their network for other reasons. Curating and restricting their provider networks may also allow insurers to improve the coordination and efficiency of care for their enrollees.
At the same time, physicians may or may not want to be a part of a Medicare Advantage network. They may not want the extra paperwork and time that may come with accepting another insurer, may not want additional patients, or may have concerns with a plan’s payment rates or other terms of a given plan’s contract.
This report is the first known study to examine the size and composition of Medicare Advantage plans’ networks, focusing on physicians. This analysis draws upon data from 391 plans, offered by 55 insurers, in 20 counties, accounting for 14 percent of all Medicare Advantage enrollees nationwide in 2015. The report analyzes the size of provider networks across and within the 20 counties, overall and by specialty, and looks at the relationship between network size and other plan features, including plan types, premiums, star ratings, and insurers. We defined Medicare Advantage networks as broad if they included 70 percent or more of the physicians in a county, medium if they included between 30 and 69 percent of the physicians in a county, and narrow if they included less than 30 percent of the physicians in a county.
Growing evidence indicates that many plans do not maintain accurate directories.5 For example, in an investigation, CMS found that the directories had many errors and 45 percent of the doctors listed had incorrect information in plans’ directories.6 Unlike CMS, we do not assess the accuracy of the directories, nor do we assess whether the physicians in the directories actually accept the insurance.
Read this article here.
Date published: 9/6/2024
Title: Income and Assets of Medicare Beneficiaries in 2023
Synopsis: This analysis highlights that most Medicare beneficiaries live on relatively low incomes and have modest financial resources to draw upon in retirement if they need to cover costly medical care or long-term services and supports, with notable disparities by age, race and ethnicity, and gender. For example:
- One in four Medicare beneficiaries lived on incomes below $21,000 per person in 2023, while half lived on incomes below $36,000 per person. Median income declined with age among older adults, was lower for women than men, and lower for Black and Hispanic than White beneficiaries.
- One in four Medicare beneficiaries had savings below $16,950 per person in 2023, while half had savings below $103,800 per person. As with income, median savings declined with age among those ages 65 and older, were lower for women than men, and were substantially lower for Black ($22,100) and Hispanic ($20,050) than White ($158,950) beneficiaries.
- One in four Medicare beneficiaries had no home equity at all in 2023, while half of all Medicare beneficiaries had home equity below $124,450 per person.
- More than one in five Black and Hispanic beneficiaries had no savings or were in debt, compared to fewer than one in ten White beneficiaries. Nearly half of all Black and Hispanic beneficiaries had no home equity, compared to one in five White beneficiaries.
Read this article here.
Date published: 9/6/2024
Title: Explaining the Prescription Drug Provisions in the Inflation Reduction Act
Synopsis: The prescription drug provisions included in the Inflation Reduction Act will:
- Require the federal government to negotiate prices for some drugs covered under Medicare Part B and Part D with the highest total spending, beginning in 2026
- Require drug companies to pay rebates to Medicare if prices rise faster than inflation for drugs used by Medicare beneficiaries, beginning in 2023
- Cap out-of-pocket spending for Medicare Part D enrollees and make other Part D benefit design changes, beginning in 2024
- Limit monthly cost sharing for insulin to $35 for people with Medicare, beginning in 2023
- Eliminate cost sharing for adult vaccines covered under Medicare Part D and improve access to adult vaccines in Medicaid and CHIP, beginning in 2023
- Expand eligibility for full benefits under the Medicare Part D Low-Income Subsidy Program, beginning in 2024
- Further delay implementation of the Trump Administration’s drug rebate rule, beginning in 2027
This brief summarizes these provisions and discusses the expected effects on people, program spending, and drug prices and innovation.
Read this article here.
Date published: 8/24/2024
Title: “Use of Prior Authorization in Medicare Advantage Exceeded 46 Million Requests in 2022”
Synopsis: “Virtually all enrollees in Medicare Advantage (99%) are required to obtain prior authorization for some services – most commonly, higher cost services, such as inpatient hospital stays, skilled nursing facility stays, and chemotherapy. This contrasts with traditional Medicare, where only a limited set of services require prior authorization. Prior authorization requirements are intended to ensure that health care services are medically necessary by requiring approval before a service or other benefit will be covered. Medicare Advantage insurers typically use prior authorization, along with other tools, such as provider networks, to manage utilization and lower costs. This may contribute to their ability to offer extra benefits and reduced cost sharing, typically for no additional premium, while maintaining strong financial performance.”
Read this article here.
Published: Aug 08, 2024
Title: Humana to pay $90 mln to settle claim that it overcharged Medicare for drugs
Synopsis: Humana (HUM.N), opens new tab has agreed to pay $90 million to settle a whistleblower lawsuit by one of its former actuaries accusing the health insurer of overcharging the U.S. government for prescription drugs, the whistleblower’s lawyers announced on Friday.
The whistleblower, Steven Scott, said that Humana, which contracts with the federal Medicare program to administer prescription drug benefits, misrepresented its true costs in order to get a more lucrative contract. It is the first settlement with any insurer over allegations of fraud tied to Medicare’s prescription drug contracting process, according to the law firm Phillips & Cohen, which represents Scott.
Read this article here.
Date published: 8/16/2024
Title: Healthgrades America’s 50 Best Hospitals
Synopsis: Hospital quality is one of the most important factors when choosing a doctor for in-patient care. Healthgrades has been helping people evaluate and compare hospital performance to make more informed choices since 1998. Hospital quality is not one-size-fits-all, which is why outcomes-focused tools like Healthgrades quality awards and ratings are critical to helping people make informed choices about where to seek care.
Read this article here.
Date published: 8/24/2024
Title: PBMs hold ‘enormous power’ over drug prices: FTC
Synopsis: “The three largest PBMs — CVS Caremark, Cigna’s Express Scripts, and UnitedHealth’s OptumRx— handle 79% of U.S. medical prescriptions for approximately 270 million people. Integrating further with health insurers allows even more control over medication prices and access, according to the FTC’s report. On top of that, PBMs also contributed to a 10% closure rate of independent pharmacies in rural locations between 2013 and 2022.”
“PBMs and their affiliated entities may have the incentive and ability to engage in steering a growing share of prescription revenues to their own pharmacies through specialty drug classification, self-preferential pricing, and pharmacy contracting procedures to target and control the business operations of pharmacies,” the report concludes.”
Read this article here.
Date published: 7/11/2024
Title: The Inflation Reduction Act and Medicare.
Synopsis: The Inflation Reduction Act provides meaningful financial relief for millions of people with Medicare by improving access to affordable treatments and strengthening the Medicare Program both now and in the long-run.
The new drug law makes improvements to Medicare that will expand benefits, lower drug costs, keep prescription drug premiums stable, and improve the strength of the Medicare program.
Read this article here.
Date Published: 7/11/2024
Title: Insurers brought in $50B through ‘questionable’ Medicare Advantage coding.
Synoposis: The Journal’s investigation is the latest examining upcoding by MA plans. A 2022 report in The New York Times alleged some insurers incentivized employees or physicians to add diagnoses to patients’ reports. Nearly every major payer has been accused of overbilling by a whistleblower, the federal government or an investigation by HHS’ Office of Inspector General.
MedPAC, which advises the government on Medicare issues, estimates the federal government will spend $83 billion more on Medicare Advantage beneficiaries than if they were enrolled in fee-for-service Medicare. Coding intensity in MA will be 20% higher than in fee-for-service in 2024, according to the commission.
Read this article here.
Date published: 7/11/2024
Title: “Gaps in Medicare Advantage Data Remain Despite CMS Actions to Increase Transparency.”
Synopsis: “Medicare Advantage insurers are not required to report prior authorization requests, denials, and appeals by type of service, for specific plans within a contract, or reasons for prior authorization denials. They are also not required to report to CMS complete information on denied claims for inpatient, physician and other services already delivered to enrollees. Other information is collected by CMS, but not published, including out-of-pocket spending by Medicare Advantage enrollees, and the characteristics of enrollees who switch Medicare Advantage plans or disenroll to get coverage under traditional Medicare. Some of this information would also be useful to Medicare beneficiaries when choosing among the large number of plans offered in their area. CMS recently put out a Request for Information (RFI) seeking input on additional Medicare Advantage data that could further improve program oversight and beneficiary decision making..”
Read this article here.
Date published: 4/10/2024
Title: “CMS hospital star ratings offer limited measure of surgical quality”.
Synopsis: Although CMS hospital star rating was associated with postoperative mortality, serious complications, and readmissions, there was wide variation in surgical outcomes within each star rating group. These findings highlight the limitations of the CMS hospital star rating system as a measure of surgical quality and should be a call for continued improvement of publicly reported hospital grade measures.
Read this article here.
Title: “Older Americans say they feel trapped in Medicare Advantage plans”.
Synopsis: “Timmins, though, discovered that his enrollment in a Premera Blue Cross Medicare Advantage plan would mean a limited network of doctors and the potential need for preapproval, or prior authorization, from the insurer before getting care. The experience, he said, made getting care more difficult, and now he wants to switch back to traditional, government-administered Medicare.
But he can’t. And he’s not alone.””
Read this article here.
Date Published: 1/13/24
Title: “Humana reports major decline in Medicare Advantage star ratings.”
Synopsis: “The percentage of Humana Medicare Advantage members enrolled in plans rated 4 stars or higher for 2025 has dropped significantly, which is expected to negatively affect 2026 revenues.
Based on preliminary 2025 MA Star Ratings data from CMS, Humana has approximately 1.6 million, or 25%, of its members currently enrolled in plans rated 4 stars and above for 2025, a reduction from 94% in 2024, according to regulatory documents filed Oct. 2.”
Read this article here.
Date published: 10/2/2024
Title: “Cigna to pay $172M over alleged Medicare Advantage fraud”.
Synopsis: “The Cigna Group will pay $172.3 million to resolve allegations that it violated the False Claims Act by submitting incorrect Medicare Advantage patient data to CMS to receive higher payments from the agency.
The U.S. Attorney’s Office for the Eastern District of Pennsylvania alleged Sept. 30 that Cigna also falsely certified that the submitted data was accurate, failed to withdraw the “untruthful” data and did not repay CMS. ”
Read this article here.
Date Published: 10/3/23
Title: “Reduced Coinsurance for Certain Part B Rebatable Drugs under the Medicare Prescription Drug Inflation Rebate Program”.
Synopsis: “President Biden’s historic Inflation Reduction Act requires drug companies to pay rebates to Medicare when prescription drug prices increase faster than the rate of inflation for certain drugs furnished to people with Medicare. This new inflation rebate applies to Medicare Part B rebatable drugs, which are single source drugs and biological products, including certain biosimilar biological products, beginning January 1, 2023. ”
Read this article here.
Date Published: 10/2/23
Title: “Hospitals are dropping Medicare Advantage left and right”.
Jakob Emerson – 17 hours ago
Synopsis: “Among the most commonly cited reasons are excessive prior authorization denial rates and slow payments from insurers. Some systems have noted that most MA carriers have faced allegations of billing fraud from the federal government and are being probed by lawmakers over their high denial rates.
“It’s become a game of delay, deny and not pay,” Chris Van Gorder, president and CEO of San Diego-based Scripps Health, told Becker’s. “Providers are going to have to get out of full-risk capitation because it just doesn’t work — we’re the bottom of the food chain, and the food chain is not being fed.”
Read this article here.
Date Published: 9/28/23
Title: “Triple set of vaccines coming: What to know.”
Synopsis: “Vaccines for the three most closely watched viruses — COVID-19, flu and respiratory syncytial virus — will soon be available just before the respiratory virus season is in full swing.
Questions remain about the rate at which U.S. adults will receive the vaccines after fewer than 23 percent of adults chose to receive the COVID-19 booster last fall, according to KFF News. On top of that, by the end of the 2022-23 flu season, the CDC reported that only 54 percent of adults chose to get the flu vaccine.”
Read this article here.
Date Published: 9/13/23
Title: “How is Medicare Advantage funded?”
Synopsis: “Every month, Medicare pays into Advantage plans an amount that covers the Part A and Part B costs of beneficiaries. If a plan also offers prescription drug coverage, Medicare provides a separate payment. The amount of the monthly payments depends on two main factors:
- the healthcare practices in the county where each beneficiary lives, which influences a procedure called the bidding process
- the health of each beneficiary, which governs how Medicare raises or lowers the rates, in a system known as risk adjustment.”
Read this article here.
Date Published: 2/23/2023
Title: From ‘game-changer’ to ‘we all lose’: 9 nurse leaders weigh in on virtual nursing
Synopsis: “More systems and hospitals are trying virtual nurses as staffing shortages continue. Trinity Health plans to roll out virtual nurses at its hospitals in Michigan and nationwide. Ardent Health Services also has plans to implement the company’s virtual nursing platform at Albuquerque, N.M.-based Lovelace Medical Center.”
Note: The St. Alphonsus Hospitals are part of the Trinity Health Plans.
Read this article here.
Follow on update on Trinity here.
Date Published: 2/21/23
Title: 100 top rural and community hospitals, by state
Synopsis: “Hospitals are rated using publicly available data sets and scored across eight performance pillars. “The Chartis Rural Hospital Performance INDEX is the industry’s most comprehensive and objective assessment of rural provider performance,” according to the firm’s website.”
Note: Idaho had no entries on this list.
Read this article here.
Date Published: 2/19/23
Title: “The 20% Medicare cut coming for hospitals”.
Synopsys: Since January 2020, hospitals nationwide have received a 20 percent increase in the Medicare payment rate through the hospital inpatient prospective payment system to treat COVID-19 patients — that policy ends May 11.
Read this article here.
Date posted: February 18, 2023.
Title: “An Overview of the Medicare Part D Prescription Drug Benefit”
Synopsis: Learn how Medicare Prescription Drug plans are funded. This is an up-to-date article.
Read this article here.
Date posted: February 17, 2023
Title: “Mileage Varies for Different Hip Surgery Approaches”
Synopsis: If you are considering a hip replacement, this article should help you understand the different surgical approaches for doing such. You might use your favorite search engine to learn the differences between your recovery time, pain level and how long the new implant could last.
Understanding the content of this article could put in a better position to understand your pre-op counseling sessions with your selected surgeon.
Read this article here.
Date posted: February 17, 2023.
Title: “50 hospitals and health systems with great orthopedic programs headed into 2023.”
Synopsis: If you have planned orthopedic needs in 2023, this is a must-read article.
Read this article here.
Date posted: February 13, 2023
Title: “Becker’s Hospital Review is pleased to release its top oncology hospitals.
Synopsis: The hospitals and health systems featured on this list have earned recognition nationally as top cancer care providers and many are on the cutting edge of novel therapies and researcher to improve outcomes and access to care.”
If you have been diagnosed with cancer, this is a must-read article.
Read this article here.
Date posted: February 9, 2023
Title: Some services covered by Original Medicare (Fee for Service) require ‘prior authorization’.
Synopsis: Bookmark the page below to keep up on these evolving rules. Individuals enrolled in a Medigap (Medicare Supplement plan) as well as individuals enrolled in Medicare Part A and/or B should check this article periodically. Individuals enrolled in Part C (Medicare Advantage plans) can find prior authorization rules in their plan’s Evidence of Coverage.
Read this article here.
Date Posted: February 8, 2023
Title: “Over 35 million prior authorization requests were submitted to Medicare Advantage insurers in 2021, according to a new report (opens in a new tab or window) from the Kaiser Family Foundation (KFF).
Synopsis: Two million of these requests, or 6%, were fully or partly denied, according to Jeannie Fuglesten Biniek, PhD, associate director of the Program on Medicare Policy, and Nolan Sroczynski, MSPH, a data analyst for the Program on Medicare Policy, at KFF.”
Read this article here.
Date posted: February 6, 2023
Title: There are about 150,000 people currently enrolled in Idaho Medicaid who either don’t qualify or have not been in contact with DHW during the public health emergency (the federal COVID-19 public health emergency).
Synopsis: Starting today, Feb. 1, and continuing through July, DHW will send out about 30,000 re-evaluation notices a month. People have 60 days to respond before they will be removed. If they respond in that time, they will be re-evaluated for Medicaid eligibility. Those who do not qualify for Medicaid will be able to discuss their options for accessing health insurance with YHI.”
Read this article here.
Date posted: February 4, 2023
Title: “US spends most on health care but has worst health outcomes among high-income countries, new report finds”
Read this article here.
Synopsis: “Americans are living shorter, less healthy lives because our health system is not working as well as it could be,” the report’s lead author, Munira Gunja, senior researcher for The Commonwealth Fund’s International Program in Health Policy and Practice Innovation, said in a news release. “To catch up with other high-income countries, the administration and Congress would have to expand access to health care, act aggressively to control costs, and invest in health equity and social services we know can lead to a healthier population.”
Read this article here.
Date posted: February 2. 2023
Title: “Insurers that face the largest potential Medicare Advantage payment clawbacks”
Read this article here.
“The nation’s largest insurers are gearing up for upcoming changes to Medicare Advantage risk adjustment rules that could collectively cost them up to $3 billion in returned payments, with Humana potentially facing the biggest penalties, Bloomberg reported Jan. 24.”
Read this article here.
Date posted: January 26, 2023
Title: “The 11 worst-rated Idaho nursing homes, according to the government.”
Synopsis: If this article is not available, you can use the tool here to find Skilled Nursing Facilities by zip code.
We suggest you avoid ALL facilities rated below ‘3’ stars AND concentrate your search on facilities rated ‘5’ (preferably) or ‘4’ stars (if ‘5’ star facilities do not have an immediate vacancy).
Read this article here.
Date posted: January 25, 2023
Title: “Denver, CO – January 17, 2023 – Healthgrades, the #1 site Americans use to find a doctor or hospital, today announced the recipients of the 2023 America’s Best Hospitals Awards and State Rankings. This year’s achievements recognize the national leaders in overall clinical excellence and the top-ranked hospitals for specialty care by state.”
Synopsis: Find which of the top 50, 100 or 250 hospitals in the US excel at the surgery you are considering. Start your research by clicking here.
Read the press release here.
Date posted: January 17, 2023
Title: “96 prescription medications lost their exclusivity in 2022…Generics coming soon? Listed med’s include: Estradiol and progesterone capsules; Diclofenac topical solution; Breyna (budesonide and formoterol fumarate dihydrate).”
Read this article here.
Read an update here.
Date posted: January 2, 2023
Synopsis: “50 drugs on Mark Cuban’s pharmacy with biggest cost reductions”
Read this article here.
Date posted: December 27, 2022
Title: CMS issues new ruling limiting third parties who conduct Medicare Advantage marketing
Synopsis: “In response to what CMS reports as a substantial increase in the number of Medicare beneficiary complaints associated with third-party marketing organizations (“TPMOs”) that sell, or assist in the sale of, MA and Part D plans, the Final Rule codifies several new communications and marketing requirements aimed at further safeguarding Medicare beneficiaries and indirectly increasing regulatory oversight over TPMOs. The revised regulations will become effective on June 28, 2022.”
Read this article here.
Date posted: September 20, 2022
Title: “Mark Cuban’s generic drug company, Mark Cuban Cost Plus Drug Co., launched an online pharmacy Jan. 19 that produces low-cost versions of high-cost generic drugs. Here is a list of the 31 medications for which MCCPDC offers a savings of $100 or more.”
Read this article here.
Date posted: April 4, 2022
Title: “Free Over-the-Counter COVID-19 Tests”
Synopsis: The highlights of this article include:
“…we are expanding access to free over-the-counter COVID-19 testing for people with Medicare Part B, including those enrolled in a Medicare Advantage plan. People with Medicare Part B will now have access to up to eight FDA-approved, authorized or cleared over-the-counter COVID-19 tests per month at no cost. This is all part of our overall strategy to ramp -up access to easy-to-use, at-home tests free of charge,”
Read this announcement here.
Date Published: 4/3/2022
Title: “2021-2030 Projections of National Health Expenditures”.
Synopsis: “Medicare spending growth is projected to average 7.2% over 2021-2030, the fastest rate among the major payers. Projected spending growth of 11.3% in 2021 is expected to be mainly influenced by an assumed acceleration in utilization growth, while growth in 2022 of 7.5% is expected to reflect more moderate growth in use, as well as lower fee-for-service payment rate updates and the phasing in of sequestration cuts. Spending is projected to exceed $1 trillion for the first time in 2023. By 2030, Medicare spending growth is expected to slow to 4.3% as the Baby Boomers are no longer enrolling and as further increases in sequestration cuts occur.
Read this announcement here.
Date Published: 3/28/2022
Synopsis:” CMS Redesigns Accountable Care Organization Model to Provide Better Care for People with Traditional Medicare”
The highlights of this article include: “How are beneficiaries affected by ACO REACH?
Beneficiaries with Traditional Medicare retain all of their rights, coverage, and benefits, including the freedom to see any Medicare provider. Like previous ACO models, the ACO REACH Model prohibits limited networks, prior authorization or any other means of restricting care. Even if a beneficiary is aligned to a REACH ACO, they always have the freedom to see any Medicare-enrolled provider. CMS expects that beneficiaries whose primary care provider is part of a REACH ACO will see and feel improvements in the quality of health care they are getting because of the ACO REACH Model. For example, they may receive increased access to telehealth, home visits after leaving the hospital, cost sharing support to help with co-pays, or other enhanced services and incentives. Moreover, the new Health Equity provisions are expected to provide greater access for underserved communities, reaching beneficiaries who have not previously received coordinated care.
Starting in PY2023, CMS is requiring each REACH ACO to have both a Medicare beneficiary and consumer advocate serving on the REACH ACO’s governing body who will hold voting rights (the same person is no longer permitted to fill both roles) to ensure beneficiary representation in the REACH ACO’s governance.
In addition, CMS will closely monitor levels of care provided over time and compare care delivery patterns to a reference population to determine if REACH ACOs are stinting on beneficiary care. CMS also will conduct compliance audits throughout the year, investigate beneficiary complaints, and conduct beneficiary experience of care surveys (CAHPS) annually to measure changes in beneficiary satisfaction. Lastly, CMS will monitor whether beneficiaries aligned to the model are being shifted into or out of Medicare Advantage.
If at any time a Medicare beneficiary or their caregiver has concerns about the ACO REACH Model, the Innovation Center has a model liaison that is part of the Medicare Beneficiary Ombudsman team in the Offices of Hearings and Inquiries. The model liaison can be reached thru 1-800 Medicare and will assist in facilitating communications with the Medicare Quality Improvement Organizations (QIOs), the CMS regional offices, and ACO REACH Model team to ensure the beneficiary’s concerns are heard.”
Read this announcement here.
Date Published: 2/24/2022
Synopsis: Mayo Clinic halts scheduling of out-of-network Medicare Advantage patients.
The highlights of this article include:
“The Mayo Clinic in Minnesota is no longer scheduling appointments for patients in most Medicare Advantage plans.”
“The change occurred because Mayo saw a significant increase in patients covered by ‘non-contract’ MA insurers. That increase, officials said, threaten to crowd out patients covered by in-network insurers.
“Mayo doesn’t have the capacity to serve an ever-increasing number of patients and needs to remain a good steward with its contracted plans.”
Be sure you read the 2nd announcement as it addresses how Mayo will work with Medicare beneficiaries at their Scottsdale AND Jacksonville facilities. The 1st attachment addressed their do the same for their Rochester, Mn. resources.
Read their first announcement (Rochester facility) here.
Read their 2nd announcement (Jacksonville and Scottsdale sites) here.
Date posted: February 18, 2022
Date updated: January 2, 2023
Synopsis: The Idaho Governor signed bill 1143 on 4/26/2021. This new law will be effective 3/1/2022.
The effects of this law will be felt by insurance companies offering Medigap plans in Idaho, future Idaho Medicare beneficiaries interested in a Medigap plan and potentially, current Idaho Medigap policy holders.
The highlights of this legislation include:
- “Initial and subsequent conditions of eligibility, including an annual period during which a policyholder may terminate an existing Medicare supplement policy and be eligible to purchase any other Medicare supplement policy on a guaranteed issue basis”;
- “Attained age rating prohibited; issue age rating prohibited for policies issued after March 1, 2022; and community rating permitted.”
The bill in its entirety is available here. Please read this at your convenience.
Date Published: 2/18/2021
Synopsis: “The Healthgrades 2021 Report to the Nation analyzes the performance of nearly 4,500 hospitals as measured by risk-adjusted mortality and complication rates. The analysis shows wide performance gaps persist among hospitals. The data indicates a wide variation in clinical outcomes for the same treatment at different hospitals at national, regional, and local levels. ”
“Neither patients nor their physicians can assume their local hospital is the best choice for their procedure or condition; but using the Healthgrades 2021 Specialty Excellence AwardsTM and ratings can help inform where to seek the best care. In this moment where risk mitigation is of utmost importance, it’s imperative to know how well a hospital performs when it comes to providing the specific care an individual needs.”
Access the article here
Date Published: 2/18/2021
Synopsis: “CMS will terminate its agreement with Nampa, Idaho-based Healing Arts Day Surgery effective Jan. 20, the agency announced.”
“The center failed to adhere to requirements to participate in Medicare.
Healing Arts Day Surgery is an ASC affiliated with Nampa-based Treasure Valley Gastroenterology. The practice and surgery center are located adjacent to each other and share a building.”
Access the article here
Date Published: 1/7/2021
Synopsis: “CMS Issues Waivers of 3-Day Stay and Spell of Illness.”
These waivers mean that skilled nursing facility (SNF) care without a 3-day inpatient hospital stay will be covered for beneficiaries who experience dislocations or are affected by the COVID-19 outbreak. Due to the current crisis, CMS also is utilizing the authority under section l8l2(f) providing renewed SNF coverage to beneficiaries without starting a new spell of illness and allowing them to receive up to an additional 100 days of SNF Part A coverage. More detail and background information are provided below.
Access the article here
Date published: 3/14/2020
Synopsis: “CMS Launches Groundbreaking Model to Lower Out of Pocket Expenses for Insulin”
“The Part D Senior Savings Model allows Medicare Part D prescription drug plans to offer beneficiaries plan choices that provide a broad range of insulins at a $35 copay”
Access the article here
Date published: 3/11/2020
Synopsis: “Medicare’s Private Option Is Gaining Popularity, and Critics”
“Most enrollees in traditional Medicare buy supplemental coverage to protect them from potentially high out-of-pocket costs. In 2016, out-of-pocket spending in the program averaged $3,166, excluding premiums, according to the Kaiser Family Foundation.
Supplemental coverage sometimes comes from a former employer, a union or Medicaid, although many people buy a commercial Medigap plan. But the best, and sometimes only, time to buy a Medigap policy is when you first join Medicare.
During the six months after you sign up for Part B (outpatient services), Medigap plans cannot reject you, or charge a higher premium, because of pre-existing conditions. After that time, you can be rejected or charged more, unless you live in one of four states (Connecticut, Massachusetts, Maine and New York) that provide some level of guarantee to enroll at a later time with pre-existing condition protection.
Mr. Stein’s cancer diagnosis made the switch to original Medicare virtually impossible. “We were just shocked to learn that,” he recalled.
His coverage problems led to a frenzied scramble in November that ultimately involved treatment at four hospitals — and a last-minute switch to a different Advantage network that includes his preferred physician.
The problems have taken their toll. “When you’re in the middle of a health crisis, the last thing you need is to be negotiating with health providers and insurance,” said Mr. Stein’s wife, Lisa Hartman. “We spent as many hours talking with all these people about squaring away our insurance as we did actually getting treatment.””
Access the article here (If you have an online subscription to read the New York Times, you will need to login. If you are without a subscription you can sign up to access a limited number of articles at no cost.)
Date published: 2/21/2020
Synopsis: “If you are/will be subject to the IRMAA (income related monthly adjustment amount) for your Medicare Part B and Part D premiums and had a ‘life changing event’ you may be eligible for lower monthly premiums.”
“In the case of certain major life-changing events that result in a significant reduction in MAGI, an individual may request to have the determination made for a more recent year than the second preceding year.82 Major life-changing events include (1) death of a spouse; (2) marriage; (3) divorce or annulment; (4) partial or full work stoppage for the individual or spouse; (5) loss by individual or spouse of income from income-producing property when the loss is not at the individual’s direction (such as in the case of a natural disaster); and (6) reduction or loss for individual or spouse of pension income due to termination or reorganization of the plan or scheduled cessation of the pension.83 Certain types of events, such as those that affect expenses but not income or those that result in the loss of dividend income because of the ordinary risk of investment, are not considered major life-changing events.84”
Access the article here (page 16)
Date published: 2/17/2020
Synopsis: “Half Truths and Medicare Advantage Commercials’
“If you watched any television in the last several months, you probably saw a slew of commercials for Medicare Advantage plans. One that pops up frequently features a former professional football player who once did a commercial wearing pantyhose.”
“Based on my preliminary plan research, here are some important points not mentioned in the commercials:
- These benefits appear to be more common in health maintenance organization (HMO) plans. Except for an emergency, the benefits are only available through a network of selected providers, which can limit the individual’s choice.
- The plan likely will require prior approval or authorization. Before receiving care, the plan must review and approve the physician’s order.
- There are limits on these benefits. For example, two meals a day for five days after hospitalization with a limit of four hospitalizations, and a private home aide four hours a day for no more than 31 days in a year.
- And, most important, the plans we researched require members to select only one benefit per calendar year.”
We encourage you to read the article in its entirety to learn the caveats about this advertising.
Access the article here.
Date published: 2/12/2020
Synopsis: “CMS finalizes decision to cover Acupuncture for Chronic Low Back Pain for Medicare beneficiaries”.
While a small number of adults 65 years of age or older have been enrolled in published acupuncture studies, patients with chronic low back pain in these studies showed improvements in function and pain. The evidence reviewed for this decision supports clinical strategies that include nonpharmacologic therapies for chronic low back pain. CMS notes too that while there is variation in covered indications and frequency of services, a number of large private payers provide some coverage of acupuncture for certain indications.
Access the article here.
Date published: 2/3/2020
Synopsis: “Medicaid Facts and Figures”.
- “71,395,465 individuals were enrolled in Medicaid and CHIP in the 51 states that reported enrollment data for October 2019.[1]
- 64,699,741 individuals were enrolled in Medicaid.
- 6,695,724 individuals were enrolled in CHIP.
- New adult group enrollment (VIII Group) was 15,181,880 for the 3rdquarter of 2018.[2]”
Access the article here.
Date published: 1/30/2020
Synopsis: “CMS Releases Enhanced Drug Dashboards Updated with Data for 2018”.
“The continued public release of what Medicare and Medicaid pay for prescription drugs puts manufacturers on notice: the public is watching what you are charging patients. Accountability – the consequence of greater transparency in drug pricing – is an important component of the Trump Administration’s efforts to lower prices and empower patients with the information they need to make informed decisions.”
Access the article here.
Date published: 12/19/2019
Synopsis: “A Small Share of People with Medicare Advantage or Stand-alone Medicare Part D Coverage Voluntarily Switch Plans During Open Enrollment ”.
“According to an analysis of data from the Centers for Medicare & Medicaid Services (CMS), one-third of Medicare beneficiaries living in the community said it was very difficult or somewhat difficult to compare Medicare options in 2017, while nearly half said they rarely or never review or compare their Medicare options..”
Access the article here.
Date published: 12/2/2019
Synopsis: “Drugmakers Boost Prices Up to 909%, Defying Political Pressure.”
“….analysts at the firm found that pharmaceutical companies are getting aggressive in their price hikes again. Wells Fargo’s analysis of Wolters Kluwer PriceRx data found that companies have raised medicine costs by 27% on average last month, with a subsidiary of Teva Pharmaceutical Industries Ltd hiking the price for a generic anti-diuretic by 909%. Closely held Epic Pharma LLC came second on the list of top increases, jacking up prices on two versions of its drug by 399%. Merck & Co., Fresenius SE, Novartis AG’s Sandoz, and Spectrum Pharmaceuticals Inc. were also on the list.”
Access the article here.
Date published: 7/9/2019
Synopsis: “Seniors’ out-of-pocket costs for cancer drugs continue to rise steadily, with patients paying thousands of dollars each year despite efforts to close the Medicare Part D “donut hole.”
“Prices for 13 anticancer drugs available through Medicare Part D in 2010 rose an average 8% over inflation every year over the past decade”
“People are paying more for the same drugs today than they did before the donut hole closed,”
“There’s a sense that closing the donut hole fixed a lot of the problems with Part D,” she said. “It’s important to recognize that closing the donut hole did help a lot of people, but people who are filling these very expensive drugs don’t really benefit enough from that policy change. They need more direct intervention.”
Access the article here.
Date published: 5/29/2019
Medicare News: “CMS delays national coverage determination for CAR-T therapies”
Synopsis: “The agency said Friday that it had delayed its national coverage determination for CAR-Ts, quoting an unnamed CMS spokesperson as saying that it would not be issuing the determination for CAR-T cell therapy on Friday, but that a decision was forthcoming. It posted a proposed decision memo in February.”
Access the article here.
Date published: 5/20/2019
Medicare News: Fortune praised Harrison’s leadership in launching Civica Rx, a Utah-based nonprofit generic drug manufacturer and distributor that’s working to make generic medications more available and affordable in hospitals across the nation
Synopsis: “Fortune praised Harrison’s leadership in launching Civica Rx, a Utah-based nonprofit generic drug manufacturer and distributor that’s working to make generic medications more available and affordable in hospitals across the nation.”
“With six partners, he formed an independent nonprofit drugmaker, Civica Rx. The venture has signed up some 900 health systems as customers; it should be producing generics by year’s end.”
Access this article here.
Date published: 4/19/2019
Medicare News: “Medicare Part B and D Drug Spending Dashboards Now Available”
Synopsis: The Medicare Part B and D Drug Spending Dashboard are interactive, web-based tools that presents spending information for individual medications covered by Medicare Part B (drugs administered in doctors’ offices and other outpatient settings and paid through the Medicare Part B program) and Part D (drugs patients generally administer themselves and that are paid through the Medicare Part D program).
Drug spending metrics for Part D drugs are based on the gross drug cost, which represents total spending for the prescription claim, including Medicare, plan, and beneficiary payments. The Part D spending metrics do not reflect any manufacturers’ rebates or other price concessions as CMS is prohibited from publicly disclosing such information. However, high-level rebate summary information is available for 2014. All Part D organization and plan types are included, while over-the-counter drugs in the PDE data are excluded.
Drug spending metrics for Part B drugs represent the full value of the product, including the Medicare payment and beneficiary liability. All Part B drug spending metrics are calculated at the Healthcare Common Procedure Coding System (HCPCS) level.
Access the Part D dashboard here and the Part B dashboard here.
Medicare News: ” Major Findings for National Health Expenditures: 2018-2027…As a result of comparatively higher projected enrollment growth, average annual spending growth in Medicare (7.4 percent) is expected to exceed that of Medicaid (5.5 percent) and private health insurance (4.8 percent).”
Synopsis: “Medicare spending growth is projected to average 7.4 percent over 2018-2027, the fastest rate among the major payers. Underlying the strong average annual Medicare spending growth are projected sustained strong enrollment growth as the baby-boomers continue to age into the program and growth in the use and intensity of covered services that is consistent with the rates observed during Medicare’s long-term history.”
Access this article here.
Date published: 2/20/2019
Medicare News: “Medicare Advantage Plans Cleared To Go Beyond Medical Coverage — Even Groceries.”
Synopsis: “Air conditioners for people with asthma, healthy groceries, rides to medical appointments and home-delivered meals may be among the new benefits added to Medicare Advantage coverage when new federal rules take effect next year.
On Monday, the Centers for Medicare & Medicaid Services (CMS) expanded how it defines the “primarily health-related” benefits that insurers are allowed to include in their Medicare Advantage policies. And insurers would include these extras on top of providing the benefits traditional Medicare offers.
“Medicare Advantage beneficiaries will have more supplemental benefits making it easier for them to lead healthier, more independent lives,” said CMS Administrator Seema Verma..”
Access this article here.
Date published: 4/2/2018
Medicare News: “CMS Office of the Actuary releases 2017-2026 Projections of National Health Expenditures”.
Synopsis:”Medicare: Among the major payers for healthcare over the 2017-2026 period, Medicare is projected to experience the most rapid annual growth at 7.4 percent, largely driven by enrollment growth and faster growth in utilization from recent near-historically low rates.
Medicaid: Medicaid is projected to average 5.8 percent annual growth over 2017-2026, which is slower than the average observed for 2014-2016 of 8.3 percent, when the major impacts from the Affordable Care Act’s expansion took place.”
Access this article here.
Date published: 2/14/2018
Medicare News: “Molina To Join Idaho’s Medicare-Medicaid Coordinated Plan”
Synopsis: “The Idaho Medicaid program confirmed that it had contracted with Molina Healthcare to offer Medicare Medicaid Coordinated Plan (MMCP) starting January 1, 2018. At that date, state residents eligible for both medicare and Medicaid (dual eligible) will have a choice for plans: the existing plan offered by Blue Cross of Idaho and the new plan to be offered by Molina Healthcare.”
Access this article here.
Date published: 8/6/2017
Medicare News: A Kaiser Family Foundation analysis of private Medicare plan
Synopsis: “For Medicare Advantage enrollees who place a high value on access to a specific hospital in their area, the analysis underscores the importance of shopping carefully for a plan and the difficulties in doing so. Provider directories are not posted on the Medicare.gov “plan finder” tool, which is a government-sponsored resource to help consumers shop for plans available in their area. Provider directories obtained directly from the plans can be confusing or outdated. For instance, 11 of the 231 provider directories examined in this study included hospitals that had been closed or torn down.”
Access this article here.
