From Inside Health Insurance Exchanges - In March, it seemed improbable if not impossible that carriers could avoid double-digit rate hikes for 2015 policies sold on public insurance exchanges. With the health insurer tax, reinsurance fees, a marketplace user fee and scant information about their new enrollees, several actuaries told HEX that big rate hikes were almost certain (HEX 3/20/14, p. 1). But proposed and approved premium increases being touted by state regulators, so far, have been in the low single-digits. Why? Read more
From Health Plan Week - Wal-Mart Stores, Inc. on Oct. 6 unveiled a program that calls for brokers affiliated with Tranzact subsidiary DirectHealth.com to offer 2015 individual plans on and off public exchanges and Medicare plans at 2,700 of its 4,311 U.S. stores, on the phone or online. The retailer is already active in the sector, via deals with carriers like Humana Inc. and their co-branded Humana-Walmart Medicare Prescription Drug Plans (HPW 2/17/14, p. 8).… Read more
From ACO Business News - It’s not easy to earn shared savings in either of Medicare’s accountable care organization programs: Only about one-quarter of Medicare Shared Savings Program (MSSP) ACOs will get a payout, along with half the Pioneers, financial and quality results released last month by CMS indicate. The results were positive for CMS, which was able to tout that 11 Pioneers and 53 MSSP providers had saved CMS $372 million while improving quality (see… Read more
From Medicare Advantage News - It was largely more of the same in the new National Committee for Quality Assurance (NCQA) rankings of Medicare Advantage plans. Kaiser Permanente plans occupied the first three places, as they did a year ago (MAN 10/10/13, p. 3). And not a single PPO made it into the top 23 in the rankings, which were released last month and again were prepared in partnership with Consumer Reports magazine. But while… Read more
From Drug Benefit News - CVS Health’s CVS/caremark PBM unit will pay the U.S. $6 million to settle allegations that it knowingly failed to reimburse Medicaid for prescription drug costs that were the responsibility of private health plans administered by the PBM, the U.S. Department of Justice said on Sept. 26. The settlement comes as a result of a whistleblower lawsuit filed by former Caremark employee Donald Well. Read more
From Report on Medicare Compliance - CMS has instructed Medicare administrative contractors (MACs) to get off the sidelines and defend claim denials that are appealed to administrative law judges. In Medicare Transmittal 543, which takes effect Oct. 27, CMS says MAC physicians should make a case for some MAC medical review decisions that resulted in claim denials, were appealed by providers up the chain and are now scheduled for ALJ hearings. Not all ALJ hearings require their… Read more
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