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September 6, 2017

Hot Topic

CMS is getting ready to assess all the adequacy of provider networks for all Medicare Advantage plans that haven’t undergone an evaluation in the past three years. Here’s a look at CMS’s path to greater oversight.

$32M MA Settlement Involved Alleged ‘Rented Network’ Scheme
A recent $32.5 million settlement between a Florida-based MA plan operator and the federal government reflects the DOJ’s growing scrutiny over MA plans’ risk adjustment practices...

Under CMS’s New Network Review Policy, 2017 MA Applicants Are Coming Up Short
As CMS carries out a new policy of reviewing Medicare Advantage plans’ entire provider networks for adequacy if they request service area expansions, plans are dealing with a stricter-than-ever exceptions process...

MA Provider Network Exceptions Should Be Few and Far Between, CMS Officials Stress
CMS this year made several major network review changes that have reportedly caused headaches for some Medicare Advantage organizations requesting service area expansions for contract year 2017...

Today's AIS Health Datapoint

154,103 ... is the number of enrollees in UnitedHealthcare's new Medicaid managed care plan in Missouri, which began enrolling members in May. The insurer absorbed much of Aetna Better Health of Missouri's membership. Aetna lost its Missouri Medicaid bid at the end of 2016.

From THE AIS GUIDE TO BLUE CROSS AND BLUE SHIELD PLANS. (Not affiliated with the Blue Cross and Blue Shield Association or its member companies.)

            The AIS Guide to Blue Cross and Blue Shield Plans is now online!

Quote of the Day

“For PrEP, we have seen an uptick in some [Truvada] access restrictions, but the UnitedHealthcare requirements were the most egregious….[There have been] numerous complaints filed under the ACA’s non-discrimination protections citing discriminatory plan designs that effectively bar people living with HIV from access to lifesaving medications.”

— Amy Killelea, an attorney and the director of health systems integration at the National Association of State and Territorial Apprenticeship Directors (NASTAD), which represents officials who administer HIV programs, speaking to Health Plan Week about insurers’ coverage policies for Gilead’s HIV drug Truvada (emtricitabine/tenofovir disoproxil fumarate).

Click here to read the HEALTH PLAN WEEK article in which this quote appeared — "UnitedHealth Draws Fire on Truvada Policy; Are Other Plans Walking a Fine Line?" (Free for HPW subscribers; $17 for non-subscribers.)


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