January

2021 Advance Notice Elevates EDS Use, Leaves Out ESRD

January 16, 2020

The biggest news out of CMS’s Jan. 6 release of Part I of the 2021 Advance Notice may be that there was no news. As expected, CMS proposed continuing to phase out risk score data based on diagnoses contained in the legacy Risk Adjustment Processing System (RAPS) and increasing the use of encounter data that still vexes some Medicare Advantage organizations. But the document left out any mention of possible payment revisions for the expected influx of MA enrollees with end-stage renal disease (ESRD) next year, raising the question of when (and how) CMS might address a payment structure that is seen as inadequate by some industry stakeholders.

To access this post, you must purchase a subscription plan. Click Here to purchase.

Already a member? Click Here to login.

CMS Suggests Use of NPPES for Verifying MA Directory Entries

January 16, 2020

Though a small assist in the gargantuan task that is improving Medicare Advantage provider directory accuracy, CMS’s new plan to use the National Plan and Provider Enumeration System (NPPES) as a reference source may help insurers gain better insight into the accuracy of their own data. But insurers should be wary of the database’s shortcomings, and they will have to work with their provider partners to ensure that they are making timely updates to the NPPES, industry experts advise.

To access this post, you must purchase a subscription plan. Click Here to purchase.

Already a member? Click Here to login.

Early Look at AEP Data Shows Medicare Advantage Membership Gains of 8.8%

January 16, 2020

Preliminary enrollment figures from the 2020 Annual Election Period (AEP) indicate that Medicare Advantage enrollment surpassed 24.3 million lives, up 8.8% from 22.4 million posted a year ago. The January enrollment report from CMS reflects enrollments accepted through Dec. 6, 2019, just one day before the AEP closed. Final enrollment figures will be disclosed in the February report. CMS has projected overall MA enrollment growth of 10% from 2019 to 2020.

To access this post, you must purchase a subscription plan. Click Here to purchase.

Already a member? Click Here to login.

News Briefs

January 16, 2020

✦ Bright Health plans to acquire California-based family-owned health plan Universal Care. Doing business as Brand New Day, the 37-year-old company serves Medicare-eligible seniors and special needs populations in 12 California counties with a focus on care management and patient-primary care relationships, according to a release from the companies. Venture-backed Bright Health started on the exchanges in 2016 and began selling MA plans in 2018; the company has since expanded its offerings by 300% and now sells plans in the individual and Medicare Advantage markets in 12 states. The Brand New Day transaction, which is expected to close this year and still requires regulatory approval, will give Bright Health a “strong presence in California with an established and philosophically aligned partner,” said President and Vice Chairman Mike Mikan. Read more at https://prn.to/39TQEPk.

To access this post, you must purchase a subscription plan. Click Here to purchase.

Already a member? Click Here to login.

2020 Outlook: For Insurers, There’s More Than One ACA Court Case to Watch

Chart: Texas v. United States: A Look Back

January 13, 2020

Though the upcoming elections will shine a bright spotlight this year on the health care policy positions of lawmakers and the Trump administration, the courts will play just as big of a role — if not more — than politicians when it comes to shaping the future of the Affordable Care Act’s health insurance reforms.

The biggest case at play is Texas v. United States, which challenges the validity of the entire ACA based on Congress’ decision in 2017 to zero out the individual mandate’s tax penalty (see infographic, p. 7). Because the elimination of the tax penalty makes the individual mandate unconstitutional, Republican-led states argue, the rest of the law also has to go, as it is “inseverable” from the mandate.

To access this post, you must purchase a subscription plan. Click Here to purchase.

Already a member? Click Here to login.

AHIP Launches Pilot to Field-Test Automated Prior Authorization

January 13, 2020

Health insurer trade group America’s Health Insurance Plans (AHIP) is partnering with six insurers to test systems and technology designed to automate parts of the prior authorization process in a bid to develop best practices.

The initiative, which AHIP calls the Fast Prior Authorization Technology Highway, or Fast PATH, will run for six months, during which AHIP and its partners will collect data to be used for an evaluation of the processes and technology used. The trade group will attempt to determine how much money and time an automated system saves providers and insurers.

To access this post, you must purchase a subscription plan. Click Here to purchase.

Already a member? Click Here to login.