This week, our In Focus section reviews the Pathways HUB model, an approach designed to help coordinate outreach by specialized community health workers who are incentivized to engage high-need populations. An HMA webinar, held May 9, 2019, with Mark Redding, co-developer of the Pathways HUB model, and Heidi Arthur, HMA can be viewed here.
On May 16, 2019, the Centers for Medicare & Medicaid Services (CMS) issued its final rule, Modernizing Part D and Medicare Advantage to Lower Drug Prices and Reduce Out-of-Pocket Expenses (Final Rule). The proposed rule, which was issued in November 2018, included a number of provisions intended to improve drug price transparency and expand use of utilization management tools to further Medicare Advantage and Part D cost-cutting efforts. However, in response to significant pushback from beneficiary advocates, physician groups, insurers, and pharmaceutical stakeholders, CMS elected not to implement key provisions. These include proposals to allow Part D plans to exclude protected class drugs from formularies as a result of price increases or if the drug is a new formulation of an existing single-source drug as well as proposed reforms to pharmacy price concessions that would require discounts be passed on to beneficiaries at the point of sale. Commenters in opposition to the pharmacy price concession proposal contend that these reforms would result in higher Part D premiums. While CMS has postponed addressing this provision in this Final Rule, the recently issued Department of Health and Human Services (HHS) Office of Inspector General (OIG) proposed rule, if finalized, may include fundamental changes to these pricing arrangements and other federal safe harbors to the anti-kickback statute.
This week, our In Focus section reviews the Kentucky Medicaid managed care organizations (MCOs) request for proposals (RFP), issued by the Kentucky Finance and Administration Cabinet on May 16, 2019. The Kentucky Cabinet for Health and Family Services (CHFS), Department for Medicaid Services (DMS) will select up to five Medicaid MCOs to manage health care services for more than 1.2 million people, starting July 2020. Contracts are estimated at more than $7 billion.
This week, our In Focus summarizes the findings of an HMA Information Services analysis of Medicaid managed care plan profitabilty, based on data from annual statutory filings made with the National Association of Insurance Commissioners (NAIC). For information on how to subscribe to HMA Information Resources, contact Carl Mercurio, firstname.lastname@example.org.
This week, our In Focus section reviews updated information issued by the Department of Health & Human Services (HHS) Centers for Medicare & Medicaid Services (CMS) on Medicaid expansion enrollment from the “January 2019 Medicaid and CHIP Applications, Eligibility Determination, and Enrollment Report,” published on April 25, 2019. Additionally, we review 2019 Exchange enrollment data from the “Health Insurance Exchanges 2019 Open Enrollment Period: Final State-Level Public Use File,” published by CMS on March 25, 2019. Combined, these reports present a picture of Medicaid and Exchange enrollment in 2019, representing 72.4 million Medicaid and CHIP enrollees and 11.4 million Exchange enrollees.
This week, our In Focus section reviews the Centers for Medicare & Medicaid Services (CMS)-issued Fiscal Year (FY) 2020 Medicare Part A proposed rules. Between April 17 and April 23, 2019, the CMS issued the proposed rules for general acute care hospitals paid under the Inpatient Prospective Payment System (IPPS), the skilled nursing facility (SNF) prospective payment system (PPS), the Inpatient Rehabilitation Facility (IRF) PPS, the Long-Term Care Hospital (LTCH) PPS, the Hospice PPS, and the Inpatient Psychiatric Facility (IPF) PPS. These proposed regulations include annual payment rate changes and other proposed policy changes. Comment deadlines for these rules vary.