News

Changes Coming for Medicare Advantage and Part D Plans in the 2025 Plan Year

• Changes are coming for Medicare Advantage (MA) and Part D plans for the 2025 plan year. Consumer costs are increasing through higher premiums and greater out-of-pocket expenses, while payers are reducing drug formularies and provider networks. There are also fewer MA plans in the 2025 plan year, as payers focus on profitability by exiting poorly performing areas instead of reducing benefit offerings. Despite this, there are a higher number of special needs plans and the number of counties without any MA plan continues to decrease. Part D plans also experienced changes from new mandates but were largely unaffected despite concerns about significantly higher premiums. Experts predict that the slight increase in premiums for prescription drug plans will not result in Part D plan enrollees moving to MA plans. However, it is unknown what will change when the detailed information on drug formularies is released later in October. With all of these changes, brokers are seeing an increase in work as consumers try to make an informed decision during open enrollment, which starts on October 15 (Health Payer Specialist, October 7).

Federal Legislation

AHA Advocates for Lame Duck Package without Site-Neutral Payment Policies

• The American Hospital Association (AHA) is advocating for Congress to adopt two specific pay-fors in the lame duck package that do not include site-neutral payment policies. AHA supports delaying Medicare cuts for clinical laboratory services and preventing CMS from enforcing the new nursing home staffing requirements. Additionally, AHA hopes to delay Medicaid DSH cuts, extend Medicare telehealth and the hospital-at-home policies, and streamline MA plan prior authorization among a few other priorities. The House has passed site-neutral payment policies, but the Senate has not advanced any similar legislation. Any further legislative action may depend on the outcome of the election (Inside Health Policy, October 3).

Federal Regulation and Guidance

CMS Extends Due Date for Public Comments on Medicaid and CHIP Parity Compliance Templates and Instructional Guides

• On October 7, CMS extended the deadline for submission of public comments on the Medicaid and CHIP parity compliance templates and instructional guides from October 29, 2024, to December 2, 2024. Comments can be submitted to MedicaidandCHIPParity@cms.hhs.gov (Medicaid.gov, October 7).

CMS Releases NBPP 2026 Proposed Rule

• In alignment with the Biden Administration’s commitment to ensuring accessibility and affordability of Marketplace coverage, CMS released a draft of the HHS Notice of Benefits and Payment Parameters (NBPP) for 2026. With this rule, CMS seeks to increase transparency for consumers, advance health equity, and stabilize the market. The proposed rule includes parameters and provisions regarding fraudulent marketplace activities, premium thresholds, risk-adjustment activities, silver-loading, essential community providers (ECP), and standardized plans. CMS will take comments on the proposed rule through November 12 (Inside Health Policy, October 4; CMS, October 4).

CMS Releases FY2025 IPPS Interim Final Action

• On September 30, ahead of the start of FFY2025, CMS released an interim final action that revises the Medicare wage index, establishes a transitional payment exception for low-wage hospitals, and updates the hospital Inpatient Prospective Payment System (IPPS). The release of this document follows the decision in Bridgeport Hospital v. Becerra, which removed low wage index hospital policies, which provided additional funds to hospitals to encourage higher worker pay. Within this interim report, CMS is working on recalculating the IPPS hospital wage index to remove the low wage index for this fiscal year. The rule update also includes determinations for the Long-Term Care Hospital Prospective Payment System (LTCH PPS). CMS is taking comments on the final action until November 29, 2024, electronically here, as well as by mail (Fierce Healthcare, October 2).

Federal Studies and Reports

Data from S&P Capital IQ Pro Shows Increase in Patient Hospital Stays

• According to data analyzed by Health Payer Specialist and published by S&P Capital IQ Pro, most states have seen an increase in hospital patient days for the time period beginning the first quarter of 2022 through the second quarter of 2024. The increase was apparent across Medicaid, Medicare, and coverage for both groups and individual enrollees. The heat map demonstrated a 21.89% increase in Medicaid patient days, a 4.1% increase in Medicare patient days, a 16.03% increase for individual major medical coverages, and a 19.52% increase for group major medical coverage (Health Payer Specialist, October 7).

GAO Recommends Implementation of Hospital Price Transparency Enforcements

• On October 2, the GAO submitted a report to the House’s Committee on Energy and Commerce regarding a request for more information on hospital pricing data completeness and accuracy. As part of this report, the GAO reviewed relevant laws, regulations, and studies and interviewed CMS and AHA experts, as well as 16 stakeholder organizations that represented patients, health plans, and data users. The GAO recommends that CMS assess hospital data to ensure it is completed sufficiently and accurately and implement appropriate enforcement tools as necessary. Currently, CMS does not have assurance of the usability of the data, nor the appropriate resources to make accuracy checks; therefore, nulling the ability to use the data to increase competition as it was intended. GAO asks that CMS investigate cost-effective enforcement options such as soliciting stakeholder feedback, risk-based or random sampling. HHS agreed with the GAO’s recommendations and will further look into whether and how to effectively implement the assessments and other enforcement activities (Fierce Healthcare, October 3; GAO, October 3).

CMS Releases Largely Favorable Report on Hospital At-Home Care

• On September 30, CMS released a report on at-home acute care provided by hospitals, known as the Acute Hospital Care at Home (AHCAH) initiative. The program allows certain Medicare-certified hospitals to treat patients with an inpatient-level of care in the patients’ homes. The AHCAH program was initiated during the COVID-19 pandemic but was extended until the end of this year. As of July 2024, there were 332 hospitals across 38 states participating in the initiative. The report shows that the Medicare patients in the initiative were more likely to be white and living in urban areas and less likely to be enrolled in Medicaid or receiving low-income subsidies compared to in-facility patients. Additionally, there were fewer conditions treated in the initiative. Patients in the AHCAH were primarily treated for respiratory, circulatory, renal, and infectious diseases. Quality of care between at-home and in-facility patients was mixed. At-home patients had lower thirty-day mortality rates for the top ten treatment conditions. When comparing thirty-day readmissions, AHCAH participants had significantly higher rates of readmission for some MS-DRGs, especially for complex clinical conditions. AHCAH patients were also more likely to have a longer length of stay but had lower Medicare costs compared to in-facility patients. In virtual listening sessions, patients described being more relaxed and less depressed receiving treatment in their homes and clinicians expressed support of the program. These results could influence Congress as it decides whether to extend the program (Modern Healthcare, October 4; Fierce Healthcare, October 1).