Week in Washington 06/13/24

MA Stars Lawsuits

CMS lost another lawsuit over Medicare Advantage STARS last week. In addition to losing its case against SCAN over failing to follow the Administrative Procedures Act (APA) around changes to the Medicare Stars, CMS lost a similar case to Elevance Health late last week. A US district Court ruled that CMS must adjust Elevance’s Georgia carriers’ star rating given CMS’s failure to properly follow the APA (Elevance requested that CMS redo star ratings for six of its subsidiaries). The judge wrote that CMS should consider providing similar relief to other carriers injured by APA violation. CMS has not publicly commented yet if it would appeal either the SCAN or Elevance decisions.

New National Health Expenditure Data

CMS’s Office of the Actuary released their latest estimates on health care spending in the US. The National Health Expenditure (NHE) data estimates that health expenditures are projected to grow by 7.5% in 2023. This increase is driven by a 10.1% increase in spending in hospital care. According to the NHE projections, the combination of Medicaid redetermination and the scheduled end for the enhanced ACA subsidies is expected to increase the uninsured rate from 22.8 million in 2023 to 29.6 million in 2026.

Weight Loss Drugs and ACA Coverage

KFF  released a new report around prevalence of inclusion of GLP-1 drugs on ACA Marketplace plans’ formulary. KFF found that inclusion was common for diabetes but not for weight loss. They also found that usage of utilization management strategies for these drugs was common. It should be noted that that currently many obesity drugs (Wegovy, Zepbound, and Saxenda) are not covered by the ACA risk adjustment model.

Medicare Advantage Prior Authorization Bill

A bipartisan bill that would require Medicare Advantage Plan to increase the speed at which they conduct prior authorization reviews is gaining steam in Congress. The new bill would codify current regulations in place and therefore would protect the current prior authorization requirements in the event that the Supreme Court restricts the federal government’s ability to issue regulations.

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