Wakely Wire

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Whitepapers, briefs, press releases and more

Summary & Impacts of 2026 Medicare Advantage Advance Notice

The Centers for Medicare & Medicaid Services (CMS) recently released the 2026 Advance Notice of Methodological Changes for Medicare Advantage Capitation Rates and Part C/D Payment Policies, which proposes important changes in plan payments, risk adjustment and other financial and regulatory requirements for 2026. Wakely summarizes key changes that will affect Medicare Advantage pricing for ... Read more

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Concentration of Specialty Services in Medicaid Provider Networks

Medicaid consumers, providers, managed care organizations, and states all have an interest in ensuring access to specialty care for Medicaid beneficiaries. We sought to interrogate the national Transformed Medicaid Statistical Information System (TMSIS) database to learn more about specialty provider networks and examine the provision of specialty services across various states. The concentration of specialty ... Read more

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Week in Washington 1/30/25

Budget Freeze Confusion This week health policy news was dominated by the Trump Administration instituting  funding freeze on financial assistance. Early in the week the White House announced, via a memo, a freeze in financial assistance programs, including grants and loans.  This resulted in a wide freeze in federal funds including states being unable to ... Read more

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Newsworthy Findings

White House Rescinds Memo Pausing Federal Funding Following Pushback

The Office of Management and Budget canceled a memo pausing federal funding that caused widespread confusion and alarm this week.

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Editor's Note
The purpose of the freeze is to allow the new administration to review federal spending and whether it aligns with the recent executive orders.

CMS Withdraws Appeal of UnitedHealth's Star Ratings Lawsuit

CMS has withdrawn its notice of appeal without providing an explanation for the change.

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Editor's Note
The lawsuit is about a single foreign language test phone call that United argues disconnected on the test caller’s part before they were able to engage with the customer service agent.

Medicare Advantage Insurers Made Nearly 50 Million Prior Authorization Determinations in 2023

Virtually all enrollees in Medicare Advantage (99%) are required to obtain prior authorization for some services – most commonly, higher cost services, such as inpatient hospital stays, skilled nursing facility stays, and chemotherapy.

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Editor's Note
The total prior authorizations equated to about 2 determinations on average per Medicare Advantage enrollee.

Medicare Advantage Members Gain Access to Innovative Digital Therapeutics Through New Partnership

Medicare Advantage members in Massachusetts and Arizona now have a powerful new resource to help manage pain and physical function, thanks to a unique partnership between eternalHealth and Kaia Health. This collaboration brings clinically validated, low cost digital therapy to Medicare Advantage members, empowering them to take control of their health from the comfort of their homes.

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Editor's Note
For this example, this partnership has given members access to Kaia Health’s solutions for musculoskeletal (MSK) conditions, allowing personalized therapy programs to be developed.

Main Line Health Threatens to Go Out of Network with Cigna Over Contract Dispute

Main Line Health says Cigna hasn’t updated its reimbursement rate since 2016, however Cigna says it is negotiating in good faith to find a solution that keeps healthcare affordable for patients.

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Editor's Note
Cigna told Healthcare Dive the insurer is working “in good faith” with Main Line to find a solution that keeps healthcare affordable for patients, but the insurer said if the health system ultimately chooses to go out of network they have a robust system of providers in the area that can accept Main Line patients.

Bonus Article

Just for Fun

Math Joke:

What do you call a number that just can’t stand still?

Prior Week

Q: Why did the student eat his math homework?

A: Because his teacher said it was a piece of cake

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