RISE summarizes recent regulatory-related headlines.
State of the Union: Biden urges cap on cost of insulin for all, vows to protect Medicare from cuts
Vowing to stop anyone who tries to cut Medicare and Social Security, President Biden seemingly got Republicans to agree to keep both programs intact during Tuesday’s State of the Union. Halfway through his prepared remarks, Biden said some Republicans want Medicare and Social Security to sunset every five years. When Republicans heckled him and Rep. Marjorie Taylor Greene, R-Ga., yelled, “Liar,” Biden went off his script and accepted the response as an agreement from the GOP to not touch the programs, which he called a lifeline to millions of seniors. “Let’s all agree — and we apparently are — let’s stand up for seniors,” Biden said. When members of both parties stood up and applauded, Biden said, “We will not cut Social Security. We will not cut Medicare,” Biden said. “If anyone tries to cut Social Security — which apparently they’re not going to do — and if anyone tries, and Medicare, I’ll stop them. I’ll veto it.” During the remarks, he also praised bipartisan support to cap the cost of insulin at $35 a month on Medicare for seniors but called on Congress to expand it to those millions of Americans who are not on Medicare but have Type I diabetes and need insulin to save their lives. “Let’s cap the cost of insulin at $35 a month for every American who needs it,” he said.
KFF report: Medicare Advantage plans denied 6% of prior authorization requests in 2021
Medicare Advantage (MA) plans denied two million prior authorization requests for health care services in whole or in part in 2021, about six percent of the 35 million requests submitted on behalf of enrollees that year, according to a new Kaiser Family Foundation (KFF) analysis.
Prior authorization requires providers to obtain approval in advance from the health plan before providing a specific service or procedure to a patient. It’s meant to ensure health care services are medically necessary, but providers complain that it magnifies the administration burden and creates barriers to the patient receiving necessary care.
RELATED: CMS proposes rule to overhaul the prior authorization process: 5 things to know
The analysis also finds variations in both the volume of prior authorization requests and denial rates across insurers. In general, insurers with higher numbers of prior authorization requests denied a lower share of those requests. The variation across insurers likely reflects differences in the services subject to prior authorization and the frequency with which contracted providers are exempted from these requirements, as well as variations in the use of other tools to manage utilization by plan enrollees.
Only about 11 percent of denials of prior authorization requests were appealed, KFF said in an announcement. However, of the appeals that were filed, the vast majority (82 percent) resulted in fully or partially overturning the initial denial.
KFF researchers said the high rate of successful appeals raises questions about whether a larger share of the initial prior authorization requests should have been approved. Alternatively, it could reflect problems with documentation that were subsequently rectified during the appeal. In either case, medical care ordered by physicians or other practitioners ultimately deemed necessary by the insurers was potentially delayed by the prior authorization process.
In late December 2022, the Centers for Medicare & Medicaid Services (CMS) proposed policies to streamline prior authorization requirements and reduce disruption for enrollees. Additional prior authorization policies were included in the 2024 MA proposed rule.
Supplemental benefits: GAO offers recommendations to CMS on data collection
A new report from the U.S. Government Accountability Office (GAO) examines how many people use additional supplement benefits, like dental, vision, and in-home support services, offered by MA plans. The GAO analyzed the data of 3,893 plans, reviewed CMS guidance, and interviewed officials from CMS and six MA organizations. The agency found that about a third of them offered at least one of the supplemental benefits. However, plans’ reporting of people's use of additional benefits was incomplete for two reasons: CMS guidance on encounter data doesn’t specifically mention the submission of such data for supplemental benefits, although it says plans must submit guidance encounter data for each benefit provided to an enrollee. In addition, CMS said there are challenges to collecting and submitting encounter data for certain supplemental benefits. For example, there is no procedure code for the newer supplemental benefits, such as food and produce. As a result, GAO has recommended that CMS clarify guidance on the extent to which encounter data submissions must include data on the use of supplemental benefits and address circumstances where submitting encounter data for supplemental benefits is challenging for MA plans, such as when a given benefit lacks an applicable procedure code. The Department of Health and Human Services (HHS) concurred with the recommendations.
HHS proposes rule to expand access to birth control coverage under ACA
To bolster access to birth control at no cost, HHS and the Departments of Labor and the Treasury recently proposed a rule to strengthen access to birth control coverage under the Affordable Care Act (ACA). Under the ACA, most plans are required to offer coverage of birth control with no out-of-pocket cost. The latest rule proposes to expand and strengthen access to this coverage so that all women who need or want birth control are able to obtain it. The action is the latest effort by the Biden-Harris Administration to bolster access to birth control at no cost.
“Now more than ever, access to and coverage of birth control is critical as the Biden-Harris Administration works to help ensure women everywhere can get the contraception they need, when they need it, and–thanks to the ACA–with no out-of-pocket cost,” said HHS Secretary Xavier Becerra, noting that the proposed rule aims to ensure that tens of millions of women across the country who have and will benefit from the ACA will be protected. “It says to women across the country, we have your back.”
HHS said that in 2018, final regulations expanded exemptions for religious beliefs and moral convictions allowing private health plans and insurers to exclude coverage of contraceptive services. The proposed rules would remove the moral exemption and retain the existing religious exemption. The 2018 rules include an optional accommodation that allows objecting employers and private colleges and universities to completely remove themselves from providing birth control coverage while ensuring women and covered dependents enrolled in their plans can access contraceptive services at no additional charge. Under the 2018 rules, these women and covered dependents would get this contraceptive access only if their employer or college or university voluntarily elects the accommodation—leaving many without access to no-cost contraceptives.
The proposed rules aims to create an independent pathway for individuals enrolled in plans arranged or offered by objecting entities to make their own choice to access contraceptive services directly through a willing contraceptive provider without any cost. This would allow women and covered dependents to navigate their own care and still obtain birth control at no cost in the event their plan or insurer has a religious exemption and, if eligible, has not elected the optional accommodation. The proposed rules would leave in place the existing religious exemption for entities and individuals with objections, as well as the optional accommodation for coverage.
CMS sets ACA special enrollment period for consumers losing Medicaid
As states prepare to remove millions of people from Medicaid as the COVID-19 public health emergency protections expire, CMS has announced a marketplace special enrollment period for qualified individuals and families who lose Medicaid or Children’s Health Insurance Program (CHIP) coverage. Consumers will be able to enroll in marketplace health insurance coverage between March 31, 2023 and July 31, 2024 and attest to a last day of Medicaid or CHIP coverage within the same time period. Eligible consumers will have 60 days after they submit their application to select a marketplace plan and coverage starting the first day of the month after they select a plan.