RISE summarizes recent regulatory-related headlines.
CMS issues statement on prescription drug costs
The Centers for Medicare & Medicaid Services (CMS) this week published a statement indicating that like the Biden administration, lowering the cost of prescription drugs is a top priority of the new administration. Prior to the inauguration, Biden’s CMS released the list of 15 drugs selected for the second cycle of the Medicare Drug Price Negotiation Program.
As this second cycle begins under the Trump administration, CMS said it is “committed to incorporating lessons learned to date from the program and to considering opportunities to bring greater transparency in the Negotiation Program.” CMS said it intends to provide opportunities for stakeholders to provide specific ideas to improve the Negotiation Program, consistent with the goals of achieving greater value for beneficiaries and taxpayers and continuing to foster innovation.
ACA insurers denied 1 in 5 in-network claims in 2023
HealthCare.gov insurers denied nearly one out of every five claims (19 percent) submitted for in-network services and an even larger share (37 percent) share of claims for out-of-network services in 2023, according to a new KFF analysis.
The study examined data from CMS on 425 million claims submitted to 175 insurers selling marketplace coverage in 2023, the most recent year available. The Affordable Care Act requires certain entities to report data about claims denials and appeals to encourage transparency about how insurance coverage works for enrollees. The publicly available data does not include marketplace plans sold on state-based marketplaces or employer health plans, the nation’s primary source of private health coverage.
KFF analysts found a huge variation across HealthCare.gov insurers, which had in-network denial rates as low as one percent and as high as 54 percent in 2023 in some states. Nationwide, high-volume insurers with higher in-network denial rates across HealthCare.gov states included Blue Cross Blue Shield of Alabama (35 percent for its 12 plans in that state), UnitedHealth Group (33 percent across 274 plans in 20 states), Health Care Service Corporation (29 person across 915 plans in four states), Molina Healthcare (26 percent across 72 plans in nine states), and Elevance Health (23 percent across 154 plans in seven states).
Of limited information available on in-network claims denial reasons, the most common reason for denial was a general “other” reason (34 percent), while 16 percent involved excluded services, nine percent involved lack of prior authorization or referral, and six percent involved medical necessity. Other common reasons for denials included administrative issues (18 percent) and exceeding benefit limits (12 percent).
Consumers appealed about one percent of denied in-network claims in 2023. Following those appeals, insurers often upheld their initial denials (56 percent), and consumers rarely took the next step to file an external appeal.
CDC report on bird flu studies delayed
Studies about the bird flu that were set to appear in the official journal of the Centers for Disease Control and Prevention (CDC), the Morbidity and Mortality Weekly Report, have been delayed as an outbreak escalates across the country, KFF Health News reports. The reports would reveal whether veterinarians who treat cattle have been unknowingly infected by the bird flu virus and documents cases in which people carrying the virus might have infected their pet cats.
The scientific reports have been swept up in an “immediate pause” on communications by federal health agencies ordered by Dorothy Fink, the acting secretary of the Department of Health and Human Services. Fink’s memo covers “any document intended for publication,” she wrote, “until it has been reviewed and approved by a presidential appointee.” It was sent on President Donald Trump’s first full day in office.
That’s concerning, former CDC officials said, because a firewall has long existed between the agency’s scientific reports and political appointees. Neither the White House nor HHS officials responded to requests for comment. CDC spokesperson Melissa Dibble said, “This is a short pause to allow the new team to set up a process for review and prioritization.”
At least 67 people have tested positive for the bird flu in the U.S., with the majority getting the virus from cows or poultry. But studies and reporting suggest many cases have gone undetected because testing has been patchy.
A person close to the CDC, speaking on the condition of anonymity because of concerns about reprisal, expected the MMWR to be on hold at least until Feb. 6. The journal typically posts on Thursdays, and the HHS memo says the pause will last through Feb. 1.
Advocates support CMS plan to cover FDA-approved anti-obesity medications
A dozen health care advocacy organizations and nearly 20,000 grassroots advocates from across the country have called on CMS to support and finalize a proposed rule to expand Medicare and Medicaid coverage to include critical, FDA-approved anti-obesity medications. The move, they say, could benefit 7.5 million Americans enrolled in the programs who are living with obesity and being denied access to lifesaving treatments. The calls for action came via a pair of letters spearheaded by the Health Equity Coalition for Chronic Disease (HECCD) and submitted to CMS.
Leaders behind the effort say the proposed rule comes at an urgent moment, as an estimated 42 percent of American adults are currently living with obesity, and as some studies estimate that more than half of Americans will be living with obesity by 2030.
“By finalizing this policy, CMS has an era-defining opportunity to potentially reverse decades of deteriorating public health and rising obesity rates experienced by millions of Americans—in communities both rural and urban, big and small,” they wrote. “This policy will usher in a new era of American public health while also cementing a commitment to ensuring that all Americans have access to evidence-based care and the opportunity to live longer and healthier lives.”