RISE summarizes recent regulatory-related headlines.
MA plans to receive nearly $12B in Star rating quality bonuses in 2024
Medicare Advantage (MA) plans will receive at least $11.8 billion in bonus payments in 2024, according to a new KFF analysis, which examined trends in bonus payments to MA plans and enrollment in plans that receive higher quality Star ratings.
The report found that:
- After increasing by more than 400 percent between 2015 and 2023, federal spending on MA quality bonus payments will decline by $1 billion (eight percent) to $11.8 billion in 2024. The decrease is due in part to the end of COVID-19 policies that temporarily boosted Star ratings for some plans.
- However, total spending on MA plan bonuses is higher in 2024 than in every year between 2015 and 2022.
- The two biggest MA insurers in the country, UnitedHealthcare and Humana, will receive half of the total bonus payments in 2024 ($3.4 billion for UnitedHealth and $2.5 billion for Humana).
- Kaiser Permante will receive the highest payment per enrollee: $516.
- Seventy-two percent of MA enrollees are in plans that will receive bonus payments in 2024.
- The average bonus payment per enrollee is highest for employer- and union-sponsored MA plans ($456) and lowest for special needs plans ($330), which researchers note raises questions about the implications of the quality bonus program for equity.
NCQA announces 2024 health plan ratings
Five health plans out of 1,019 plans achieved a coveted five-star rating from the National Committee for Quality Assurance (NCQA) in 2024, according to its annual health plan rating list released on Monday.
The ratings evaluate commercial, Medicare, and Medicaid health plans based on patient experience and clinical quality data from calendar year 2023, when approximately 227 million people were enrolled in health plans that reported Healthcare Effectiveness Data and Information Set (HEDIS®) results to NCQA. The top-rated health plans included:
- Blue Cross and Blue Shield of Massachusetts, a commercial PPO plan
- Independent Health Association, Inc., New York, a commercial HMO/POS combined plan
- Kaiser Foundation Health Plan of Colorado, a Medicare HMO
- Kaiser Foundation of Health Plan of the Mid-Atlantic States, Inc., in the District of Columbia, Maryland, and Virginia, a commercial HMO
- Network Health Insurance Corporation (NHIC), a Medicare PPO in Wisconsin
“Annual Health Plan Ratings are vital to providing health care consumers with transparent and objective information about the quality and performance of health plans. Ratings not only help individuals make informed choices to receive the best possible care but also motivate health plans to improve their operations, with a focus on quality, equity and accountability,” said NCQA President Margaret E. O’Kane in the announcement.
NCQA continues to prioritize health equity in its ratings methodology. This year, NCQA increased the scoring threshold for the Race/Ethnicity Diversity of Membership measure and increased the measure weight from 0.5 to 1.0. Collecting race and ethnicity data is crucial for closing gaps in quality of care and promoting health equity, NCQA says. By encouraging broader stratification and collection of race and ethnicity data by health plans, ratings can drive continuous quality improvement across the health care industry, ensuring that all patients receive the best possible care.
Walgreens to pay $100.6M to resolve allegations of fraudulent prescription billing
The Department of Justice (DOJ) says Walgreens Boots Alliance Inc. and Walgreen Co. will pay $106.8 million to resolve alleged violations of the False Claims Act and state statutes for billing government health care programs for prescriptions never dispensed.
The government alleges that, between 2009 and 2020, Walgreens, which operates one of the largest retail pharmacy chains in the country, submitted false claims for payment to Medicare, Medicaid, and other federal health care programs for prescriptions that it processed but that were never picked up by beneficiaries. As a result, Walgreens received tens of millions of dollars for prescriptions that it never actually provided to health care beneficiaries.
As part of the resolution, Walgreens received credit under the department’s guidelines for taking disclosure, cooperation, and remediation into account in False Claims Act cases. Walgreens also enhanced its electronic pharmacy management system to prevent this from occurring in the future and self-reported certain conduct. Because Walgreens previously refunded $66,314,790 pertaining to the settled claims, the company will receive credit for this amount.
The federal share of the recovery is $91,881,530, and individual states, which jointly fund state Medicaid programs, through separate settlement agreements with the Medicaid participating states, will receive a total of $14,933,259.
The federal government’s settlement with Walgreens resolves three cases pending in the District of New Mexico, Eastern District of Texas, and Middle District of Florida under the qui tam, or whistleblower, provision of the False Claims Act, which permits private parties to file suit for false claims on behalf of the United States and to share in any recovery. Steven Turck, a former Walgreens pharmacy manager, filed the qui tam suit in the Eastern District of Texas related to billing Medicare, Medicaid, and other federal health care programs, and will receive $14,918,675. Andrew Bustos, a former Walgreens district pharmacy supervisor, filed the qui tam suit in the District of New Mexico related to billing Medicare Part B and will receive $1,620,000.