Stay ahead of the latest regulatory shifts and healthcare breaking news with Headlines from the Hill.
In this month’s edition you will find:
- Medicaid Managed Care Plans: CMS called on to provide clear guidelines for states.
- Major trade associations highlight the benefits of healthcare mergers and acquisitions.
- Medicare Advantage Prior Authorization: Revised bill proposed.
- State healthcare cost caps: What does this mean for hospital operating margins?
- Medicaid redetermination timeline extension: What to expect.
Medicaid Managed Care Plans: CMS called on to provide clear guidelines for states.
A recent Government Accountability Office (GAO) report recommends that CMS should provide clear guidelines for states to monitor Medicaid managed care plans' prior authorization decisions. The report also notes that the agency should clarify whether plans can deploy the utilization management method in states that do not have those requirements to ensure that millions of beneficiaries aged 20 and under can access essential care they are entitled to.
While House Energy & Commerce ranking Democrat Frank Pallone (NJ), who requested the GAO probe, agreed with the recommendations, CMS stressed that it is working with states to gather data on current oversight activities and that any new mandates would require notice and comment rulemaking. The report found that managed care plans often have inconsistent prior authorization requirements for specific services across states.
Although states must oversee managed care plans, none of the states selected for the report assessed a representative sample of denials to evaluate the appropriateness of prior authorization decisions.
Major trade associations highlight the benefits of healthcare mergers and acquisitions.
The International Forum on Advancements in Healthcare (IFAH) and other trade associations provided comments to the Department of Justice Antitrust Division (DOJ), Department of Health and Human Services (HHS), and Federal Trade Commission (FTC) regarding the Request for Information on Consolidation in Health Care Markets.
IFAH comments highlighted that hospital and healthcare system mergers and acquisitions (M&As) bring critical value and a strong, resilient foundational structure to the US healthcare delivery system. The comments outline multiple improvements and benefits that M&A creates for patients, caregivers and communities – all of which improve patient access and care.
The comment letter further urges the agencies to evaluate each potential hospital merger transaction individually, on a case-by-case basis, considering all the relevant facts at hand rather than focusing on ownership structure. Additionally, the comments urged the agencies to consider health insurer consolidation when discussing competition policy in healthcare.
Medicare Advantage Prior Authorization: Revised bill proposed
A bipartisan group of senators and House members announced they would be introducing a revised bill to reform the Medicare Advantage prior authorization process.
The group introduced the Improving Seniors’ Timely Access to Care Act companion bills on June 11, 2024. The sponsors are seeking support and have shared a website that provides background on the bill and where you can add your endorsement and learn more about the legislation.
According to the sponsors, more than 300 organizations endorsed the bill, and 30 senators and 94 House members have signed on as original co-sponsors.
State healthcare cost caps: What does this mean for hospital operating margins?
State-specific caps on how much health systems can increase patient and payers fees could compress nonprofit hospitals’ revenue and reduce operating margins at a time when the sector is already struggling with expense pressures, Fitch Ratings said in a report.
States including Massachusetts, Nevada, Oregon, Rhode Island and Washington have already established caps for price increases, which Fitch says has limited provider rates and levels of reimbursement and constrained operating flexibility.
The state efforts come amid a nationwide push to lower healthcare costs, including government initiatives reducing surprise billing and negotiating prices of certain prescription drugs.
Medicaid redetermination timeline extension: What to expect
Key data on the Medicaid redetermination process has been invaluable to the agency’s oversight – and the public’s understanding – of the renewal process and will continue beyond June.
Starting in July, states must report data on the outcomes of renewals and fair hearings in a new Eligibility Processing Data Report that will replace the unwinding report, the agency says.
This data will:
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- Help the agency monitor retention and disenrollments
- Ensure renewals are done in a way that minimizes burdens on beneficiaries and provides timely resolution to hearings
- Track state activities to identify potential compliance
- Ensure states will be able to efficiently administer their state plans
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The agency plans to continue publicly reporting renewals and other data, but it may make changes after certain waivers expire.
