/ en Fri, 25 Apr 2025 21:19:57 -0500 Fri, 28 Mar 25 14:32:40 -0500 /news/headline/2025-03-28-aha-releases-first-health-care-plan-accountability-update-2025 <p>The AHA today released its <a href="/health-care-plan-accountability-update-march-25-2025">Health Care Plan Accountability Update</a>, covering the latest developments in Medicare Advantage, legislation and regulation of private health insurers, as well as other resources from the last quarter. <br> </p> Fri, 28 Mar 2025 14:32:40 -0500 Commercial Insurer Accountability /health-care-plan-accountability-update-march-25-2025 <div class="container"><div class="row"><div class="col-md-8"><h2><span>TOP NEWS</span></h2><h3><a class="ck-anchor" id="challenges"><span>AHA report examines how growth of MA heightens challenges for rural hospitals</span></a></h3><p>A new AHA <a href="/guidesreports/growing-impact-medicare-advantage-rural-hospitals-across-america" target="_blank">report</a> highlights how certain practices by Medicare Advantage plans are increasing rural hospitals' vulnerabilities and threatening access to care in rural communities.   </p><p>In the report, the AHA found that rural hospitals are receiving only 90.6% of Traditional Medicare rates on a cost basis from MA plans. The report also found that insurers’ requirements interfere with clinicians’ ability to provide timely and effective care. For example, 81% of rural clinicians report declines due to insurer requirements. Rural MA patients face longer hospital stays as well, spending 9.6% more time in the hospital before transitioning to post-acute care compared to similar Traditional Medicare patients. Administrative burdens have also grown, with nearly 4 in 5 rural clinicians reporting an increase in administrative tasks over the past five years, and 86% saying these demands have negatively impacted patient outcomes.</p><p>“With MA plans accounting for more than half of total Medicare enrollment and growing, it’s more important than ever that the program works for patients and the providers who care for them,” <a href="/press-releases/2025-02-20-new-aha-report-shows-growing-pressure-medicare-advantage-rural-hospitals-ability-care-communities" target="_blank">said</a> AHA President and CEO Rick Pollack. “It is critical for policymakers to address the harmful impact of Medicare Advantage’s low reimbursements and excessive administrative burdens to help ensure rural hospitals can continue to provide care to their patients and communities." </p><h3><a class="ck-anchor" id="agendas"><span>AHA releases 2025 Advocacy and Rural Advocacy agendas</span></a></h3><p>The AHA released its 2025 <a href="/system/files/media/file/2025/01/AHA-2025-Advocacy-Agenda-20250114.pdf">Advocacy Agenda</a>  detailing the association's key priorities for Congress, the Administration, regulatory agencies and courts. AHA also released its 2025 <a href="/rural-advocacy-agenda" target="_blank" title="2025 Rural Advocacy Agenda">Rural Advocacy Agenda</a> which includes the difficulties rural hospitals face due to challenges imposed by commercial and Medicare Advantage plans. </p><h3><a class="ck-anchor" id="payment"><span>CMS finalizes notice of benefit and payment parameters for 2026 </span></a><span> </span></h3><p>The Centers for Medicare & Medicaid Services <a href="https://www.federalregister.gov/documents/2025/01/15/2025-00640/patient-protection-and-affordable-care-act-hhs-notice-of-benefit-and-payment-parameters-for-2026-and" target="_blank">released</a> its standards for the health insurance marketplaces for 2026, including those for the issuers and brokers who assist marketplace enrollees. The final rule enhances CMS' authority to address and curtail misconduct by agents and brokers, such as fraudulent changes to an enrollee's health care coverage. The final rule went into effect Jan. 15.  </p><h3><a class="ck-anchor" id="marketplace"><span>CMS says record 24.2 million enrolled in Marketplace coverage for 2025 </span></a><span> </span></h3><p>The Centers for Medicare & Medicaid Services <a href="https://www.cms.gov/newsroom/press-releases/over-24-million-consumers-selected-affordable-health-coverage-aca-marketplace-2025" target="_blank">announced</a> a record 24.2 million consumers selected health coverage through the Health Insurance Marketplace for the 2025 enrollment period that ended Jan. 15. The total was more than double the number of enrollees from 2021, CMS said. Of this year's total, 3.9 million consumers signed up for the first time. </p><h3><a class="ck-anchor" id="partd"><span>AHA supports policy, technical changes to Medicare Advantage, Part D for 2026</span></a> </h3><p>The AHA voiced <a href="/2025-01-27-aha-comments-cms-medicare-advantage-part-d-proposed-rule-contract-year-2026?utm_source=newsletter&utm_medium=email&utm_campaign=aha-today" target="_blank">support</a> for the Centers for Medicare & Medicaid Services' proposed rule on policy and technical changes to Medicare Advantage and Part D for contract year 2026. The proposal includes strengthened oversight of Medicare Advantage Organizations and provided additional protections to ensure MA beneficiary access to basic benefits. It also includes provisions promoting more timely access to care, strengthening behavioral health provider networks, and reducing the administrative burden of plan requirements on health care providers.  <strong> </strong></p><h2><span>MEDICARE ADVANTAGE NEWS </span></h2><h3><a class="ck-anchor" id="insurers"><span>KFF: MA insurers made nearly 50 million prior authorization determinations in 2023</span></a><span> </span></h3><p>An <a href="https://www.kff.org/medicare/issue-brief/nearly-50-million-prior-authorization-requests-were-sent-to-medicare-advantage-insurers-in-2023/" target="_blank">analysis</a> by KFF released Jan. 28 found that Medicare Advantage insurers made nearly 50 million prior authorization determinations in 2023. The finding reflects continued year-over-year increases from 2022 (42 million) and 2021 (37 million) as more people have enrolled in MA. KFF also found that in 2023 there was an average of nearly two prior authorization determinations per MA enrollee.   </p><p>The analysis found that insurers fully or partially denied 3.2 million prior authorization requests (6.4%) in 2023, a smaller share than 2022 (7.4%). In 2023, 11.7% of denied prior authorization requests were appealed in MA and of those cases, 81.7% were partially or fully overturned </p><h2><span>TELL US YOUR STORY</span></h2><p>We want to hear about your experience with commercial health plans and how inappropriate use of prior authorization, payment delays and other harmful policies are affecting your patients. We welcome submissions in writing or by video or image upload. We will not use any information publicly without your permission.</p><img src="/sites/default/files/inline-images/image_16.png" data-entity-uuid="305ddbc5-61b2-404d-b383-76d70b82b7b2" data-entity-type="file" alt="image" width="759" height="311"><p>Log in to our AHA.org to access the <a href="/healthplanaccountability" target="_blank" title="Health Care Plan Accountability Page">Health Plan Accountability page</a> and scroll to the bottom to submit your story or experience. You may also upload documents, videos or other supporting material.</p></div><div class="col-md-4"><div class="panel module-typeC"><div class="panel-heading"><h3 class="panel-title"><span>In This Issue:</span></h3></div><div class="panel-body"><ol><li><a href="#challenges">AHA report examines how growth of MA heightens challenges for rural hospitals</a></li><li><a href="#agendas">AHA releases 2025 Advocacy and Rural Advocacy agendas</a></li><li><a href="#payment">CMS finalizes notice of benefit and payment parameters for 2026</a></li><li><a href="#marketplace">CMS says record 24.2 million enrolled in Marketplace coverage for 2025</a></li><li><a href="#partd">AHA supports policy, technical changes to Medicare Advantage, Part D for 2026</a></li><li><a href="#insurers">KFF: MA insurers made nearly 50 million prior authorization determinations in 2023</a></li></ol></div></div> <section class="top-level-view js-view-dom-id-743051a23a7a1e1d065677131524a4463a111df45a5bfbddd4703a1a2a50a209 resource-block"> <p><img alt="Health Plan Accountability Update logo" data-entity-type="file" data-entity-uuid="582e961a-bd33-4ad7-b90d-7ff22d7aed7e" src="/sites/default/files/inline-images/Health-Plan-Accountability-Update-header-900x400.png" /></p> <div class="resource-wrapper"> <div class="resource-view"> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-care-plan-accountability-update-march-25-2025" hreflang="en">Health Care Plan Accountability Update - March 25, 2025</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2025-03-28T10:36:59-05:00">Mar 28, 2025</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-care-plan-accountability-update-december-2024" hreflang="en">Health Care Plan Accountability Update - December 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-12-16T16:04:56-06:00">Dec 16, 2024</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-plan-accountability-update-october-2024" hreflang="en">Health Plan Accountability Update - October 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-10-15T23:47:39-05:00">Oct 15, 2024</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-care-plan-accountability-update-march-28-2024-july-1-2024" hreflang="en">Health Care Plan Accountability Update: March 28, 2024 - July 8, 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-07-08T00:46:22-05:00">Jul 8, 2024</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-plan-accountability-update-march-2024" hreflang="en">Health Plan Accountability Update: March 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-03-28T13:38:13-05:00">Mar 28, 2024</time> </span> </div></div> </div> </div> </section> </div> --><div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/system/files/media/file/2025/03/health-plan-accountability-update-3-25-2025.pdf" target="_blank" title="Click here to download the March Health Plan Accountability Update.">Download the PDF.</a></div><div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/healthplanaccountability" target="_blank" title="Click here to explore all AHA resources on Health Plan Accountability.">Visit Health Plan Accountability</a></div></div></div></div> Fri, 28 Mar 2025 10:36:59 -0500 Commercial Insurer Accountability /news/headline/2025-03-11-aha-brief-urges-court-oppose-motion-multiplan-end-antitrust-case <p>The AHA March 10 filed a <a href="/amicus-brief/2025-03-11-aha-amicus-brief-challenges-multiplan-inc-motion-dismiss-antitrust-litigation">friend-of-the-court brief</a> in the U.S. District Court for the Northern District of Illinois, urging the court to oppose a motion by data analytics firm MultiPlan to dismiss claims that the company conspired with insurers to reduce out-of-network reimbursements for hospitals and health systems.  <br><br>“[I]t is imperative that courts hold commercial insurers to the same standards as everyone else,” AHA wrote. “If, as Plaintiffs allege, MultiPlan has facilitated collusion among commercial insurers throughout the country, this Court’s intervention will help preserve the viability of many struggling hospitals that cannot survive without competitive reimbursements.” <br> <br>The Federation of ����������s joined the AHA in the filing. </p> Tue, 11 Mar 2025 16:04:32 -0500 Commercial Insurer Accountability /amicus-brief/2025-03-11-aha-amicus-brief-challenges-multiplan-inc-motion-dismiss-antitrust-litigation <div class="container"><div class="row"><div class="col-md-8"><h2>Interest of Amici Curiae</h2><p>The ���������� Association (AHA) represents nearly 5,000 hospitals, health care systems, and other health care organizations. Its members are committed to improving the health of the communities that they serve, and to helping ensure that care is available to and affordable for all Americans. The AHA educates its members on health care issues and advocates on their behalf, so that the perspectives of hospitals and health systems, along with the patients they serve, are considered in formulating health policy. One way in which the AHA promotes its members’ interests is by participating as amicus curiae in cases with important and far-ranging consequences.</p><p>The Federation of ����������s (FAH) represents more than 1,000 tax-paying community hospitals and health systems throughout the United States. Its members include teaching, acute, inpatient rehabilitation, behavioral health, and long-term care hospitals. They provide patients and communities in 46 states, the District of Columbia, and the Commonwealth of Puerto Rico with access to high-quality, affordable care, including inpatient, ambulatory, post-acute, emergency, children’s, and cancer services. Through advocacy and policy analysis, the FAH promotes market-based innovation, investments in the health care workforce, and the protection of access to full-service hospitals.</p><p>The AHA’s and FAH’s member hospitals have a significant interest in this case. Commercial insurance reimbursements comprise the majority of many hospitals’ revenue. Moreover, because government programs like Medicare do not cover the costs of providing care, commercial reimbursements can be the difference between losing money, breaking even, or earning a sustainable margin.<a href="#fn1"><sup>1</sup></a> The AHA’s and FAH’s member hospitals thus depend on competition among commercial payors to ensure that commercial reimbursement rates are sufficient to cover hospitals’ costs and preserve access to care throughout the United States.</p><h2>Introduction</h2><p>This lawsuit comes at a crucial time for the health care sector. Since the onset of COVID-19, the prices for key inputs—including labor, prescription drugs, and medical equipment—have grown dramatically. America’s hospitals and health systems have borne the lion’s share of these increased costs. Government reimbursements were inadequate before the pandemic; they have since fallen even further behind. In December 2024, for example, the Medicare Payment Advisory Commission noted in a preliminary presentation to Commissioners that hospital Medicare margins were at an all-time low of <em>negative 12.6%, and were projected to remain at that level in 2025.</em><a href="#fn2"><sup>2</sup></a> These worrisome statistics do not include Medicaid shortfalls, which compound the problem even further. According to AHA analysis, the difference between Medicaid payments and costs in 2023 was <em>$27.5 billion.</em><a href="#fn3"><sup>3</sup></a> And to make matters worse, reimbursements from commercial payors have failed to keep pace with hospitals’ increased costs. The result is dire: more than a third of all U.S. hospitals have negative operating margins, bond defaults are up, and hundreds of rural hospitals are on the brink of collapse.</p><p>The situation is much different for the commercial insurance companies that use MultiPlan’s repricing tool. Commercial payors like UnitedHealthcare are some of the largest companies in the world. They generate hundreds of billions of dollars in revenue each year and earn sizeable profits. In 2020, while hospitals were devastated by the COVID-19 outbreak, insurers banked record profits. Several years later, this economic divergence between providers and payors remains consistent. Hospitals and health systems continue to struggle financially. Insurers do not.</p><p>Against this backdrop, it is imperative that courts hold commercial insurers to the same standards as everyone else. The AHA and FAH respectfully submit this <em>amicus</em> brief to offer a broader perspective on what is really at stake here. If, as Plaintiffs allege, MultiPlan has facilitated collusion among commercial insurers throughout the country, this Court’s intervention will help preserve the viability of many struggling hospitals that cannot survive without competitive reimbursements.</p><p><a href="/system/files/media/file/2025/03/AHA-Amicus-Brief-Challenges-MultiPlan-Inc-Motion-to-Dismiss-Antitrust-Litigation.pdf" target="_blank" title="Click here to download the AHA Amicus Brief Challenges MultiPlan, Inc. Motion to Dismiss Antitrust Litigation PDF."><em><strong>Read the full </strong></em><strong>amicus</strong><em><strong> brief.</strong></em></a></p><hr><ol><li id="fn1"><em>See</em> Am. Hosp. Ass’n, <em>The Financial Stability of America’s Hospitals and Health Systems Is at Risk as the Costs of Caring Continue to Rise,</em> at 1 (Apr. 2023) (hereinafter “2023 Cost of Caring Report”), <em>available at</em> <a href="/system/files/media/file/2023/04/Cost-of-Caring-2023-The-Financial-Stability-of-Americas-Hospitals-and-Health-Systems-Is-at-Risk.pdf">/system/files/media/file/2023/04/Cost-of-Caring-2023-The-Financial-Stability-of-Americas-Hospitals-and-Health-Systems-Is-at-Risk.pdf</a>.</li><li id="fn2">Alison Binkowski et al., Medicare Payment Advisory Commission, <em>Assessing payment adequacy and updating payments: Hospital inpatient and outpatient services; and mandated report on rural emergency hospitals,</em> at 13, 15 (Dec. 12, 2024), <em>available at</em> <a href="https://www.medpac.gov/wp-content/uploads/2023/10/Tab-D-Hospital-payment-adequacy-and-REH-mandate-December-2024_SEC-1.pdf" target="_blank">https://www.medpac.gov/wp-content/uploads/2023/10/Tab-D-Hospital-payment-adequacy-and-REH-mandate-December-2024_SEC-1.pdf</a>. For this reason, the Commission recommended in January 2025 that Congress update Medicare payment rates for hospital inpatient and outpatient services by the current law amount plus 1% for 2026 and reiterated its recommendation to distribute an additional $4 billion to safety-net hospitals by transitioning to a Medicare safety-net index policy. <em>See</em> Dave Muoio, <em>MedPAC Votes to Recommend Hospital Pay Increases for 2026,</em> Fierce Healthcare (Jan. 17, 2025), <em>available at</em> <a href="https://www.fiercehealthcare.com/providers/medpac-votes-recommend-hospital-pay-increases-2026" target="_blank">https://www.fiercehealthcare.com/providers/medpac-votes-recommend-hospital-pay-increases-2026</a>.</li><li id="fn3">Am. Hosp. Ass’n, <em>Fact Sheet: Medicaid Hospital Payment Basics</em> (Feb. 2025), <em>available at</em> <a href="g/fact-sheets/2025-02-07-fact-sheet-medicaid-hospital-payment-basics">/fact-sheets/2025-02-07-fact-sheet-medicaid-hospital-payment-basics</a>.</li></ol></div><div class="col-md-4"><p><a href="/system/files/media/file/2025/03/AHA-Amicus-Brief-Challenges-MultiPlan-Inc-Motion-to-Dismiss-Antitrust-Litigation.pdf" target="_blank" title="Click here to download the AHA Amicus Brief Challenges MultiPlan, Inc. Motion to Dismiss Antitrust Litigation PDF."><img src="/sites/default/files/inline-images/Page-1-AHA-Amicus-Brief-Challenges-MultiPlan-Inc-Motion-to-Dismiss-Antitrust-Litigation.png" data-entity-uuid="c03d9b55-d4b9-49a6-9d56-8df7a52aac11" data-entity-type="file" alt="AHA Amicus Brief Challenges MultiPlan, Inc. Motion to Dismiss Antitrust Litigation page 1." width="695" height="900"></a></p></div></div></div> Tue, 11 Mar 2025 14:14:47 -0500 Commercial Insurer Accountability /health-care-plan-accountability-update-december-2024 <div class="container"><div class="row"><div class="col-md-8"><h2><span>TOP NEWS</span></h2><h3 id="drugs" name="drugs"><a href="/news/headline/2024-11-26-cms-releases-proposed-rule-2026-medicare-advantage-prescription-drug-plans" target="_blank" title="Article"><span>CMS releases proposed rule for 2026 Medicare Advantage, prescription drug plans</span></a></h3><p>The Centers for Medicare & Medicaid Services Nov. 26 proposed changes to the Medicare Advantage and prescription drug programs for contract year 2026. Those changes would permit coverage of anti-obesity medications in the Medicare and Medicaid programs; fortify existing limitations on insurer use of internal coverage criteria and requirements for MA plans to provide coverage for all reasonable and necessary Medicare Part A and B benefits; and apply additional guardrails to insurer use of artificial intelligence to ensure it does not result in inequitable treatment or access to care. CMS also proposes to update MA and Part D plan medical loss ratio reporting requirements to improve oversight, align reporting with commercial and Medicaid reporting, and request additional information on MLR and vertical integration.</p><h3 id="MAO" name="MAO"><a href="/news/headline/2024-11-12-aha-makes-recommendations-supporting-cms-proposed-mao-data-collection-and-audit-protocol" target="_blank" title="AHA Recommendations">AHA makes recommendations supporting CMS’ proposed MAO data collection and audit protocol</a></h3><p>The AHA Nov. 11 voiced strong support for the Centers for Medicare & Medicaid Services’ proposed plan for data collection and reporting requirements for Medicare Advantage organizations. In addition, the AHA supports CMS’ proposed audit protocol, which would assess MAO compliance with MA utilization management program requirements codified in the calendar year 2024 MA final rule.</p><h2><span>OTHER NEWS</span></h2><h3 id="GAO" name="GAO"><a href="/news/headline/2024-11-15-gao-finds-private-insurance-market-became-increasingly-concentrated-last-decade" target="_blank" title="GAO news article"><span>GAO finds private insurance market became increasingly concentrated last decade</span></a></h3><p>The Department of Health and Human Services' Government Accountability Office Nov. 14 released a report that determined the private health insurance market became increasingly concentrated from 2011-2022. GAO considered a market concentrated if three or fewer insurers held at least 80% of the market share, which it found for individual and employer group markets in at least 35 states. In addition, the GAO found that for the large group market, the number of states where 80% of market share was held by a single insurer doubled from six to 12.</p><h2><span>MEDICARE ADVANTAGE</span></h2><h3 id="analysis" name="analysis"><a href="/news/headline/2024-10-24-analysis-ma-plans-classify-3-4-times-many-hospital-stays-observation-visits-compared-traditional" target="_blank"><span>Analysis: MA plans more likely to classify hospital stays as observation visits, compared with traditional Medicare</span></a></h3><p>A report released Oct. 23 by Kodiak Solutions found that Medicare Advantage plans classified three to four times as many hospital stays as observation visits from July 2023 through June 2024 when compared with traditional Medicare. MA plans began classifying fewer stays as observation visits in January when a new federal regulation required MA plans to offer their members the same services received by traditional Medicare beneficiaries. But MA plans continue to classify hospital stays as observation at a much higher rate than fee-for-service Medicare. Observation rates for MA plans ranged between 18.1% to 20.2% of claims in the final six months of 2023, then fluctuated within a range of 14.4% and 16.1% in the first six months of this year. Meanwhile, observation rates in traditional Medicare within the 12-month period trended at a much lower range of 5.2% to 3.7%.</p><h3 id="oig" name="oig"><a href="/news/headline/2024-10-24-oig-report-finds-insurers-collected-billions-questionable-ma-payments" target="_blank">OIG report finds insurers collected billions in questionable MA payments</a></h3><p>A report released Oct. 24 by the Office of Inspector General for the Department of Health and Human Services found that insurers received an estimated $7.5 billion in Medicare Advantage risk-adjustments for 2023 through health risk assessments and related medical record reviews. OIG said the lack of any other follow-up visits, procedures, tests or supplies for diagnoses in the MA encounter data raises concerns that either the diagnoses are inaccurate, thus the payments are improper, or MA enrollees did not receive needed care for serious conditions reported only on HRAs or HRA-linked chart reviews. In-home HRAs and HRA-linked chart reviews generated nearly two-thirds of the estimated $7.5 billion, the report said. According to OIG, UnitedHealth Group and Humana accounted for over $5.4 billion of the estimated $7.5 billion.</p><h2><span>LEGISLATIVE ACTIVITY</span></h2><ul><li><a href="/lettercomment/2024-11-11-aha-responds-cms-medicare-advantage-data-and-audit-proposed-protocol">AHA Responds to CMS Medicare Advantage Data and Audit Proposed Protocol,</a> Nov. 11</li><li><a href="/2024-11-12-aha-urges-congress-act-key-priorities-lame-duck-session">AHA Urges Congress to Act on Key Priorities in Lame-duck Session, </a>Nov. 12</li><li><a href="/action-alert/2024-11-13-aha-asks-congressional-leadership-fund-hospitals-protect-health-care-workers">AHA Asks Congressional Leadership to Fund Hospitals, Protect Health Care Workers, </a>Nov. 13</li><li><a href="/press-releases/2024-11-26-aha-statement-cms-medicare-advantage-proposed-rule">AHA Statement on CMS Medicare Advantage Proposed Rule,</a> Nov. 26</li><li><a href="/special-bulletin/2024-11-27-special-bulletin-cms-issues-proposed-rule-cy-2026-medicare-advantage-prescription-drug-plans">Special Bulletin: CMS Issues Proposed Rule for CY 2026 Medicare Advantage, Prescription Drug Plans</a>, Nov. 27</li></ul><h2><span>TELL US YOUR STORY</span></h2><p>We want to hear about your experience with commercial health plans and how inappropriate use of prior authorization, payment delays and other harmful policies are affecting your patients. We welcome submissions in writing or by video or image upload. We will not use any information publicly without your permission.</p><img src="/sites/default/files/inline-images/image_16.png" data-entity-uuid="305ddbc5-61b2-404d-b383-76d70b82b7b2" data-entity-type="file" alt="image" width="759" height="311"><p>Log in to our AHA.org to access the <a href="/healthplanaccountability" target="_blank" title="Health Care Plan Accountability Page">Health Plan Accountability page</a> and scroll to the bottom to submit your story or experience. You may also upload documents, videos or other supporting material.</p></div><div class="col-md-4"><div class="panel module-typeC"><div class="panel-heading"><h3 class="panel-title"><span>In This Issue:</span></h3></div><div class="panel-body"><ol><li><a href="#drugs">CMS releases proposed rule for 2026 Medicare Advantage, prescription drug plans</a></li><li><a href="#MAO">AHA makes recommendations supporting CMS’ proposed MAO data collection and audit protocol</a></li><li><a href="#GAO">GAO finds private insurance market became increasingly concentrated last decade</a></li><li><a href="#analysis">Analysis: MA plans more likely to classify hospital stays as observation visits, compared with traditional Medicare</a></li><li><a href="#oig">OIG report finds insurers collected billions in questionable MA payments</a></li></ol></div></div> <section class="top-level-view js-view-dom-id-3041d79d3f8ac62991097d4198e8f8798796f01eb5777484119b59eebf5217a5 resource-block"> <p><img alt="Health Plan Accountability Update logo" data-entity-type="file" data-entity-uuid="582e961a-bd33-4ad7-b90d-7ff22d7aed7e" src="/sites/default/files/inline-images/Health-Plan-Accountability-Update-header-900x400.png" /></p> <div class="resource-wrapper"> <div class="resource-view"> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-care-plan-accountability-update-march-25-2025" hreflang="en">Health Care Plan Accountability Update - March 25, 2025</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2025-03-28T10:36:59-05:00">Mar 28, 2025</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-care-plan-accountability-update-december-2024" hreflang="en">Health Care Plan Accountability Update - December 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-12-16T16:04:56-06:00">Dec 16, 2024</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-plan-accountability-update-october-2024" hreflang="en">Health Plan Accountability Update - October 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-10-15T23:47:39-05:00">Oct 15, 2024</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-care-plan-accountability-update-march-28-2024-july-1-2024" hreflang="en">Health Care Plan Accountability Update: March 28, 2024 - July 8, 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-07-08T00:46:22-05:00">Jul 8, 2024</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-title"> <span class="field-content"><a href="/health-plan-accountability-update-march-2024" hreflang="en">Health Plan Accountability Update: March 2024</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-03-28T13:38:13-05:00">Mar 28, 2024</time> </span> </div></div> </div> </div> </section> </div> --><div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/system/files/media/file/2024/12/health-care-plan-accountability-update-december-2024.pdf" target="_blank" title="Click here to download the December Health Plan Accountability Update.">Download the PDF.</a></div><div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/healthplanaccountability" target="_blank" title="Click here to explore all AHA resources on Health Plan Accountability.">Visit Health Plan Accountability</a></div></div></div></div> Mon, 16 Dec 2024 16:04:56 -0600 Commercial Insurer Accountability /news/headline/2024-12-12-aha-discusses-impact-vertical-integration-health-care-providers <p>The AHA today participated in a panel discussion during a conference hosted by The Capitol Forum on the impact of insurer vertical integration. Molly Smith, AHA group vice president for public policy, highlighted the experiences of hospitals and health systems in helping patients navigate care in this environment.   </p><p>“This can be very disruptive for patients and providers in a community where you are trying to coordinate care,” said Smith.  </p><p>The panel also discussed the growth of Medicare Advantage, market concentration and recent actions taken by policymakers to better monitor care denials and prior authorization, as well what other steps policymakers can take to make health care more affordable and accessible.</p> Thu, 12 Dec 2024 15:58:36 -0600 Commercial Insurer Accountability /news/headline/2024-12-12-oig-warns-marketing-schemes-certain-ma-programs <p>The Department of Health and Human Services Office of Inspector General yesterday issued an <a href="https://oig.hhs.gov/documents/special-fraud-alerts/10092/Special%20Fraud%20Alert:%20Suspect%20Payments%20in%20Marketing%20Arrangements%20Related%20to%20Medicare%20Advantage%20and%20P.pdf" title="alert">alert</a> warning of marketing schemes by certain Medicare Advantage plans.</p> Thu, 12 Dec 2024 15:50:04 -0600 Commercial Insurer Accountability /news/headline/2024-12-05-court-issues-preliminary-approval-28-billion-blue-cross-blue-shield-provider-settlement <p>A $2.8 billion settlement from Blue Cross Blue Shield to health care providers resolving a 12-year antitrust lawsuit received <a href="https://whatleykallas.com/wp-content/uploads/2024/12/3225-Preliminary-Approval-Order.pdf" title="lawsuit approval">preliminary approval</a> yesterday from the U.S. District Court for the Northern District of Alabama. The settlement will also "significantly improve how Providers will interact with the Blues, bringing more transparency and efficiency to their dealings, and increase Blue Plan accountability," according to the court filing. <br> </p><p>The lawsuit alleged that BCBS member companies violated antitrust laws by agreeing to allocate markets via exclusive service areas and fixing prices paid to health care providers through the organization's BlueCard Program. </p> Thu, 05 Dec 2024 14:53:58 -0600 Commercial Insurer Accountability <div class="container"><div class="row"><div class="col-md-8"><p>Following the elections, lawmakers are returning to Washington, D.C., to tackle key funding issues, including Medicaid disproportionate share hospital (DSH) payment reductions and support for rural programs. They also will consider site-neutral payment proposals, oversight of health plans, continuation of telehealth and hospital-at-home waivers, and the prevention of violence against health care workers.</p><p>Before the lame-duck session ends and the 118th Congress adjourns, it is essential that federal lawmakers understand the challenges hospitals and health systems face and what is at stake for the patients and communities they represent. With several programs facing expiration at the end of this year, quick action is needed to preserve necessary funding and support for the nation’s health care organizations.</p><p>Here are the issues AHA leaders are <a href="/2024-11-12-aha-urges-congress-act-key-priorities-lame-duck-session" target="_blank" title="Issues AHA Leaders are calling on Congress to reinforce">calling on congressional leaders</a> to reinforce. Following is an overview of the issues and what you can do to assist these advocacy efforts.</p><h2>SUPPORT MEDICAID DSH DEAR COLLEAGUE LETTER</h2><p>At the beginning of the year, billions of dollars will be cut from the Medicaid DSH program, severely jeopardizing hospitals’ finances and threatening communities’ access to care. Contact your representative(s) and ask them to sign on to the bipartisan <a href="/system/files/media/file/2024/11/congress-dear-colleague-letter-to-stop-medicaid-disproportionate-share-hospital-dsh-payment-cuts-11-13-2024.pdf" target="_blank" title="House Dear Colleague Letter">House Dear Colleague letter</a> being circulated by Reps. Dan Crenshaw, R-Texas, Yvette Clarke, D-N.Y., Gus Bilirakis, R-Fla., and Diana DeGette, D-Colo., calling for Medicaid DSH cuts to be addressed. <a href="https://www.votervoice.net/AHA/Campaigns/118959/Respond">Click here</a> to send a message to your representatives.</p><h2><strong>LEGISLATIVE ACTION NEEDED</strong></h2><p><strong>Address the Medicaid</strong> <strong>DSH Payment Reductions. </strong>The <a href="/fact-sheets/2023-03-28-fact-sheet-medicaid-dsh-program" target="_blank" title="Medicare DSH Program Information">Medicaid DSH program</a> provides essential financial assistance to hospitals that care for our nation’s most vulnerable populations — children, impoverished, disabled and elderly. The fiscal year 2025 Medicaid DSH payment reductions are scheduled to be implemented on Jan. 1, 2025, when $8 billion in reductions take effect. The AHA calls on Congress to continue to provide relief from the Medicaid DSH cuts.</p><p><strong>Protect Rural Communities’ Access to Care.</strong> The AHA urges Congress to continue the <a href="/advocacy/advocacy-issues/2024-10-31-advocacy-issue-rural-mdh-and-lva-programs" target="_blank" title="Medicare-dependent Hospitals and Low-volume Adjustment programs">Medicare-dependent Hospitals and Low-volume Adjustment programs</a>. These programs provide rural, geographically isolated and low-volume hospitals additional financial support to ensure rural residents have access to care. These programs expire on Dec. 31, 2024. Congress should also enact a technical correction to remove barriers for Rural Emergency Hospitals to receive hospital-level reimbursement for outpatient services under Medicaid<strong>.</strong> </p><p><strong>Reject Site-neutral Payment Proposals.</strong> The AHA strongly opposes efforts to expand <a href="/advocacy/advocacy-issues/2023-09-11-advocacy-issue-site-neutral-payment-proposals" target="_blank" title="Site-neutral payment cuts information">site-neutral payment cuts</a> to include essential drug administration services furnished in off-campus hospital outpatient departments (HOPDs). Current Medicare payment rates appropriately recognize that there are fundamental differences between patient care delivered in HOPDs compared to other settings. HOPDs have higher patient safety and quality standards, and, unlike other sites of care, hospitals take important additional steps to ensure drugs are prepared and administered safely for both patients and providers. </p><p>The AHA also calls on Congress to reject legislative efforts requiring each off-campus HOPD to be assigned a separate unique health identifier from its provider as a condition of payment under Medicare or group health plans. Hospitals are already required to be transparent about the location of care delivery. This requirement would be duplicative and impose unnecessary and onerous administrative burdens and costs by needlessly requiring the overhaul of current billing practices and systems.</p><p><strong>Hold Commercial Health Plans Accountable.</strong> Certain health plan practices, such as inappropriate care denials and delayed payments, threaten patient access to care. These practices also contribute to clinician burnout and add excessive administrative costs and burdens to the health care system. The AHA urges Congress to pass the<a href="/lettercomment/2024-06-12-aha-support-house-improving-seniors-timely-access-care-act" target="_blank" title="Improving seniors timely access to care"> Improving Seniors Timely Access to Care Act</a> (H.R. 8702/ S. 4532), bipartisan legislation supported by more than half of the members of the House and Senate. The bill would streamline the prior authorization process in the Medicare Advantage program by eliminating complexity and promoting uniformity to reduce the wide variation in prior authorization methods that frustrate both patients and providers.</p><p><strong>Extend </strong><a href="/system/files/media/file/2024/05/fact-sheet-2024-telehealth-advocacy-agenda.pdf" target="_blank" title="Telehealth information"><strong>Telehealth</strong></a><strong> and </strong><a href="/system/files/media/file/2024/07/Fact-Sheet-Extending-the-Hospital-at-Home-Program-20240719.pdf" target="_blank" title="Hospitals-at-home information"><strong>Hospital-at-home</strong></a><strong> Waivers.</strong> During the COVID-19 public health emergency, Congress established a series of waivers expanding access for millions of Americans and increasing convenience in caring for patients. Telehealth provides a tremendous ability to leverage geographically dispersed provider capacity to support patient demand. The AHA calls on Congress to permanently adopt telehealth waivers and expand the telehealth workforce. </p><p>The AHA also urges Congress to pass the <a href="/lettercomment/2024-05-23-aha-support-house-bill-hospital-inpatient-services-modernization-act-2024" target="_blank" title="Hospitals Inpatient Services Modernization Act">Hospital Inpatient Services Modernization Act</a> (H.R. 8260/S. 4350), extending the hospital-at-home waiver for five years through 2029. Congressional action will reassure hospitals and health systems that are interested in developing such programs for their communities. </p><p><strong>Prevent Reimbursement Cuts for Physicians. </strong>Congress should take action to mitigate the scheduled physician reimbursement cuts for 2025 and to continue its work on broader reform for sustainable physician payment. Physicians have dealt with over two decades of conversion factor decrements, as well as significant staffing shortages and rising inflation in recent years. The scheduled 2.8% payment reduction in the 2025 Physician Fee Schedule would result in a significant risk to patients’ access to care.</p><p><strong>Protect America’s Health Care Workers.</strong> The AHA calls on Congress to enact the <a href="/system/files/media/file/2022/09/Fact-Sheet-Workplace-Violence-and-Intimidation-and-the-Need-for-a-Federal-Legislative-Response.pdf" target="_blank" title="SAVE Act information">Safety from Violence for Healthcare Employees (SAVE) Act</a> (H.R. 2584/S. 2768). This bipartisan bill would provide federal protections from workplace violence for hospital workers, similar to the protections in current law for airport and airline workers.</p><h2>FURTHER QUESTIONS</h2><p>Visit the <a href="/advocacy/action-center" target="_blank" title="AHA Action Center">AHA Action Center</a> for more resources on these issues and other priorities important to hospitals and health systems.</p><p>If you have further questions, please contact AHA at 800-424-4301.<br> </p></div><div class="col-md-4"><a href="/system/files/media/file/2024/11/aha-asks-congressional-leadership-to-fund-hospitals-protect-health-care-workers-alert-11-13-2024.pdf"><img src="/sites/default/files/inline-images/cover-aha-asks-congressional-leadership-to-fund-hospitals-protect-health-care-workers-alert-11-13-2024.png" data-entity-uuid="40f68d4b-dfe5-4e56-af78-6f8af97f13ca" data-entity-type="file" alt="Action Alert Cover Image" width="640" height="834"></a></div></div><p> </p></div> Wed, 13 Nov 2024 14:05:33 -0600 Commercial Insurer Accountability /2024-11-12-aha-urges-congress-act-key-priorities-lame-duck-session <p>November 12, 2024</p><table><tbody><tr><td>The Honorable Mike Johnson<br>Speaker<br>U.S. House of Representatives<br>Washington, DC 20515</td><td>The Honorable Hakeem Jeffries<br>Democratic Leader<br>U.S. House of Representatives<br>Washington, D.C. 20515</td></tr><tr><td>The Honorable Charles E. Schumer<br>Majority Leader<br>United States Senate<br>Washington, DC 20510</td><td>The Honorable Mitch McConnell<br>Republican Leader<br>United States Senate<br>Washington, DC 20510</td></tr></tbody></table><p><br>Dear Speaker Johnson, Leader Schumer, Leader Jeffries, and Leader McConnell:</p><p>On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers — and the 43,000 health care leaders who belong to our professional membership groups, the ���������� Association (AHA) writes regarding the forthcoming government funding deadline.</p><p>Hospitals and health systems are experiencing significant financial pressures that challenge their ability to provide 24/7 care for the patients and communities they serve.  Increased expenses for drugs and supplies, inflation and the mounting burden due to certain commercial health insurer denial and delay practices continue to strain hospitals and health systems. At the same time, underpayments in reimbursements from Medicare and Medicaid do not keep pace with these mounting costs and exacerbate the problems hospitals are having.</p><p>As Congress begins to focus on its end-of-the-year work, America’s hospitals and health systems respectfully request that you consider the following priorities.</p><p><strong>Address the Medicaid</strong> <strong>Disproportionate Share Hospital (DSH) Payment Reductions. </strong>The Medicaid DSH program provides essential financial assistance to hospitals that care for our nation’s most vulnerable populations — children, impoverished, disabled and elderly. The fiscal year 2025 Medicaid DSH payment reductions are scheduled to be implemented on Jan. 1, 2025, when $8 billion in reductions take effect. Congress should continue to provide relief from the Medicaid DSH cuts.</p><p><strong>Protect Rural Communities’ Access to Care.</strong> We urge Congress to continue the Medicare-dependent Hospitals and Low-volume Adjustment programs. These programs provide rural, geographically isolated and low-volume hospitals additional financial support to ensure rural residents have access to care. These programs expire on Dec. 31, 2024. Congress should also enact a technical correction to remove barriers for Rural Emergency Hospitals to receive hospital level reimbursement for outpatient services under Medicaid<strong>.</strong></p><p><strong>Reject Site-neutral Payment Proposals.</strong> We strongly oppose efforts to expand site-neutral payment cuts to include essential drug administration services furnished in off-campus hospital outpatient departments (HOPDs). Current Medicare payment rates appropriately recognize that there are fundamental differences between patient care delivered in HOPDs compared to other settings. HOPDs have higher patient safety and quality standards, and, unlike other sites of care, hospitals take important additional steps to ensure drugs are prepared and administered in a safe manner for both patients and providers.</p><p>HOPDs provide care for Medicare patients who are more likely to be sicker and more medically complex than those treated at physicians’ offices. This is especially true in rural and other medically underserved communities. Additional cuts will directly impact the level of care and services available to vulnerable patients in these communities.</p><p>We also call on Congress to reject legislative efforts requiring each off-campus HOPD to be assigned a separate unique health identifier from its provider as a condition of payment under Medicare or group health plans. Hospitals are already required to be transparent about the location of care delivery. This requirement would be duplicative and impose unnecessary and onerous administrative burdens and costs by needlessly requiring the overhaul of current billing practices and systems.</p><p><strong>Hold Commercial Health Plans Accountable.</strong> Certain health plan practices, such as inappropriate care denials and delayed payments, threaten patient access to care. These practices also contribute to clinician burnout and add excessive administrative costs and burdens to the health care system. We urge Congress to pass the Improving Seniors Timely Access to Care Act (H.R. 8702/ S. 4532), bipartisan legislation supported by more than half of the members of the House and Senate. The bill would streamline the prior authorization process in the Medicare Advantage program by eliminating complexity and promoting uniformity to reduce the wide variation in prior authorization methods that frustrate both patients and providers.</p><p><strong>Extend Telehealth and Hospital-at-home Waivers.</strong> During the public health emergency, Congress established a series of waivers expanding access for millions of Americans and increasing convenience in caring for patients. Telehealth provides a tremendous ability to leverage geographically dispersed provider capacity to support patient demand. Congress should permanently adopt telehealth waivers and expand the telehealth workforce.</p><p>Hospital-at-home programs are a safe, innovative way to care for patients in the comfort of their homes. With over 300 hospitals with hospital-at-home programs, many other hospitals and health systems indicate they are interested in developing programs for their communities but are reluctant to do so without congressional action. We urge Congress to pass the Hospital Inpatient Services Modernization Act (H.R. 8260/S. 4350), extending the hospital-at-home waiver for five years through 2029.</p><p><strong>Prevent Reimbursement Cuts for Physicians. </strong>Congress should take action to mitigate the scheduled physician reimbursement cuts for 2025 and to continue its work on broader reform for sustainable physician payment. Physicians have dealt with over two decades of conversion factor decrements, as well as significant staffing shortages and rising inflation in recent years. The scheduled 2.8% payment reduction in the 2025 Physician Fee Schedule would result in a significant risk to patients’ access to care.</p><p><strong>Protect America’s Health Care Workers.</strong> Congress should enact the Safety from Violence for Healthcare Employees (SAVE) Act (H.R. 2584/S. 2768). This bipartisan bill would provide federal protections from workplace violence for hospital workers, similar to the protections in current law for airport and airline workers.</p><p>We appreciate your leadership and look forward to working together to ensure patients continue to have access to quality care in their communities.</p><p>Sincerely,</p><p>/s/</p><p>Richard J. Pollack<br>President & Chief Executive Officer</p> Tue, 12 Nov 2024 14:38:12 -0600 Commercial Insurer Accountability