Courts sided with SCAN Health Plan in a star ratings lawsuit that could have implications for other plans, and a Blue Cross Blue Shield company is pulling out of the Medicare Advantage business.
Here are five Medicare Advantage developments Becker's has reported since May 22:
- Dual-eligible special needs plan enrollees are twice as likely to have prior authorization requests denied compared to all other Medicare Advantage members, a KFF analysis found. In 2021, 12% of prior authorization requests submitted to D-SNP plans were denied. The same year, all Medicare Advantage plans (which includes D-SNPs), had a 6% prior authorization denial rate.
- SCAN Health Plan won its lawsuit against CMS that claimed the agency imported the payer's 2024 Medicare Advantage star rating. Sachin Jain, MD, the plan's CEO, told Becker's the decision reaffirmed "that star ratings actually matter." Other payers, including Elevance Health, have filed similar lawsuits.
- Blue Cross and Blue Shield of Kansas City will exit the Medicare Advantage market at the end of 2024, citing increasing regulatory requirements and financial headwinds. In a statement, the company said its "relatively small" MA business was not able to compete in a changing market.
- As some major Medicare Advantage insurers look to shrink enrollments and exit markets, others are embracing the change, saying cuts from CMS are a chance to refocus strategies and provide a better product to their members.
- UnitedHealth Group said a proposed class-action lawsuit alleging an AI algorithm wrongfully denied Medicare Advantage patients care should be dismissed. In a court filing, attorneys for the insurer argued "plaintiffs have failed to exhaust the exclusive administrative appeal process set by the Medicare Act for challenging coverage determinations."