Payer Policy Updates

CMS has finalized or proposed several policy changes in 2023, including stricter audits of Medicare Advantage plans, changes to prior authorization and regulations aimed at drug prices. 

Minnesota Gov. Tim Walz signed legislation requiring insurers to cover preventive services after a Texas judge struck down some requirements for payers to cover preventive care at no cost to members under the ACA.  

CMS is proposing a new rule for drug manufacturers, pharmaceutical benefit managers and managed care plans to increase drug price transparency in Medicaid. 

The Cigna Group is again delaying implementation of a policy that would have required the submission of medical records when using modifier 25 for all evaluation and management claims billed with CPT codes 99212-99215 and a minor procedure.

A coalition of 175 organizations have signed a letter urging UnitedHealthcare not to implement a new gastroenterology endoscopy prior authorization policy that is set to go into effect June 1. 

After a three-year period of continuous Medicaid/CHIP enrollment under the COVID-19 public health emergency, states could begin terminating coverage for ineligible residents in April. With redeterminations underway, health policy experts say too many people in some states are losing health…

Florida has disenrolled nearly 250,000 individuals from its Medicaid program over the last month, the Tampa Bay Times reported May 17.

Sen. Bernie Sanders, along with Rep. Pramila Jayapal and Rep. Debbie Dingell, introduced the Medicare for All Act of 2023 on May 17 to create a federally administered single-payer healthcare system.

The U.S. 5th Circuit Court of Appeals has temporarily blocked a Texas court's ruling earlier this year that struck down an ACA provision requiring payers and employers to provide coverage for preventive services.

The Congressional Budget Office said a proposal to add work requirements for Medicaid eligibility would have "a negligible effect on employment status or hours worked by people who would be subject to the work requirements."