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Elevance Health has filed a lawsuit against the Department of Health and Human Services over its Medicare Advantage star ratings, seeking to have its 3.75 score adjusted to a 4-star rating. The insurer claims that the current rating system, influenced by statistical variances and a single secret shopper call, has cost it $375 million and negatively impacted member benefits. Elevance, which operates in 22 states and Puerto Rico, previously succeeded in a similar lawsuit regarding the 2024 ratings.
CVS Health has appointed Steve Nelson, former CEO of UnitedHealthcare, as president of Aetna, and Prem Shah as group president, focusing on performance and value creation across CVS' divisions. These changes come as CVS reported a profit of $87 million for Q3, despite incurring $1.2 billion in costs related to operational streamlining. CEO David Joyner emphasized the need for improvement in Aetna while highlighting strong performance in health services and pharmacy units.
Insurers are advocating for improvements to Medicare Advantage (MA) as they face challenges from recent payment cuts and increasing deductibles. With open enrollment underway, companies like Humana and Elevance Health are adjusting benefits, leading to concerns about access and affordability for millions of beneficiaries. Lobbying efforts are intensifying, with significant contributions to both Republican and Democratic candidates as the 2024 election approaches.
New York City has ended coverage for GLP-1 weight-loss drugs, citing an error in their inclusion, while continuing to cover them for diabetes. Meanwhile, Michigan has filed a lawsuit against PBMs Optum Rx and Express Scripts for alleged collusion with opioid manufacturers, seeking accountability for their role in the opioid crisis. Additionally, health plans are previewing their Medicare Advantage offerings for 2025, with various expansions and new benefits aimed at diverse populations.
Elevance Health's CEO, Gail Boudreaux, announced the company is exploring options following a decline in its Medicare Advantage Star Ratings for 2025, which affects member enrollment in higher-rated plans. Despite improvements in nearly 60% of measures for 2026, a narrow miss on a key contract led to significant rating impacts. The situation reflects broader industry challenges, with other insurers like UnitedHealthcare and Humana also contesting their ratings amid increased cut points.
A Senate report reveals that major Medicare Advantage insurers, including Humana, UnitedHealthcare, and CVS, are increasingly using technology to deny prior authorization claims for post-acute care, with Humana's denial rates soaring 16 times higher than its overall rates in 2022. The report criticizes these practices as profit-driven, urging the Centers for Medicare & Medicaid Services to enhance oversight and regulation of prior authorization processes. Insurers defend their actions, claiming compliance with CMS standards, while industry leaders call for accountability to protect patient care.
CareNu is launching its Medicare Advantage plan, SECUR Health Plan, targeting high-acuity patients through an Institutional Special Needs Plan (I-SNP). This model integrates an interdisciplinary team and predictive analytics to manage advanced chronic illnesses effectively. Operating in five Florida counties, SECUR Health Plan aims to provide comprehensive care for individuals with multiple chronic conditions, while also offering additional benefits like transportation and Part D coverage.
UnitedHealthcare's partnership with Hazel Health aims to provide mental health services to up to 1 million students across 14 states by 2025, ensuring access regardless of insurance status. The initiative, which has already begun in Iowa, emphasizes the importance of delivering care within school settings, where students spend significant time. Hazel Health, which previously reached 2.5 million students, is set to expand its presence and services through this collaboration.
UnitedHealthcare has filed a lawsuit against the Centers for Medicare and Medicaid Services (CMS) over a downgrade in its Medicare Advantage star ratings, claiming the decision was based on a single customer service interaction deemed "arbitrary and capricious." The insurer argues that this downgrade could significantly impact its enrollment and financial performance during the critical open enrollment period starting October 15. Other insurers, like Humana, are also facing challenges with star ratings, as they report declines in high-rated plan memberships.
UnitedHealthCare of Alabama Inc.
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