/ en Wed, 30 Jul 2025 17:29:07 -0500 Wed, 25 Jun 25 14:29:59 -0500 /health-plan-accountability-update/2025-06-25-health-plan-accountability-update-june-2025 <div class="container"><div class="row"><div class="col-md-8"><h2><span>TOP NEWS</span></h2><h3><a class="ck-anchor" id="prior"><span>HHS announces initiative with insurers to streamline prior authorizations</span></a></h3><p>The Department of Health and Human Services June 23 <a href="https://www.hhs.gov/press-room/kennedy-oz-cms-secure-healthcare-industry-pledge-to-fix-prior-authorization-system.html"><ins cite="mailto:Kristen%20Page" datetime="2025-06-24T17:00">announced</ins></a> an initiative coordinated with multiple health insurance companies to streamline prior authorization processes for patients covered by Medicare Advantage, Medicaid managed care plans, Health Insurance Marketplace plans and commercial plans. Under the initiative, electronic prior authorization requests would become standardized by 2027. HHS stated that these reforms complement ongoing regulatory efforts by the Centers for Medicare & Medicaid Services to improve prior authorization, including building upon the Interoperability and Prior Authorization final rule.</p><p>The plan is expected to make the prior authorization process faster, more efficient and more transparent, the agency said. Participating insurers pledged to expand real-time responses by 2027. HHS said that the insurers would also commit to reducing the volume of medical services subject to prior authorization by 2026, including those for common procedures such as colonoscopies and cataract surgeries.</p><p>During a news conference, HHS Secretary Robert F. Kennedy Jr. said unlike previous attempts by insurers, this initiative would succeed because the number of insurers participating represent 257 million Americans. “The other difference is we have standards this time,” he said. “We have ... deliverables. We have specificity on those deliverables, we have metrics, and we have deadlines, and we have oversight.”</p><p>Mehmet Oz, M.D., CMS administrator, said that the pledge “is an opportunity for industry to show itself.” Sen. Marshall, R-Kan., said that Congress could pursue codifying at least some portions of the initiative in the future.</p><p>Additionally, participating insurers would honor existing prior authorizations during coverage transitions. </p><h3><a class="ck-anchor" id="squeezed"><span>Report: Hospitals and health systems squeezed by persistent economic challenges</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="market"><span>CMS releases final rule on Marketplace Integrity and Affordability</span></a><span> </span></h3><p>The Centers for Medicare & Medicaid Services June 20 <a href="https://www.cms.gov/newsroom/press-releases/cms-finalizes-major-rule-lower-individual-health-insurance-premiums-americans?mkt_tok=NzEwLVpMTC02NTEAAAGbLncdm8De7YTsUKsMgLLZp51sMLIyimY3wFT628DNCsaMQlgveNdO1tSozbnh3plyfxRId1Ge3iYBeAv1OsBPFmDxnUBJpd-ynTc4jFiRVxQ-tGSK">announced</a> it finalized its 2025 <a href="https://www.cms.gov/files/document/cms-9884-f-2025-pi-rule-master-5cr-062025.pdf?mkt_tok=NzEwLVpMTC02NTEAAAGbLncdm3fVY0niaMksBy2mQsArgAw_pZPHwYt2IJvuBfQT5tIK8D6tAZXFPR0nAQ2JA6ExqB3T4hcrBc7cRYjBJahC8skSiXmYgHYeBAa23MVD75I9">Marketplace Integrity and Affordability final rule</a>. The rule shortens the open enrollment period for the federal marketplace to Nov. 1-Dec. 15 starting in 2027, and limits open enrollment periods for state-based marketplaces to Nov. 1-Dec. 31. The rule also includes a change to the premium adjustment percentage that would increase the maximum annual cost sharing limitation. Additionally, the rule makes updates to the income verification process and pre-enrollment verification process for special enrollment periods, changes to the essential health benefits, modifications to the redetermination and re-enrollment processes, and ends a SEP for low-income individuals, among other policies. Many of the provisions reinstate policies finalized during the prior Trump administration.</p><p>The AHA April 11 expressed <a href="/lettercomment/2025-04-11-aha-comments-cms-marketplace-integrity-and-affordability-rule">concerns</a> to CMS after the rule was proposed. CMS had estimated that 750,000 to 2 million consumers could lose their coverage due to the provisions. The AHA encouraged CMS to pause finalizing many of the proposals to give it and stakeholders additional time to consider the impacts while also taking action to stop brokers responsible for inappropriate enrollments. </p><h3><a class="ck-anchor" id="appeals"><span>CMS requests comments on MA service level data collection for initial determinations, appeals </span></a><span> </span></h3><p>The Centers for Medicare & Medicaid Services May 30 released a <a href="https://www.federalregister.gov/documents/2025/05/30/2025-09813/agency-information-collection-activities-submission-for-omb-review-comment-request">notice</a> requesting comments on a proposed Medicare Advantage service level data collection for initial determinations and appeals. The granular data will be used to enhance audit activities to ensure MA plans are operating in accordance with CMS guidelines and ensure appropriate access to covered services and benefits. CMS plans to use the information to hold MA plans accountable for their performance. Comments are due to the Office of Management and Budget by June 30. </p><h3><a class="ck-anchor" id="notifies"><span>CMS notifies states it will not approve or match funds for designated state health, investment programs </span></a> </h3><p>The Centers for Medicare & Medicaid Services April 10 <a href="https://www.cms.gov/newsroom/press-releases/cms-refocuses-its-core-mission-and-preserving-state-federal-medicaid-partnership">announced</a> that it does not intend to approve new or extend existing requests for federal funds to match state expenditures on designated state health and designated state investment programs. CMS said its aim is to end Medicaid spending that is duplicative of other federal funding sources or is not directly tied to health care services.  <strong> </strong></p><h3><a class="ck-anchor" id="2020"><span>Analysis finds Marketplace enrollment more than doubled since 2020</span></a> </h3><p>A KFF <a href="https://www.kff.org/policy-watch/enrollment-growth-in-the-aca-marketplaces/">analysis</a> published April 3 found that Health Insurance Marketplace enrollment reached a record high for a fourth consecutive year and has more than doubled since 2020. Marketplace enrollment totaled 24.3 million for 2025, growing by 12.9 million since 2020, a 113% increase. KFF attributed the growth to the enhanced premium tax credits instituted in 2021 that expire at the end of this year. Nearly all states experienced enrollment growth since 2020, and 20 have doubled their enrollment since then.   </p><h3><a class="ck-anchor" id="brief"></a><span>AHA brief urges court to oppose motion by MultiPlan to end antitrust case</span> </h3><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.   </p><p>“[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.”  </p><h2><span>MEDICARE ADVANTAGE NEWS </span></h2><h3><a class="ck-anchor" id="norc"><span>NORC, Coalition report finds MA patients face longer hospital stays, reduced follow-up care access</span></a><span> </span></h3><p>A <a href="https://strengthenhealthcare.org/wp-content/uploads/2025/06/PAC-Analysis-Findings.pdf">report</a> released June 17 by NORC at the University of Chicago, commissioned by the Coalition to Strengthen America’s Healthcare, found that patients enrolled in Medicare Advantage plans are more likely to experience longer hospital stays and experience delays in transfer to post-acute care facilities than those on Traditional Medicare. The report found that MA patients had 40% longer hospital stays, on average, than those with Traditional Medicare.</p><p>The study, which analyzed data from 2018 to 2022, highlights growing concerns about how MA plans may be limiting access to medically necessary post-acute care services through the use of prior authorization.</p><p>The AHA is a founding member of the Coalition. </p><h3><a class="ck-anchor" id="gao"><span>GAO says CMS should target behavioral health services in prior authorization audits</span></a><span> </span></h3><p>The Government Accountability Office May 29 released a <a href="https://www.gao.gov/products/gao-25-107342">report</a> recommending the Centers for Medicare & Medicaid Services target behavioral health services when auditing Medicare Advantage plans’ use of prior authorization. CMS said it currently does not target behavioral health services because they make up a small percentage of MA services, the report said.     </p><p>The report describes selected MA organizations’ prior authorization requirements and use of internal coverage criteria for prior authorization decisions on behavioral health services. It also examines CMS’ oversight of the use of internal coverage criteria, among other issues. GAO said that CMS “would take the recommendation under advisement in the future.” </p><h3><a class="ck-anchor" id="audits"><span>CMS to expand audits of MA plans</span></a><span> </span></h3><p>The Centers for Medicare & Medicaid Services May 21 <a href="https://www.cms.gov/newsroom/press-releases/cms-rolls-out-aggressive-strategy-enhance-and-accelerate-medicare-advantage-audits">announced</a> it will immediately begin annual audits of all Medicare Advantage plans and work to clear a backlog of audits from 2018 through 2024. The audits focus on risk adjustment data validation to confirm to CMS that diagnoses submitted by Medicare Advantage plans for determining risk adjustment payments are supported by medical records. CMS expects to complete the backlog by early 2026. The agency said it will use new technology and increase its team of medical coders from 40 to approximately 2,000 to assist with efforts.</p><h3><a class="ck-anchor" id="annual"><span>CMS leaders share insights on deregulation, MA oversight at AHA Annual Meeting </span></a><span> </span></h3><p>Leaders from the Centers for Medicare & Medicaid Services at the 2025 AHA Annual Membership Meeting May 5 discussed issues on the agency’s agenda in a fireside chat moderated by Ashley Thompson, AHA senior vice president, public policy analysis and development. Stephanie Carlton, CMS deputy administrator and chief of staff, and John Brooks, CMS deputy administrator and chief policy and regulatory officer, discussed regulatory burden and oversight of commercial health insurance plans, among other topics. Read coverage of the discussion <a href="/news/headline/2025-05-05-cms-leaders-share-insights-deregulation-medicare-advantage-oversight">here</a>.  </p><h3><a class="ck-anchor" id="partd"><span>CMS finalizes CY 2026 Medicare Advantage, Part D rates</span></a><span> </span></h3><p>The Centers for Medicare & Medicaid Services April 7 <a href="https://www.cms.gov/newsroom/press-releases/cms-finalizes-2026-payment-policy-updates-medicare-advantage-and-part-d-programs">released</a> finalized payment rates for calendar year 2026 Medicare Advantage and Part D plans. Payments to MA plans are projected to result in an increase of 5.06%, or more than $25 billion. This is an increase of 2.83% since the CY 2026 Advance Notice, which CMS attributes to an increase in the effective growth rate.</p><h3><a class="ck-anchor" id="drug"><span>CMS releases final rule for 2026 Medicare Advantage, prescription drug plans</span></a><span> </span></h3><p>The Centers for Medicare & Medicaid Services April 4 finalized <a href="https://www.federalregister.gov/documents/2025/04/15/2025-06008/medicare-and-medicaid-programs-contract-year-2026-policy-and-technical-changes-to-the-medicare">changes</a> to the Medicare Advantage and prescription drug programs for contract year 2026. The rule finalizes proposed clarifications requiring MA and Part D plans to honor medical necessity decisions rendered as part of a prior authorization process, closes loopholes in MA appeals processes by explicitly defining organizational determinations eligible for appeal, and codifies requirements designed to improve enrollee experience when interacting with dual eligible special needs plans. The administration deferred finalizing several proposals until further rulemaking can occur, including provisions on plan use of proprietary/internal coverage criteria, additional plan directory requirements and behavioral health cost-sharing.</p><p>Additionally, the rule finalizes proposals regarding vaccine and insulin cost-sharing for Part D plans and requires all Part D plans to require network pharmacies to be enrolled in the Medicare Drug Price Negotiation Program’s Medicare Transaction Facilitator Data Module. </p><h2><span>LEGISLATION AND LEGISLATIVE ACTIVITY</span></h2><h3><a class="ck-anchor" id="discuss"><span>AHA discusses how Congress can improve support for post-acute care</span></a><span> </span></h3><p>The AHA March 11 <a href="/testimony/2025-03-11-aha-statement-house-ways-and-means-subcommittee-health-hearing-march-11-2025">shared</a> ways Congress could better support patient access to post-acute care in comments for a <a href="https://waysandmeans.house.gov/event/health-subcommittee-hearing-on-after-the-hospital-ensuring-access-to-quality-post-acute-care/">hearing</a> held by the House Committee on Ways and Means Subcommittee on Health. The AHA urged Congress to rein in harmful practices by Medicare Advantage plans, repeal the minimum staffing rule and support investments in workforce development, among other actions.   </p><p>The association also highlighted the crucial role that each post-acute sector plays across the continuum of care and urged Congress to take steps to address some of the unique regulatory and policy challenges they face. </p><h2><span>STATEMENTS, LETTERS AND ADVISORIES</span></h2><p><strong>Member Advisory</strong>: <a href="/advisory/2025-04-25-updated-medicare-advantage-question-and-complaint-process-provider-organizations">Updated Medicare Advantage Question and Complaint Process for Provider Organizations</a></p><p><strong>Regulatory Advisory</strong>: <a href="/advisory/2025-04-15-cms-issues-rate-announcement-and-final-rule-cy-2026-medicare-advantage-prescription-drug-plans">CMS Issues Rate Announcement and Final Rule for CY 2026 Medicare Advantage, Prescription Drug Plans</a></p><p><strong>Statement: </strong><a href="/press-releases/2025-05-21-aha-statement-house-reconciliation-legislation">The AHA on House Reconciliation Legislation</a></p><p><strong>Letter: </strong><a href="/lettercomment/2025-05-21-aha-senate-letter-supporting-improving-seniors-timely-access-care-act">AHA Senate Letter Supporting Improving Seniors’ Timely Access to Care Act</a></p><p><strong>Letter: </strong> <a href="/lettercomment/2025-05-21-aha-house-letter-supporting-improving-seniors-timely-access-care-act">AHA House Letter Supporting Improving Seniors’ Timely Access to Care Act</a></p><p><strong>Statement:</strong> <a href="/press-releases/2025-06-16-aha-statement-senate-finance-committee-bill"><ins cite="mailto:Kristen%20Page" datetime="2025-06-24T17:49">AHA Statement on Senate Finance Committee Bill</ins></a></p><h2><span>WORTH A LOOK</span></h2><p><a href="https://www.washingtonpost.com/opinions/2025/04/22/medicare-advantage-upcoding-reform-health-care-reform/">Want to reduce ‘waste and fraud?’ Reform Medicare Advantage.</a> The Washington Post, April 2, 2025</p><p><a href="https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2024.01485?mkt_tok=NzEwLVpMTC02NTEAAAGa28dPZSq_MS3-51Ly4GKS3d8f1Pgl0VDPXbT5QFZJpBI8qqBCPDbbdhpelDWi9VxjHYJrdS09l4DXEame2ZXoRIJq-Ftj_u7jXVwV_oAeYXSRkDeX">Medicare Advantage Denies 17 Percent Of Initial Claims; Most Denials Are Reversed, But Provider Payouts Dip 7 Percent</a>. Health Affairs, June 2, 2025</p><p><a href="https://www.modernhealthcare.com/insurance/mh-unitedhealthcare-medicare-advantage-broker-commissions/">UnitedHealthcare nixes many Medicare Advantage commissions</a>, Modern Healthcare, June 2025</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="#prior">HHS announces initiative with insurers to streamline prior authorizations</a></li><li><a href="#squeezed">Report: Hospitals and health systems squeezed by persistent economic challenges</a></li><li><a href="#market">CMS releases final rule on Marketplace Integrity and Affordability</a></li><li><a href="#appeals">CMS requests comments on MA service level data collection for initial determinations, appeals</a></li><li><a href="#notifies">CMS notifies states it will not approve or match funds for designated state health, investment programs</a></li><li><a href="#2020">Analysis finds Marketplace enrollment more than doubled since 2020</a></li><li><a href="#brief">AHA brief urges court to oppose motion by MultiPlan to end antitrust case</a></li><li><a href="#norc">NORC, Coalition report finds MA patients face longer hospital stays, reduced follow-up care access</a></li><li><a href="#gao">GAO says CMS should target behavioral health services in prior authorization audits</a></li><li><a href="#audits">CMS to expand audits of MA plans</a></li><li><a href="#annual">CMS leaders share insights on deregulation, MA oversight at AHA Annual Meeting</a></li><li><a href="#partd">CMS finalizes CY 2026 Medicare Advantage, Part D rates</a></li><li><a href="#drug">CMS releases final rule for 2026 Medicare Advantage, prescription drug plans</a></li><li><a href="#discuss">AHA discusses how Congress can improve support for post-acute care</a></li></ol></div></div> <section class="top-level-view js-view-dom-id-888e857ba469a73d1424247479b4238b68865316f6b6e15478313e922ce8e08b 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-plan-accountability-update/2025-06-25-health-plan-accountability-update-june-2025" hreflang="en">Health Plan Accountability Update - June 2025</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2025-06-25T14:29:59-05:00">Jun 25, 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-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> </div> </section> </div> --><div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/system/files/media/file/2025/06/health-plan-accountability-update-june-2025.pdf" title="Click here to download the June 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> Wed, 25 Jun 2025 14:29:59 -0500 Commercial Insurer Accountability /news/headline/2025-06-23-hhs-announces-initiative-insurers-streamline-prior-authorizations <p>The Department of Health and Human Services June 23 <a href="https://www.hhs.gov/press-room/kennedy-oz-cms-secure-healthcare-industry-pledge-to-fix-prior-authorization-system.html">announced</a> an initiative coordinated with multiple health insurance companies to streamline prior authorization processes for patients covered by Medicare Advantage, Medicaid managed care plans, Health Insurance Marketplace plans and commercial plans. Under the initiative, electronic prior authorization requests would become standardized by 2027. HHS stated that these reforms complement ongoing regulatory efforts by the Centers for Medicare & Medicaid Services to improve prior authorization, including building upon the Interoperability and Prior Authorization final rule. <br> <br>The plan is expected to make the prior authorization process faster, more efficient and more transparent, the agency said. Participating insurers pledged to expand real-time responses by 2027. HHS said that the insurers would also commit to reducing the volume of medical services subject to prior authorization by 2026, including those for common procedures such as colonoscopies and cataract surgeries. <br><br>During a news conference, HHS Secretary Robert F. Kennedy Jr. said unlike previous attempts by insurers, this initiative would succeed because the number of insurers participating represent 257 million Americans. “The other difference is we have standards this time,” he said. “We have ... deliverables. We have specificity on those deliverables, we have metrics, and we have deadlines, and we have oversight.” <br> <br>Mehmet Oz, M.D., CMS administrator, said that the pledge “is an opportunity for industry to show itself.” Sen. Marshall, R-Kan., said that Congress could pursue codifying at least some portions of the initiative in the future. <br><br>Additionally, participating insurers would honor existing prior authorizations during coverage transitions. <br> </p> Mon, 23 Jun 2025 16:31:45 -0500 Commercial Insurer Accountability /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-a15ef68983ea203d65376ac5767a8a13b03e63bd76c0a1f8c1195238dfd518e0 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-plan-accountability-update/2025-06-25-health-plan-accountability-update-june-2025" hreflang="en">Health Plan Accountability Update - June 2025</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2025-06-25T14:29:59-05:00">Jun 25, 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-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> </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-4f079ade60c00306c2a246e65548bd790227fc68a1f10a8fe5fe25411421807b 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-plan-accountability-update/2025-06-25-health-plan-accountability-update-june-2025" hreflang="en">Health Plan Accountability Update - June 2025</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2025-06-25T14:29:59-05:00">Jun 25, 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-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> </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