Payer: Page 16
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PBM executives decline to revise controversial testimony to House committee
The leaders of Caremark, Optum Rx and Express Scripts had until last week to walk back statements they made in July — or face potential legal action. However, the executives are sticking to their guns.
By Rebecca Pifer • Sept. 12, 2024 -
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Major PBMs could be zeroing in on specific payer markets for dominance, study suggests
Though CVS Caremark holds a dominant share of the commercial, Medicare Part D and Medicaid managed care markets, each large pharmacy benefit manager seems to be focusing on one particular arena.
By Rebecca Pifer • Sept. 11, 2024 -
Explore the Trendline➔
Yujin Kim/Healthcare Dive
TrendlinePayer/provider relationships
As M&A intensifies and companies embrace more holistic and value-based care models, partnerships have become more closely intertwined.
By Healthcare Dive staff -
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Iowa awards Centene Medicaid managed care contract
Iowa Total Care, a subsidiary of the St. Louis-based payer, can continue doing business in Iowa’s managed care program, which paid it $2.8 billion in the last fiscal year.
By Rebecca Pifer • Sept. 10, 2024 -
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Biden administration finalizes rule raising mental health coverage standards for private plans
The rule gives additional teeth to an almost 16-year-old law meant to force health insurers to cover mental health and substance use benefits at the same level as physical healthcare.
By Rebecca Pifer • Sept. 10, 2024 -
Permission granted by Elevance Health
Elevance expands ACA plans in Florida, Texas, Maryland
The insurer’s Wellpoint subsidiary is expanding its ACA footprint for the 2025 coverage year, likely in a bid to capture enrollees who recently lost Medicaid coverage.
By Rebecca Pifer • Sept. 9, 2024 -
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Mississippi awards Medicaid contracts to Centene, Molina, TrueCare
The Magnolia State has finally issued new contracts for its Medicaid managed care program, two years later than intended after UnitedHealth and Elevance challenged the awards following unsuccessful bids.
By Rebecca Pifer • Sept. 5, 2024 -
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Molina puts CFO in charge of Medicaid, ACA marketplace businesses
Chief financial officer Mark Keim is taking the reins of the health insurer’s bread-and-butter business — Medicaid — along with a growing marketplace division.
By Rebecca Pifer • Sept. 4, 2024 -
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Drug distributors agree to $300M settlement for role in opioid epidemic
The settlement adds to the billions of dollars that McKesson, Cencora and Cardinal have already agreed to pay in restitution for flooding the U.S. with highly addictive painkillers.
By Rebecca Pifer • Sept. 4, 2024 -
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PBM executives threatened with fines and jail time for alleged perjury in House hearing
Testimony from the heads of Express Scripts, Optum Rx and Caremark in July defending pharmacy benefit managers’ business practices could be coming back to bite them.
By Rebecca Pifer • Aug. 29, 2024 -
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Surprise BillingMore than one-fifth of insurers failed to pay No Surprises awards last year, provider lobby says
The advocacy group comprised of physician firms like TeamHealth and Envision has issued the provider industry’s latest salvo against insurers over surprise billing.
By Rebecca Pifer • Aug. 28, 2024 -
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Fertility benefits are on the rise: report
More employers now offer fertility benefits, particularly fertility medications and in vitro fertilization, according to a new report.
By Emilie Shumway • Aug. 27, 2024 -
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Semaglutide coverage for weight loss could cost Medicare billions: study
If all newly eligible patients received semaglutide, Medicare Part D spending could increase by $34 billion to $145 billion each year, according to new research.
By Emily Olsen • Aug. 27, 2024 -
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Surprise BillingCMS has received 12K complaints of No Surprises noncompliance; won $1.7M in restitution
The most common complaints against providers were for surprise billing, while the top complaints for health plans included incorrectly calculating qualifying payment amounts.
By Rebecca Pifer • Aug. 22, 2024 -
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Molina extends CEO Joe Zubretsky’s contract through 2027
Zubretsky also received a stock grant that will vest at the end of 2027 if the company meets financial targets. The shares would be worth nearly $51 million based on Molina’s stock price at market close on Tuesday.
By Emily Olsen • Aug. 21, 2024 -
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Large employers forecast 7.8% hike in health costs next year, thanks to rising pharmacy spend
The growing burden of pharmaceuticals is expected to be the primary driver of higher healthcare spending in 2025, mostly due to expensive GLP-1 drugs in demand for weight loss, according to the Business Group on Health.
By Rebecca Pifer • Updated Aug. 21, 2024 -
The image by Renegomezphotography is licensed under CC BY-SA 4.0
Judge strikes down FTC noncompete ban nationwide
Obviating the ban has big implications for U.S. healthcare, an industry that frequently relies on noncompetes to lock medical workers into employment agreements with hospitals, insurers and other employers.
By Ryan Golden , Rebecca Pifer • Aug. 21, 2024 -
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Humana pays $90M to settle whistleblower allegations of Medicare Part D fraud
The insurer, which did not admit wrongdoing, agreed to the deal on the eve of a jury trial.
By Rebecca Pifer • Aug. 20, 2024 -
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Court strikes down HHS change to low-income payment formula in win for Texas hospitals
The case centered on whether patients who receive funds from a pool of state money for uncompensated care could be included in calculating hospitals’ disproportionate share funding.
By Rebecca Pifer • Aug. 19, 2024 -
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Employer healthcare costs projected to rise 9% in 2025: Aon
Inflation, expensive specialty drugs and demand for pricey glucagon-like peptide 1 medications, or GLP-1s, are pushing costs higher, according to the professional services company.
By Emily Olsen • Aug. 19, 2024 -
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Medicare drug price cuts could have limited early impact, but grow with time
Some industry watchers described the level of price discounts announced by Medicare as a "relief," though they warned of bigger future implications for drug research.
By Jonathan Gardner • Aug. 16, 2024 -
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Deep DiveMedicaid overtakes Medicare Advantage as health insurers’ bogeyman in Q2
Despite challenges in Medicaid and MA, major insurers still posted large earnings in the second quarter — many helped by health services divisions.
By Rebecca Pifer • Aug. 15, 2024 -
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Medicare reveals results of drug price negotiations
The agency said the first round of pricing talks, which involved drugs like the blood thinners Eliquis and Xarelto, will result in $6 billion in savings for taxpayers.
By Ned Pagliarulo • Aug. 15, 2024 -
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Medicare Advantage prior authorization denials increased in 2022: KFF
More than 80% of denied requests were overturned when appealed, but few beneficiaries formally questioned the decisions.
By Emily Olsen • Aug. 14, 2024 -
Permission granted by Elevance Health
Elevance, Clayton Dubilier and Rice unveil primary care venture Mosaic Health
New information is emerging about the joint care delivery platform first teased earlier this spring, which is launching without Elevance’s assets.
By Rebecca Pifer • Aug. 14, 2024 -
Rebecca Pifer/Healthcare Dive
CMS finalizes notice on Medicare coverage for breakthrough devices
The CMS will consider five medical device candidates yearly for national coverage through the new pathway, called Transitional Coverage for Emerging Technologies.
By Elise Reuter • Aug. 8, 2024
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