How New Rules Affect Healthcare Access

Looming #Medicaid changes jeopardizes margin and sustainability for substantially every healthcare organization, either directly or indirectly. Looming MCD cuts will impact seniors and people with disabilities across all 50 states in substantially every #MA contract. Transcending "membership and margin," changes will impact the real members, real providers and real care which are the foundation of #Medicare success. While we await details on spending cuts and regulatory changes, here are 3 key risks to examine in depth now: 1️⃣ #MedicareAdvantage members who lose Medicaid coverage will likely see reduced #accesstocare (i.e. #CAHPS) and increased OOP costs, creating confusion (i.e. #MemberExperience) and gaps in needed services (i.e. #HEDIS and #HOS). Thought most will stay in their current plan during the initial months of lost coverage, many #SNP members will have to switch plans. #StarRatings will be impacted. 2️⃣ Providers will face new financial pressures. Providers who lose MCD revenue will face tough decisions about patient care and staffing. Change to their payor mix will shift profit pressures increasingly MA contracts to fill the gap. MA plans may face more terminations. And the simultaneous loss of indirect cost revenue from research grants will compound disruption in academic medical centers. 3️⃣ Many vendors, particularly those delivering #supplementalbenefits and #SDOH supports, will struggle as #MCD revenue shrinks. Most will have to revise business plans, revisit rates/fees and manage investors’ expectations. MA plans need to assess business continuity risks among their vendors, identifying areas where shuttered vendors may result in failed #CMS #Compliance. What Can You Do Right Now? ✅ Instead of waiting for clarity from Washington before taking the next steps, use the next few months for accelerated preparation. ✅ Identify At-Risk Members who may lose Medicaid coverage. - Create outreach and education plans to guide them through the transition. - Customize support for those you can retain and those who will have to switch. - Tailor 2025 #RiskAdjustment and Stars activities accordingly. ✅ Strengthen Provider Alignment. - Talk with providers and create collaborative contingency plans. - Prepare to amend 2025 and 2026 contract terms, incentives and #VBC criteria as soon as the 2026 #FinalRule and MCD cuts are known. - Ensure adequate staffing in provider-facing and contracting teams to execute quickly. ✅ Scrutinize Your Vendor Network. - Communicate to all vendors the expected impact within your membership. - Request operational response plans from all critical vendors. - Collaborate with key vendors on rapid solutions, focusing on those who can align with Dr. Oz’s vision of sustained engagement using #AI and digital tools. ✅ Act now. Find wasteful, redundant and low-ROI spending that can be repurposed rapidly to protect your members, your providers, and your performance. #WhatGotYouHereWontGetYouThere #LetsRoll ⭐

With the proposed Medicaid budget cuts and new eligibility verification rules, millions of people could lose their Medicaid coverage. Not because they no longer qualify based on income, but because of stricter paperwork requirements and administrative red tape. But here's the key insight: many of these individuals will still be eligible for coverage through the ACA Marketplace. That shift creates a major opportunity for the individual and family health insurance industry. Here’s what I’m paying attention to: People losing Medicaid will qualify for Special Enrollment Periods, and many will receive premium subsidies that make ACA plans highly affordable. In some cases, the coverage may offer broader provider access than Medicaid itself. Carriers can respond with smart plan designs, competitive pricing, and enrollment support tailored to first-time Marketplace users. Brokers, agencies, and digital platforms will play a critical role in guiding these consumers. States like California, Texas, and Florida are likely to see the largest concentration of these transitions. This fall's Open Enrollment Period could be one of the most important we've seen in a long time, not because of an economic downturn, but because of how policy changes are shifting coverage dynamics. #openenrollmentperiod #healthcare #ACAmarketplace #medicaid

The April final rule on #supplementalbenefits in #MedicareAdvantage is a big deal requiring immediate action from #healthplans. The Centers for Medicare & Medicaid Services (#CMS) regulations have 3 major components: evidence, eligibility and member awareness. Beginning with the CY2025 bid process, CMS will deny a plan’s bid if it hasn’t demonstrated that its proposed supplemental benefits for the #chronicallyill (#SSBCI) is reasonably expected to improve or maintain the health or overall function of its chronically ill enrollees. CMS is also implementing annual review of SSBCI offerings for compliance. To comply with the final rule, plans must do the following: ▶️ Establish an evidence-based bibliography of clinical literature for each SSBCI offering, showing it can reasonably improve or maintain the health of chronically ill enrollees. All supporting evidence must be published within 10 years of the coverage year. ▶️ Use written, objective criteria to determine an enrollee’s eligibility for SSBCI, ensuring they meet the definition of “chronically ill enrollee” with complex conditions needing intensive care coordination. MAOs must also document when enrollees are deemed ineligible to ensure equitable access to benefits. ▶️ Include an all-channel disclaimer listing the chronic conditions required for eligibility and clarifying that additional criteria may apply. ▶️ Beginning January 1, 2026, MAOs must send mid-year notifications annually each July to each enrollee with unused supplemental benefits. CMS requires the mid-year notice to support #healthequity and inform enrollees about unused supplemental benefits. These new requirements impose huge new operational challenges for plans under tight deadlines. Get cracking now. Full rule: https://lnkd.in/e8GwBmCq

Healthcare at a Crossroads: Disruptions, Uncertainty, and the Risks Ahead In just a few weeks, sweeping policy changes have disrupted the healthcare landscape, creating uncertainty for providers, patients, and organizations that rely on federal support. These actions don’t just impact budgets—they affect lives. • Removal of Critical Health Information: Vaccine information sheets, public health data, and health equity resources have been stripped from federal websites, making it harder for providers and the public to access evidence-based guidance. • Restrictions on Gender-Affirming Care: A new executive order cuts federal funding for institutions providing medical treatments to transgender minors, despite the overwhelming medical consensus on their necessity. • Disruptions to Global Health Initiatives: Funding pauses for programs like PEPFAR and malaria vaccine research threaten to roll back decades of progress in disease prevention, treatment, and eradication efforts. • Dismantling of Diversity, Equity, and Inclusion Programs: The elimination of DEI initiatives within federal health agencies removes key resources that addressed racial and economic disparities in care access. • Uncertainty in Medicaid and Safety-Net Hospitals: Federal policy shifts and funding concerns have placed added strain on hospitals that serve low-income populations, increasing the risk of service reductions and closures. The result? Confusion, fear, and growing instability in healthcare access and coordination. Patients and providers alike are left wondering what’s next. Will essential programs be restored? Will more restrictions follow? And how do we ensure that healthcare remains focused on patient well-being, not politics? Healthcare policy should be driven by data, compassion, and the needs of those it serves—not by ideology or short-term political goals. Now is the time for healthcare leaders, advocates, and policymakers to demand clarity, stability, and a commitment to protecting public health. Lives depend on it. #HealthcarePolicy #PublicHealth #AccessToCare #HealthEquity #PolicyMatters

The Centers for Medicare & Medicaid Services (#CMS) has just announced a long-awaited final rule that brings crucial reforms to prior authorization processes. This new rule slashes patient care delays and introduces electronic streamlining for physicians to obtain the necessary prior authorization to prescribe the appropriate medications and procedures that patients desperately need. The changes outlined in the rule are expected to result in significant cost savings for physician practices, estimating a whopping $15 billion over the next decade per the Department of Health and Human Services (#HHS). Streamlining the prior authorization process electronically with time limitations on urgent and non-urgent requests will reduce hospital admissions and #readmissions linked to delays in prior authorization requests for critical medications and procedures. By doing so, we're not only saving valuable time but also improving overall outcomes for patients. Imagine a #healthcare system with instant response and transparency on medication prescriptions and procedure requests that will inform the physician-patient decision-making process. #priorauthorization #clinicalinformatics #clinicalexcellence #valuebasedcare #cmsdevelopment #healthinnovation #physicianburnout Link: https://lnkd.in/g9_9qj_3

A new rule from the Centers for Medicare and Medicaid Services strengthens Affordable Care Act coverage by introducing updates to improve access, health equity and consumer protection. The rule sets standards for health insurance brokers, simplifying the process for consumers to understand their costs and enroll in coverage with confidence. Key measures provide: ✅ Support for affordable coverage and additional safeguards for consumer protection 💰 Changes to the medical loss ratio to support models that focus on underserved communities 📊 Incentivization of health equity through ongoing measurement These updates are a big step forward in improving access to quality, affordable care – but there’s still work to do to ensure individuals maintain their coverage. We must continue advocating for resources, education and infrastructure to support these initiatives and ensure changes in coverage are communicated transparently, especially as a record 24 million people selected ACA plans for this latest enrollment period.

Today, the Biden-Harris Administration announced proposed new rules under three departments - U.S. Department of Health and Human Services (HHS), U.S. Department of Labor, and U.S. Department of the Treasury. These rules aim to build on the Affordable Care Act by enhancing coverage for recommended preventive health services. https://lnkd.in/gJYwnkTv A key aspect of these rules is ensuring that medications like pre-exposure prophylaxis (PrEP), a medicine taken to prevent getting HIV, are fully covered without any cost-sharing for patients. The accompanying guidance addresses problems where claims for these preventive services were denied or patients were charged due to coding errors by healthcare providers. The new rules and guidance clarify how health plans and insurers should process these claims, aiming to eliminate coding issues and ensure that no one is wrongly charged for preventive care. Additionally, the proposed new rule would also require coverage for over-the-counter contraceptives without cost sharing or requiring a prescription. These new proposed rules firmly ground our policies in actionable equity, moving beyond rhetoric. This initiative underscores the administration's ongoing commitment to expanding access to healthcare and reducing out-of-pocket costs for essential preventive services. But remember, these rules are only as effective as their implementation and the public's awareness of them. We count on you to help get the word out and turn these policies into practice. https://lnkd.in/g6j4aEFX #ACA #NHAS #HIV #PrEP #Equity

This week, the new administration issued executive orders focusing on the Affordable Care Act, aiming to modify eligibility requirements, reduce federal subsidies, and adjust enrollment deadlines. While these actions stop short of a full repeal—which would necessitate congressional approval—they are poised to introduce new obstacles, potentially diminishing healthcare accessibility for millions of Americans. The document included is from Politico and the outlines proposed spending cuts, including a reduction of over $5 trillion affecting Medicaid, Medicare, and the ACA. These measures would decrease state funding for Medicaid and impose stricter eligibility criteria based on citizenship status. These changes could impact states with large rural populations, where hospitals often serve as primary employers and residents heavily rely on Medicaid. Additionally, the administration plans to let ACA health insurance plan subsidies expire, which could further limit financial access to healthcare coverage. https://lnkd.in/gM63HWkf

Controversial new mental health parity regulations were released yesterday and parties are lining up on all sides to either defend them or to challenge them. Regardless, their release warrants attention on the part of employer fiduciaries trying to manage their CAA duties and managing the needs of their plan members. The bottom line is that post COVID there is HUGE demand for access to appropriate behavioral health and substance abuse resources and there simply isn’t enough supply. In addition, many health plans have created substantial obstacles to members seeking care. DOL regs now put the onus on employers and especially employer fiduciaries to test their plans for mental health/SU parity against physical health benefits and services. Per these detailed regs, health plans and fiduciaries must secure and review their data to assess the adequacy of access and appropriateness of the provider network. Sound familiar? Remember, fiduciaries must do things that are in the best interests of their plan members. Physical and behavioral health are inextricably interdependent and this is an important issue for employers. Certainly those who fail to think about it and address it will see costs borne in different ways including in their occupational risk expenditures. “They require health plans to evaluate how well they’re ensuring accessing to MH/SUD benefits, and make changes if their evaluations show that they’re providing insufficient access to care or making it harder for people to get the care they need by imposing higher copays, visit limitations, or prior authorization requirements on MH/SUD benefits as compared to physical health care benefits.” Regardless one’s position on these regs (and the complexity of them for employers), prudent fiduciaries need to think thoughtfully about the specific needs of their members by securing data and using intuitive analytics to discover the prevalence and acuity of their behavioral/SU needs in their population. They must then do an objective look at the adequacy and appropriateness of the network and resources that are apportioned to those needs. #mentalhealthparity #behavioralhealth #compliance #employers #healthdata #populationhealth #employeebenefits Christine Arnold Steve Schutzer, MD John Rodis, MD Lisa Trumble Chris Deacon Peter Hayes Dave Chase, Health Rosetta-discovering archaeologist Al Lewis 🇺🇦 Robert Capobianco Andrew S. Gordon, LSW Jamie Greenleaf AIF, CBFA, C(k)P Patrick Williams, AIF ® Julie Selesnick Stuart Sutley Michael Thompson Justin Leader Derek Moore Brian Klepper Josh Spivak Dean Jargo Derek Moore Raju Kattumenu Doug Aldeen Scott Haas Alan Gilbert Mike Baldzicki Darren Fogarty 🎙Spencer Smith, CSFS®