This week, we are reading updates on the proposed CMS pay model for prescription drugs, as well as Kaiser Family Foundation’s updates on 2019 Medicare Advantage plans and prior authorization requirements in Medicare Advantage plans.

Medicare Advantage 2019 Spotlight:  First Look | Kaiser Family Foundation | October 16, 2018

More than 20 million Medicare beneficiaries (34%) are enrolled in Medicare Advantage plans, which are mainly HMOs and PPOs offered by private insurers as an alternative to the traditional Medicare program. This brief provides an overview of the Medicare Advantage plans that will be available in 2019, based on an analysis of data from the Centers for Medicare and Medicaid Services (CMS).

Read the full review on here.

Prior Authorization in Medicare Advantage Plans:  How Often Is It Used? | Kaiser Family Foundation | October 24, 2018

This year, during the annual Medicare Open Enrollment period, more than 60 million people on Medicare have the opportunity to choose between traditional Medicare and Medicare Advantage plans. In making this decision, they are encouraged to take into account a number of factors, including premiums, cost-sharing, extra benefits, drug coverage, quality of care, and provider networks. A potentially overlooked consideration is access to covered services; specifically, how prior authorization may affect beneficiaries’ access to covered services.


Medicare Advantage plans can require enrollees to get approval from the plan prior to receiving a service, and if approval is not granted, then the plan generally does not cover the cost of the service. Medicare Advantage enrollees can appeal the plan’s decision, but relatively few do so. 

Read the full article on here.

New CMS pay model targets soaring drug prices | Modern Healthcare | October 25, 2018

The Trump administration on Thursday accelerated its efforts to bring prescription drug costs under control, announcing the first mandatory CMS pay model. 


Speaking at the Hubert Humphrey building, President Donald Trump introduced an aggressive proposal from HHS to drive down prescription drug rates paid by Medicare Part B by indexing them to the much lower prices paid by other advanced countries and changing the way physicians are paid for administering those drugs. 


HHS projected that the new proposal would save the government and Medicare beneficiaries more than $17.2 billion over five years. 

Read the update on here.