Anomaly CEO: UnitedHealth will likely grow again as Medicare Advantage is here to stay
Mike Desjadon, Anomaly CEO, joins 'The Exchange' to discuss Medicare Advantage, care denials, and much more.
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Axios
2 days ago
- Axios
Traditional Medicare to add prior authorizations
Medicare is requiring more pre-treatment approvals in its fee-for-service program in a bid to root out unnecessary care, federal regulators announced Friday. The big picture: Traditional Medicare historically hasn't required prior authorizations to access most drugs or services, a major perk for enrollees. Prior authorization in privately-run Medicare Advantage plans has become a hot-button issue, with Congress and federal regulators working to rein in the practice. Federal inspectors found in 2022 that prior authorization in MA prevented some seniors from getting medically necessary care. Major health insurers this week made a voluntary pledge to streamline and improve the prior authorization process across all health insurance markets. State of play: Medicare's innovation center announced that it will solicit applications from companies to run the prior authorization program. Medicare is looking for companies with experience using AI and other tools to manage pre-approvals for other payers, and with clinicians who can conduct medical reviews to check coverage determinations. The program will start Jan. 1, 2026 and run through the end of 2031. It will only apply to providers and patients in New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington. The change will apply to 17 items and services, including skin substitutes, deep brain stimulation for Parkinson's Disease, impotence treatment and arthroscopy for knee osteoarthritis. CMS selected the services based on previous reports and evidence of fraud, waste and abuse, as well as what's already subject to prior authorization in Medicare Advantage. Overuse of skin substitutes to help heal wounds has especially come under fire in recent years. Medicare spent more than $10 billion on the products in 2024 — more than double what was spent the year before, according to the New York Times. CMS noted that it may make other services subject to the prior authorization program in future years. Providers in the geographic areas can choose whether or not they want to submit an authorization request before delivering a service. But if they decide not to, they'll be subject to post-claim review and risk not getting paid for a service that was already delivered. "In general, this model will require the same information and clinical documentation that is already required to support Medicare FFS payment but earlier in the process, namely, prior to the service being furnished," the notice reads. Zoom in: The companies hired to manage the program will be paid based on how much they saved the government by stopping payments for unnecessary services. "Under the model, we will work to avoid any adverse impact on beneficiaries or providers/suppliers," CMS wrote in the notice.
Health Line
2 days ago
- Health Line
Does Medicare Cover Famotidine?
Famotidine is a generic drug that doctors prescribe to treat conditions related to excess stomach acid production, such as stomach ulcers and gastroesophageal reflux disease (GERD). It's available in over-the-counter (OTC) and prescription strengths, and companies may sell it under the brand names Pepcid AC or Zantac 360. Medicare Part D drug plans generally cover prescription famotidine, though there may be some variation based on the specific plan. Original Medicare doesn't cover OTC famotidine. However, some Medicare Advantage (Part C) plans may include OTC benefits that members can use toward this medication. Part D coverage for famotidine Medicare-approved private insurance companies sell Part D prescription drug plans. If you have Original Medicare, you can buy a stand-alone Part D plan, whereas people with Medicare Advantage plans often have Part D plans in their coverage. Each plan has a formulary. This is a list of medications that the plan covers. Part D plans generally include prescription famotidine in their formularies. However, since specifics vary by insurance carrier, plan, and location, there's no guarantee that all plans include coverage for famotidine. To learn whether your Medicare drug plan includes coverage for famotidine, consult your plan details or a representative. Over-the-counter famotidine and Medicare Many Medicare Advantage plans include coverage for OTC products as part of their additional benefits. If your Medicare Advantage plan includes OTC benefits, you can likely use them to buy famotidine. Generally, with OTC benefits, members can get a benefits card that works like a debit card. The plan adds funds to the card at regular intervals, and you can use it at participating retailers to buy eligible products. The specific retailer and product lists may depend on the plan, but Walgreens, for example, offers various famotidine products in different strengths and quantities through its OTC benefits program. Famotidine cost with Medicare The cost of famotidine may depend on its strength, quantity, form, and whether it's a generic or brand-name product. Formularies place covered drugs into tiers. These tiers typically correspond with a drug's cost, with lower tier drugs often carrying lower copayments or coinsurance. A plan's formulary may cover multiple versions of famotidine. If so, the oral tablet form is likely to be a tier 1 drug, whereas the oral suspension may be a tier 4 drug. However, this may not be the case for all plans that cover famotidine.
CNBC
2 days ago
- CNBC
Tariffs will drive core inflation above 3 percent range, says Point72's Dean Maki
CNBC's Steve Liesman and Point72 Asset Management's Dean Maki, join 'The Exchange' to discuss the Fed's next moves and the economy.
