Caraline Coats

Major Changes Coming For The KC Market 📢 Blue KC to Exit Medicare Advantage Market by 2025 Due to Regulatory Demands 📢 Blue Cross and Blue Shield of Kansas City (Blue KC) has announced its departure from the Medicare Advantage (MA) market by the end of 2024, citing increased regulatory demands and financial pressures as primary reasons for the decision. The company will shift its focus to employer-sponsored health plans, Medicare supplement plans, and Affordable Care Act plans while ensuring uninterrupted, quality service to current MA members through 2024. With a smaller MA membership base, Blue KC finds it challenging to compete economically at scale, leading to the difficult but necessary market exit. In a statement, Blue KC's President and CEO, Erin Stucky, expressed disappointment, saying, “We explored every alternative path for our MA members and are disappointed we must exit this line of business.” This move aligns with industry trends, as other insurers, like Oscar Health, have also exited the MA market due to similar challenges, including the impact of regulatory changes such as the CMS's benchmark payment adjustments on the profitability of MA plans for smaller insurers. #Healthcare #MedicareAdvantage #BlueKC #RegulatoryChallenges #InsuranceIndustry #HealthPlans #CMS #MarketExit

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In 2023 Medicare Advantage was enjoying a long and profitable growth streak, with plans expanding geographically into previously under or unserved areas. With the CMS changes to 'risk adjusting', 2024 became a difficult year. Now in 2025, plans are generally retreating from unprofitable markets, limiting product offerings, and cutting generous benefits for things that Medicare does not cover. It seems that health systems have had enough. As Medicare Advantage plans scrambled to maintain profitability, the administrative burden on providers increased and health systems are saying - enough and exiting participation.

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#CMS will require states and #Medicaid insurers to annually report how carriers spend state-directed payments to #providers, how their rates compare to #Medicare, and survey #ManagedCare enrollees about their experience with insurance companies. CMS also mandated states create “one-stop-shop” websites that allow enrollees to compare the quality ratings of #MedicaidManagedCare plans. Hmm. Medicaid continues to look more and more like #MedicareAdvantage with each new set of federal rules: more ongoing #HealthcareReform on the margins via national rule-making. #HealthcareTransformation #TripleAim #QuadrupleAim #PrimaryCare #SDOH #PopultionHealth #PublicPrivatePartnership #PublicPrivatePartnerships #DSNP #DualEligible #BehavioralHealth #MentalHealth #HealthEquity #FoodisMedicine #HealthcareQuality #HealthcareCosts #HHS

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All attention is on government programs #Medicaid & #Medicare. The big three continue to build out #health services capabilities to balance out the insurance risk. And all three own their own integrated #PBM’s

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Medicare Advantage & Part D Star Ratings Released!   Proud to share that at Press Ganey, we support 100% of all 5-Star plans and 77% of all 4, 4.5, and 5-Star plans.   Here are some of the industry insights from the 2025 Ratings: ➡️ 5-Star MAPD plans dropped from 38 in 2024 to just 7 in 2025. ➡️ 4-Star or higher plans fell from 44% to 40% YoY. ➡️ 62% of members will be in 4-Star+ plans, down from 76% last year. ➡️ Over 5 years, CAHPS has remained steady, but with declines in Getting Needed Care and Prescription Drugs. ➡️ HOS trends have also stayed steady, despite year-to-year fluctuations.   If you’re looking to boost your CAHPS or HOS as part of your Stars strategy, we’re ready to help! Using our healthcare expertise and Book of Business experience data, we can help you identify specific insights and opportunities to tackle your Stars agenda. Be on the lookout for our first member experience trends report later in 2024. 

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Medicare Advantage unrest, Change Healthcare fallout and more big takeaways from insurers’ Q1 https://lnkd.in/eyg48k7e via Healthcare Dive #MedicareAdvantage #ChangeHealthcare #Cybersecurity #CMS #Medicaid

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With a proposed Medicare provider payment rate for 2025 that is below 1994 rates, many online are directing their frustration at Centers for Medicare & Medicaid Services. In reality, much of the challenges with the payment rate are statutory in nature, meaning they are due to laws passed by Congress and out of the control of CMS. Let us hope that Congress recognizes the importance of the Medicare system and realizes that their action is necessary to protect it. Read more here. Thanks to MedPage Today & Genevieve Friedman. https://lnkd.in/gYRrDvVf

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😳Humana faces a significant challenge following the release of preliminary 2025 Medicare Advantage (MA) Star Ratings data from CMS. Only 25% of its MA members are now enrolled in plans rated 4 stars or higher, a steep decline from 94% in 2024. 👉🏻The drop was driven primarily by the performance of contract H5216, which covers nearly half of Humana’s MA members, including over 90% of its Group MA plans, and saw its rating fall from 4.5 to 3.5 stars. 💴This will impact quality bonus payments in 2026. Humana is actively appealing some results and working to improve operating discipline to regain its industry-leading position. 🧘Key initiatives will focus on member engagement, customer experience, and technology enhancements to drive long-term value. Medicare Advantage open enrollment kicks off 10/15 and goes until 12/7. STAR ratings expected to be released to the public around 10/10! 📉Down 22% in premarket! https://lnkd.in/gUTT84tR

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The new health insurance rules for senior citizens are a step in the right direction, aiming to provide better health coverage and make insurance more accessible and affordable for the elderly #2050healthcare #eldercare

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Over 50% of U.S. hospitals are in the red. 📉 Rising costs, reimbursement cuts, and cyberattacks are driving financial challenges across the healthcare industry. What does this mean for patient care? Get the insights here 👇

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Interesting trends in the insurance industry

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Condensed summary of the 1300+ page 2025 #CMS rules for #MedicareAdvantage #HealthPlans issued on April 1. Rules cover the 34 million Americans receiving #healthcare through MA financing. The updated MA #compliance officer bible & more important if incremental #healthcarereform via federal rule-making. #PrimaryCare #HealthcareTransformation #SDoH #HealthcareQuality #HealthEquity #PublicPrivatePartnership #PublicPrivatePartnerships

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The highest increase since 2012 highlights the pressing need for further action to curb increases in medical cost trend. Insurers should prepare for tougher contract negotiations as providers strive to enhance their financial standing and offset stagnant Medicare and Medicaid reimbursement rates.

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Something to consider for #vbc: The average Medicare beneficiary sees two specialists, and 30% of beneficiaries see five or more(!). Managing VBC contracts with multiple providers and overlapping episodes can be complex (think a pregnant woman with diabetes, a diabetic/CHF patient undergoing hip replacement). Some helpful ideas in the blog here (e.g. the importance of provider transparency), but of course, it's all about the specifics of your situation.

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#CMS touts #MedicareAdvantage premium stability, #HealthPlan choice (typically most people have 34 plans to choose from), excellent monitored #provider network adequacy, aggressive #marketing oversight (1000 TV ads rejected) & #PartD copay improvements on a conference call. Expects total 2025 MA enrollment to exceed 35 million. #HealthcareReform #HealthcareTransformation #HealthEquity #PrimaryCare #HealthcareCosts #HealthcareQuality #PatientCenteredCare #PublicPrivatePartnership #PublicPrivatePartnerships

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"CVS Health blamed the declines on higher usage and more costly claims related to its Medicare Advantage policies." More dominos falling... It's simple math Hospital costs keep accelerating Utilization due to sickness keeps increasing Yet rimbursement via government programs is going DOWN! This is business 101 And you don't need a crystal ball to see what's coming... #Healthcare #business #hr #benefits #ceo #insurance #Medicare

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Higher utilization in Medicare Advantage will force payers to further reduce reimbursements to providers through rate cuts, increased denials, downcoding, benefit reductions (more bad debt) and excessive administrative hassles. Now is the time to increase Medicare Advantage reimbursements for 2025! We are working with our clients to issue MA RFP’s to payers to strategically align with 1 or 2 MA plans next year and address declining MA yields. We can help you develop and execute your MA strategy to improve overall reimbursements. Let us show you how! Learn more about how to optimize your Medicare Advantage Contracts👉 https://lnkd.in/gRB3rMw3 #EllsworthConsulting #HealthcareInnovation #ConsultingServices #HealthcareLeadership #PayerNegotiations #HealthcareConsulting #HealthcareManagement #ContractNegotiation #HealthcareContracts #ContractStrategies #ContractSolutions #NegotiationSuccess

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7 Medicare Advantage Strategies for Success in 2025, if you have MA lives, this is a must read. Happy Wednesday! https://lnkd.in/eZ9S_huy

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