In a new analysis, the Bipartisan Policy Center (BPC) examines the progress of a new provider type in the Medicare payment system that allows certain rural hospitals to avoid closure and continue serving their communities. Since January 2023, 30 hospitals have converted to the model that limits services to emergency and outpatient care.   The report highlights factors preventing facilities from choosing this option despite financial pressures and offers policy recommendations for making the REH a sustainable care delivery option.

Reality has again failed to support the spin surrounding the 340B Drug Pricing Program. For 2023, discounted purchases under the 340B program reached a record $66.3 billion—an astounding $12.6 billion (+23.4%) higher than its 2022 counterpart. The gross-to-net difference between list prices and discounted 340B purchases also grew, to $57.8 billion (+$5.5 billion). 340B purchases are now almost 40% larger than Medicaid’s prescription drug purchases. Hospitals again accounted for 87% of 340B purchases for 2023. Purchases at every 340B covered entity type grew, despite drug prices that grew more slowly than overall inflation. Read the article for full details and our analysis.

Integrating both virtual and in-person appointments can support the delivery of quality care. Discover information and resources on how to use a hybrid care approach. View the Best Practice Guide.

Lawmakers and telemedicine advocates say Pennsylvania’s new law will lead to increased health care access – and healthier Pennsylvanians. Read more.

On October 24, the Pennsylvania Department of Human Services (DHS) published the September 2024 Managed Care Enrollment Information. This report contains the number of consumers that are medical assistance eligible and managed care eligible at any time during the month. The data is based on capitation payments and therefore each consumer Medicaid paid for in the month is counted.

The commonwealth’s health insurance marketplace continues to transform four years after the state took ownership from the federal government. Pennie, which was created to provide the opportunity for individuals and families who don’t have access to employer-sponsored health insurance or government-run coverage like Medicare or Medicaid, has allowed the commonwealth and its health partners to maintain local control and operation of customer service, reinsurance programs and more. Read more.

IBX’s Keystone Health Plan East continued to have Pennsylvania’s highest claim denial rate last year among plans sold on the Obamacare marketplace, the Pennsylvania Insurance Department reported this month. Read more.

With Enhanced Premium Tax Credits set to expire at the end of 2025, customer affordability is a huge focus for consumers. The enhanced premium tax credits were first enacted by the American Rescue Plan in 2021 and then were extended by the Inflation Reduction Act in 2022 but without congressional action, millions could see premiums increase by hundreds of dollars. Beginning November 1, customers will likely see an increase in plan premiums on Pennie.com for the 2025 plan year. While the PA Department of Insurance approved rates, some counties will see increased competition and changes to the second lowest-cost silver plan which is used along with income and family size to calculate a household’s premium tax credit. In this article, Pennie Executive Director, Devon Trolley, speaks on affordability and highlights the potential savings available to customers as nine in 10 people receive financial savings to assist with premiums and lowering the cost of copay and deductibles.

DHS issued MA Bulletin 99-24-08 Pennsylvania’s Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program Periodicity Schedule and Coding Matrix, effective Oct. 29, 2024. This bulletin applies to all providers enrolled in the Medical Assistance (MA) Program who provide EPSDT screens for MA beneficiaries in the fee-for-service and managed care delivery systems. Providers rendering services in the managed care delivery system should address any payment related questions to the appropriate MA managed care organization. This is in response to CMS published highly anticipated guidance on early and periodic screening, diagnostic, and treatment (EPSDT) benefit. Under the EPSDT requirements at Section 1905(a)(4)(B) and (r) of the Social Security Act, children under age 21 are entitled to Medicaid coverage of Section 1905(a) services that are medically necessary to correct or ameliorate physical or mental conditions, even if these services are not covered under the state plan.

CMS updated the Medicare Benefit Policy Manual, Chapter 13 (PDF) with CY 2024 requirements and payment policies for Rural Health Clinics and Federally Qualified Health Centers.

The updated booklets can be found using these links:

·       Information for Rural Health Clinics (PDF) booklet

·       Federally Qualified Health Center (PDF) booklet

·       Instruction to your Medicare Administrative Contractor (PDF)