Medicare To Test Prior Authorizations In 6 States As Part Of A Pilot Program

The New York Times: Medicare Will Require Prior Approval For Certain Procedures
Private insurers often require a cumbersome review process that frequently results in the denial or delay of essential treatments that are readily covered by traditional Medicare. ... The Centers for Medicare and Medicaid Services plans to begin a pilot program that would involve a similar review process for traditional Medicare, the federal insurance program for people 65 and older as well as for many younger people with disabilities. The pilot would start in six states next year, including Oklahoma, where Ms. Ayres lives. (Abelson and Rosenbluth, 8/28)

WVTM13: Medicare Program To Use AI For Pre-Approval Of Medical Procedures
But the most controversial part of the program is how the government will make decisions on what is and isn't covered. The program contracts private AI firms to review cases, which, experts say, could lead to inappropriate denials. The AI firms have an incentive to say "no" to coverage because of the direct payments they make for each denial. Health experts worry it could lead to many patients being denied services they are legally entitled to. (Lu, 8/29)

In related news about prior authorization —

Modern Healthcare: Unpacking CMS' Prior Authorization Rule On Interoperability
Payers and providers are on the clock to comply with federal interoperability rules designed to streamline prior authorization. In June 2024, the Centers for Medicare and Medicaid Services finalized a regulation that set prior authorization transparency requirements and sped up mandatory reporting timelines for government-sponsored health plans. The rule kicks in on Jan. 1, with additional deadlines in January 2027, when the industry will need to stand up infrastructure that facilitates seamless data exchange between payers, providers and patients. (Early, 8/29)

On health care coverage in Maryland, North Carolina, Missouri, and elsewhere —

Maryland Matters: Maryland Market Threatens To Push More Medicare Advantage Plans Out Of The State 
Tens of thousands of retirees could learn that their current health care plan will no longer be available in Maryland this fall, as major insurance providers consider ending their Medicare Advantage plans for next year. About 25% of Maryland Medicare recipients use a supplemental Medicare care program that helps low-income retirees use a private insurer for health coverage that often provides additional services such as vision, dental and transportation assistance. (Brown, 9/1)

The Charlotte Ledger: Doctors On Demand, No Insurance Required 
When city of Charlotte workers get sick, they don’t have to wait weeks for a primary care appointment or shell out a co-pay for an urgent care visit. Instead, they can often be seen on the same day, at no charge, at one of six local clinics run by Marathon Health. (Crouch, 9/2)

KFF Health News: When Hospitals And Insurers Fight, Patients Get Caught In The Middle
Amy Frank said it took 17 hours on the phone over nearly three weeks, bouncing between her insurer and her local hospital system, to make sure her plan would cover her husband’s post-surgery care. Many of her calls never got past the hold music. When they did, the hospital told her to call her insurer. The insurer told her to have the hospital fax a form to a special number. The hospital responded that they’d been instructed to send faxes to a different number. “It was just a big loophole we were caught in, going around and around,” Frank said. (Sable-Smith, 9/2)

On funding cuts in Kentucky, Vermont, and Connecticut —

The Washington Post: Medicaid Cuts Threaten Rural Hospitals — And Access To Maternity Care
Jacalyn Stuff was nearing the end of her first trimester when doctors at UK St. Claire Regional Medical Center delivered shattering news: her twins were in danger. Then came a second blow: Those doctors — the ones she had come to know and trust, the ones less than 10 minutes from her home — could no longer treat her. During the following 10 weeks, Jacalyn — then 19 — had to travel repeatedly to hospitals able to provide more advanced maternity care. Appointments at the one 70 miles away in Lexington required $30 for a tank of gas. Appointments at the one 100 miles away in Cincinnati required gas and a hotel stay. And they all required Jacalyn either to bring her infant son or to find a babysitter. (Abutaleb, 9/1)

AP: ‘We Had No Choice’: Holland Food Shelf To Shut Down Amid Federal Funding Losses
The Holland Food Shelf announced Tuesday it would close its doors the last week of September, citing the loss of federal nutrition assistance funds and high rent costs as major factors in the decision. “We can’t do it without funding,” said Don Stevens, executive director of the pantry’s nonprofit operator, Abenaki Helping Abenaki, and chief of the Nulhegan band of the Coosuk Abenaki Nation. “It’s not just us, right?” he added, referencing Vermont Foodbank’s recent cuts in addition to other struggles in the state’s food assistance network. (Wells-Spackman, 8/29)

The CT Mirror: What Worries CT Hospital Leaders About Trump's Big Beautiful Bill
Connecticut’s health care leaders and state officials have been warning for months about the potentially devastating impacts of President Donald J. Trump’s One Big Beautiful Bill Act on access to care for millions of Americans. Nearly two months after the law’s passage, hospital executives here say there are critical details still unknown that make it difficult to determine exactly how it will impact providers and patients. (Golvala, 9/2)

On Social Security and aging —

KFF Health News: Social Security Praises Its New Chatbot. Ex-Officials Say It Was Tested But Shelved Under Biden
John McGing couldn’t reach a human. That might be business-as-usual in this economy, but it wasn’t business; he had called the Social Security Administration, where the questions often aren’t generic and the callers tend to be older, disabled, or otherwise vulnerable Americans. McGing, calling on behalf of his son, had an in-the-weeds question: how to prevent overpayments that the federal government might later claw back. His call was intercepted by an artificial intelligence-powered chatbot. (Tahir, 9/2)

The Wall Street Journal: More Older Americans Are Aging Alone. Who Will Take Care Of Them?
Duane Johnson starts his route about 8 a.m., driving through mountain roads, some gravel and single-lane, bringing frozen meals to aging farmers, coal miners, veterans and teachers who are homebound. Most live alone. One woman in her 80s told him he was the first human she had seen in two weeks. “I become friends with most of them,” he says. Johnson works for Mountain Empire Older Citizens, a nonprofit organization that began 51 years ago with three people who organized a meal-delivery program in the Appalachian Mountains of southwest Virginia. Its mission then, as now, was to help older adults live independently. (Ansberry, 9/1)