Payer Notebook: AHIP takes issue with proposed rule on coverage for FDA-approved breakthrough devices

America's Health Insurance Plans this week submitted comments to a Centers for Medicare and Medicaid Services' proposed rule on Medicare Coverage of Innovative Technology and Definition of "reasonable and necessary." The proposed rule would establish a new Medicare coverage pathway for Food and Drug Administration-approved breakthrough devices under which national Medicare coverage for both traditional fee-for-service Medicare and Medicare Advantage would begin on the same day as a breakthrough device receives FDA approval, and would last up to four years. 

This approach could put seniors, people with disabilities and the solvency of the Medicare Trust Fund at risk, AHIP said. Currently, when a medical device is approved by the FDA, it must be further evaluated by a plan's medical policy committee to assess clinical efficacy and safety for this population. The proposed pathway entails a less rigorous evidence-based process that could result in premature coverage of unproven devices for the Medicare population, with no requirement for device manufacturers to conduct additional clinical studies focused on the Medicare population during the coverage period. 

AHIP is also concerned about the potential for unintended consequences of a part of the rule that proposes to codify a modification of Medicare's definition of "reasonable and necessary" to allow for commercial coverage of an item or service to serve as evidence of appropriateness for the "reasonable and necessary" assessment. 

UnitedHealth Group is launching a program for living organ donors. It will provide $12,000 of financial support for each living donor who provides organs to one of its employees. UHG said it is eager to share its financial and legal model for providing this benefit to other employers.

The program has a deeply human genesis, the company said: An employee of Optum, which is part of UnitedHealth Group, faced her own need for an organ when her brother volunteered to be her living donor. UnitedHealth Group wanted to help with the financial hardship experienced by living donors, often in lost wages, in undertaking transplant surgery to support individuals in need.

Priority Health in Michigan has announced the launch of their new MyPriority Telehealth PCP plans that will go into effect on January 1, 2021. The new plans are designed for consumers who are seeking health coverage that is virtual-first. Members who choose one of the MyPriority Telehealth PCP plans will have a doctor assigned as their primary care physician through Doctor on Demand and all visits will take place virtually. The member will need a referral from their doctor to seek care in a traditional office setting with a specialist, as needed. Emergency care does not have this same restriction.

Zipari, a consumer experience platform built for the health insurance industry, has announced the additions of Scott Morris as senior vice president, chief information security officer and Michael Grimaldi as senior vice president of Technology Shared Services. They both join from BlueCross BlueShield of Western New York. Morris will be directing Zipari's information and cybersecurity program, and Grimaldi will lead technology services throughout the company, which include architecture, core engineering and quality assurance. The two are joining shortly after John Walsh, chief technology officer, and signifies a time of growth for the company, Zipari said. 

The nonprofit Blue Shield of California has announced it is providing more than $50 million in premium credits for its customers facing economic hardship caused by the COVID-19 pandemic. Blue Shield is applying a one-time premium credit to bills issued for the month of November or December for its fully-insured employer customers. Premium credits will also be applied to November bills for people enrolled in Blue Shield dental and/or vision plans, plus those enrolled in Blue Shield's Medicare Supplement plans.

Anthem Blue Cross is introducing Blue Connection, a new health plan option offering digital tools and a concierge experience. Services include a user-friendly interface to help select a primary care physician, online appointment scheduling for office visits, and digital and telephonic follow-up care with specialists. Offered as an Exclusive Provider Organization, Blue Connection includes direct access to more than 3,500 doctors and healthcare professionals across the Bay Area, including more than 2,500 behavioral health providers. 

For employers, Blue Connection offers up to 25% savings compared to Anthem's standard PPO, along with integrated pharmacy benefits through IngenioRx and access to Sydney Health, Anthem's new artificial intelligence personal health assistant app.

The Blue Cross Blue Shield Association has announced that its board of directors has named Kim A. Keck as BCBSA's new president and chief executive officer, and a member of the board of directors, effective Jan. 4, 2021. Keck is currently president and chief executive officer of Blue Cross & Blue Shield of Rhode Island. She is the first woman to serve as the association's president and CEO since the organization's founding four decades ago. Keck will take BCBSA's reins from Scott Serota, who is retiring from BCBSA after more than two decades as president and CEO.

Health Partners Plans has announced the expansion of its work to address the social determinants of health. New efforts include the launch of its PartnerUp HealthCompass program and its work with Pennsylvania stakeholders to convene healthcare and community leaders for an SDOH Regional Council in Pennsylvania. PartnerUp HealthCompass brings together all of Health Partners Plans' SDOH initiatives and resources under one program.

New efforts include: a program that engages community-based health workers to provide members with face-to-face assistance to food resources in communities; partnering with the Community Learning Center to offer GED courses, exams, financial literacy and career development workshops; and launching a literacy initiative designed to help improve health literacy and empower members around education, which kicked off during the pandemic and has donated more than 8,000 books to children who lack access to them. 
 
Twitter: @SusanJMorse
Email the writer: susan.morse@himssmedia.com