Jefferson Health Plans Urges CMS for Clarity on Medicare Advantage Changes

Carter Struck

TARGETED NEWS SERVICE (founded 2004) features non-partisan 'edited journalism' news briefs and information for news organizations, public policy groups and individuals; as well as 'gathered' public policy information, including news releases, reports, speeches. For more information contact MYRON STRUCK, editor, editor@targetednews.com, Springfield, Virginia; 703/304-1897; https://targetednews.com

WASHINGTON, Feb. 26 -- Jefferson Health Plans (JHP) submitted a public comment letter to the U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services regarding the proposed changes to the Medicare Advantage Plan Benefit Package and Formulary for calendar year 2027. In the letter, JHP emphasized the necessity for clear guidance on several aspects of the proposed changes to facilitate effective implementation for healthcare providers and members alike.

JHP, a subsidiary of Thomas Jefferson University, operates a comprehensive health coverage system across Pennsylvania and New Jersey, providing Medicare Advantage, Medicaid, and Children's Health Insurance Program plans. The organization is recognized for its commitment to quality care and innovations in managed care, driven by a goal of enhancing community health through integrated service delivery.

The letter articulated JHP's strong support for the Centers for Medicare & Medicaid Services' (CMS) objectives aimed at improving transparency and understanding of utilization management criteria. However, the organization raised concerns regarding the clarity of certain proposed requirements, particularly surrounding the Prior Authorization (PA) and Step Therapy (ST) file layout specifications. JHP is seeking clarification on several critical factors to ensure that the changes do not inadvertently complicate the provision of care.

Among the issues highlighted, JHP requested confirmation on whether the term "same RxNorm ingredient" refers to ingredient-level grouping rather than specific biosimilars, which could prevent unnecessary duplication of PA groups. The organization also called for clarity regarding the discontinuation of therapeutic-category PA groupings, which might have substantial operational implications.

Additionally, the letter noted the lack of a defined standard for "indication code" requirements, emphasizing the potential for inconsistencies in submissions due to the absence of a standardized code system. JHP called on CMS to adopt a single, authoritative reference file that would streamline the process for healthcare providers and ensure data accuracy across the board.

JHP also expressed concerns regarding the operational burdens of requiring separate PA records for each indication due to many biologics having multiple FDA-approved uses, urging CMS to allow a single PA record to encompass multiple indications to reduce redundancy and complexity.

In conclusion, JHP respectfully requested that CMS consider these recommendations to ease operational burdens and enhance data quality, compatibility, and the overall member experience in the Medicare Advantage program. The organization remains committed to collaborating with CMS to ensure the delivery of high-quality, equitable care to all members.

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The letter was signed by:

Krista Hoglund, ASA, MAAA, MBA

EVP, President

Jefferson Health Plans, Philadelphia, Pennsylvania

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Read full text of letter here: https://www.regulations.gov/comment/CMS-2025-1857-0014

TARGETED NEWS SERVICE (founded 2004) features non-partisan 'edited journalism' news briefs and information for news organizations, public policy groups and individuals; as well as 'gathered' public policy information, including news releases, reports, speeches. For more information contact MYRON STRUCK, editor, editor@targetednews.com, Springfield, Virginia; 703/304-1897; https://targetednews.com