CHA News – Holding Insurers Accountable

What’s happening: A Los Angeles Superior Court Judge has ruled on CHA’s lawsuit against Anthem Blue Cross, finding that it is the responsibility of health plans to arrange for and transition to post-acute care services for their members. 

What else to know: Despite finding in favor of CHA on key points, the judge nonetheless decided to “abstain” from further involvement in the case. 

A little more than two weeks ago, the deadline passed for California lawmakers to introduce bills for this year’s legislative session. In all, some 2,350 bills are in play this year — a number in line with historical trends.  

What’s happening: In December, CHA’s board approved three advocacy priorities for California hospitals in 2025: Insurer Accountability, Office of Health Care Affordability (OHCA), and Securing Hospitals. New and updated advocacy materials on these priority issues are now available on CHA’s website.  

What’s happening: A Los Angeles Superior Court judge has delayed the Jan. 27 court hearing on two motions by Anthem Blue Cross — to dismiss CHA’s lawsuit and strike requested remedies — to Feb. 14. In the lawsuit, CHA claims Anthem failed to provide timely post-hospital care for its members.  

What else to know: CHA has filed opposition to each of the motions, disputing both Anthem’s legal arguments and its characterization of the facts. The judge’s decision could come as soon as the hearing, but no later than May 14. The judge gave no reason for delaying the hearing. 

What’s happening: CHA submitted comments in response to the Centers for Medicare & Medicaid Services’ (CMS) proposed policy and technical changes to Medicare Advantage (MA) and Part D programs for contract year 2026.   

What else to know: Finalization of the proposed rule is expected in April — in time for MA plans to bid to CMS and offer MA products for plan year 2026. The rule, once finalized, will take effect Jan. 1, 2026.  

What’s happening: A Los Angeles Superior Court judge will hear two motions by Anthem Blue Cross on Jan. 27 to dismiss CHA’s lawsuit and strike requested remedies. In the lawsuit, CHA claims Anthem failed to provide timely post-hospital care for its members.  

What else to know: CHA has filed opposition to each of the motions, disputing both Anthem’s legal arguments and its characterization of the facts. The judge’s decision could come as soon as the hearing, but no later than April 28.  

What’s happening: With additional information available on the Blue Cross Blue Shield (BCBS) antitrust claims settlement process, hospitals will benefit from reviewing the recent BCBS antitrust settlement agreement’s potential impact with their legal counsel, including whether to remain in or opt out of the settlement.  

What else to know: BCBS plans (referred to as Blue Plans) have agreed to a $2.8 billion settlement to resolve legal allegations from a slew of providers who claim the insurers colluded to prevent competition and lower reimbursements. The settlement will bring a decade-long legal battle to a close, should it secure final approval.  

What’s happening: The Centers for Medicare & Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure has responded to a congressional letter, signed by several members of the California delegation, that urged CMS to take steps that will ensure Medicare Advantage (MA) plan beneficiaries have access to medically necessary inpatient rehabilitation facility (IRF) care.  

What else to know: In the letter, Ms. Brooks-LaSure notes several recent rules issued by CMS that seek to ensure that MA plans adhere to CMS requirements, including network adequacy, prior authorization, and data collection. Ms. Brooks-LaSure also agrees to take the writers’ comments into consideration for future policy development.   

What’s happening: On. Dec. 16, the California Department of Managed Health Care (DMHC) announced that it fined Blue Cross of California (Anthem Blue Cross) $3.5 million for mishandling member grievances and not responding on time.  

What else to know: Anthem Blue Cross has paid the $3.5 million fine and acknowledged its failure to follow law, which states that “health plans must resolve a standard grievance within 30 days and send a written resolution to the member.”  

What’s happening: Beginning Feb. 14, 2025, the Centers for Medicare and Medicaid Services (CMS) will require giving “Observation Change of Status Notices” to patients who are reclassified from inpatient to observation (outpatient) status.  

What else to know: CMS has issued updated information on these new requirements for communication to affected patients. Hospitals will be required to provide a Medicare Change of Status Notice (MCSN) to eligible Medicare patients who are reclassified from inpatient to outpatient receiving observation services.

What’s happening: The California Department of Managed Health Care (DMHC) has fined Blue Cross of California (Anthem Blue Cross) $500,000 after a health plan member was forced to file 17 grievances in order to obtain coverage for cancer care, including chemotherapy.  

What else to know: Anthem Blue Cross has acknowledged its failure to respond to the member’s grievances and agreed to pay the fines, repay providers, and take corrective action involving the grievance process.   

What’s happening: The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule for contract year 2026 that would increase oversight of Medicare Advantage (MA) plans.  

What else to know: The rule includes additional proposed changes to the prior authorization process and guardrails for artificial intelligence use.  

What’s happening: CHA issued an alert asking members to urge their congressional representatives to support hospital priority issues in year-end legislation. 

What else to know: Outreach is needed by Dec. 20 when Congress will wrap up the session.  

What’s happening: In a Nov. 18 letter to the California congressional delegation, CHA outlined legislative priorities for the remainder of the 118^th Congress — which must act by Dec. 20 to fund the federal government.  

What else to know: It is likely that some health care extensions and policies could be a part of Congress’ funding package. 

What’s happening: In a Nov. 12 letter to the Centers for Medicare & Medicaid Services (CMS), CHA conveyed its strong support for proposed implementation of additional data collection and audit procedures for Medicare Advantage (MA) plans’ utilization management policies and tools — and shared additional comments.  

What else to know: CHA has consistently advocated for greater oversight of MA plans by CMS to ensure beneficiary access to medically necessary services. 

What’s happening: The U.S. Senate Permanent Subcommittee on Investigations (PSI) released a report revealing that the three largest Medicare Advantage (MA) plans intentionally target costly stays in post-acute care facilities to increase profits.  

What else to know: These MA plans denied prior authorization (PA) requests for post-acute care requests at far higher rates than they did for other types of care, resulting in diminished access to post-acute care for MA beneficiaries and an increase in the number of post-acute care services subject to PA. The PSI’s investigation also provided insight into automation and predictive technologies in the PA process.  

What’s happening: Several California representatives joined fellow members of Congress in urging the Centers for Medicare & Medicaid Services (CMS) to take steps that will ensure Medicare Advantage (MA) plan beneficiaries have access to medically necessary inpatient rehabilitation facility (IRF) care.    

What else to know: In the letter, the authors observe that, by statute, MA must cover all services included under traditional Medicare, including inpatient rehabilitation — an essential service for many beneficiaries when recovering from a major medical event.  

What’s happening: On Oct. 8, California Department of Managed Health Care (DMHC) and Department of Health Care Services (DHCS) officials announced they have reached settlement agreements with the largest Medi-Cal plan in the state. 

What else to know: The two agreements with the Local Initiative Health Authority for Los Angeles County (L.A. Care Health Plan) — a $35 million settlement with the DMHC and a $20 million settlement with the DHCS — require that L.A. Care Health Plan improve its operations to ensure timely access to medically necessary health care services for all plan members, among other actions.  

What’s happening: The Department of Health Care Services (DHCS) has issued a new technical assistance resource to support Medi-Cal managed care plans (MCPs) and others in implementing transitional care services (TCS) for Medi-Cal members who need long-term services and supports (LTSS) needs.  

What else to know: Under the CalAIM population health management program, MCPs are responsible for delivering TCS to enrollees before, during, and after their transition from one care setting to another.  

What’s happening: As previously reported, the Centers for Medicare & Medicaid Services (CMS) has developed a process that allows providers to submit questions and complaints related to Medicare Advantage (MA) plan appeals or claims payment issues. 

What else to know: The form serves as a mechanism for Medicare providers seeking CMS assistance to resolve specific MA claims issues; CMS will enter complete complaint forms into the complaints tracking module and direct the MA to investigate the case.   

What’s happening: The Centers for Medicare & Medicaid Services (CMS) has issued detailed information about data collection and audit procedures for Medicare Advantage (MA) (Part C) plans. 

What else to know: The information will allow CMS to conduct a comprehensive review of plan compliance with utilization management requirements, including new requirements on development, appropriateness, and public accessibility of internal coverage criteria.   

What’s happening: CHA has issued a members-only summary of the Mental Health Parity Final Rule that aims to improve access to mental health services by requiring health plans to make changes when inadequate access is provided.    

What else to know: The regulations are effective Nov. 22.  

What’s happening: The California Department of Managed Health Care (DMHC) has taken enforcement actions, including a total of $8.5 million in fines, against Blue Cross of California Partnership Plan and Anthem Blue Cross for their failure to address payment disputes with health care providers in a timely manner.  

What else to know: In addition to paying the fines, the plans must improve response times by removing barriers that create delays, monitoring provider disputes more regularly, and adding staff to handle provider disputes. Per two letters of agreement, Blue Cross is expected to complete the corrective actions before Dec. 31.      

What’s happening: Hyve Health, the creator of the CHA-endorsed Vitality Index Payer Scorecard, has entered into a national partnership on payer accountability with the Healthcare Financial Management Association.   

What else to know: CHA continues to encourage members to enroll in the scorecard tool, which will provide critical information to support CHA’s advocacy to hold insurers accountable for timely and accurate reimbursement.   

What’s happening: CHA continues to await a response to the lawsuit filed against Anthem Blue Cross on April 23.    

What else to know: In the interim, CHA continues to collect information to support its position that many managed care plans, including Anthem Blue Cross, are violating certain provisions of the Knox-Keene Act.   

What’s happening: Statewide and national media coverage of the CHA lawsuit against Anthem Blue Cross includes print articles, news videos, and mentions on local radio stations. 

What else to know: CHA filed the lawsuit on April 23 against Anthem Blue Cross, one of California’s largest health insurance companies.  

This week, all four of CHA’s state advocacy priorities converged in Sacramento, with significant developments on each. Sharing a brief recap of this week’s activities and next steps. 

What’s happening: CHA is endorsing member participation in the Vitality Index Payer Scorecard, which will provide critical information to support CHA’s advocacy to hold insurers accountable for timely and accurate reimbursement.  

What else to know: The CHA Board of Trustees has endorsed this tool, which will automatically draw de-identified claims and remittance information from hospitals without requiring additional reporting or surveys.