CareFirst Sues on Star Ratings
The now annual tradition of a Medicare Advantage (MA) plan suing over Star ratings continues. CareFirst BlueCross BlueShield is suing the Centers for Medicare and Medicaid Services (CMS) over its 2026 Star Ratings, alleging improper calculations cost the insurer an estimated $32 million in quality bonus payments.
The plan says CMS departed from its own guidance when it used corrected patient safety data released after the close of the plan preview period to calculate Star Ratings. CareFirst says it received a 3.5-star rating instead of 4 Stars for a contract with about 30,000 enrollees.
CareFirst says its Drug Plan Quality Improvement Measure for the contract was impacted by CMS contractor Acumen updating data after the close of the Plan Preview period. CMS has a hard rule that issues must be raised by plans before or during Plan Preview 1 and CareFirst says that CMS should have to follow the same rules. CMS declined to review the ratings when CareFirst raised the issue.
With some limited exceptions, especially the challenge to guard rail calculations, CMS has won more suits than not. But CareFirst raises a reasonable issue about process and holding the agency to the same rules as plans.
#medicareadvantage #stars #quality #cms
https://www.beckerspayer.com/legal/carefirst-bcbs-sues-over-2026-medicare-advantage-star-ratings/
Senate GOP Pressuring Leaders On Healthcare
Senate Majority Leader John Thune, R-SD, is under pressure from Senate Republicans to bring healthcare legislation to the Senate floor as the midterms approach and affordability dominates headlines. Conservatives want reforms like President Trump has proposed in a second reconciliation bill. At the same time, moderates want a vote on an Exchange subsidy compromise but talks for a bill that could reach 60 votes have stalled.
#exchanges #healthcare #healthcarereform #coverage #affordability
https://thehill.com/homenews/senate/5702369-trump-republican-health-plan
Affordability Does Not Change With VBP
A Health Affairs Forefront blog argues value-based payments (VBP) is not the answer to the ongoing cost crisis in healthcare. VBP is growing and has support, but the authors note that current pilots, including accountable care organizations (ACOs), have poor savings track records. Any slowdown on spending is not correlated to VBO introduction. Technology appears to have led to any slowdown. The authors say that VBP’s metrics may discriminate against primary care investments. The blog says high and misvalued unit prices (in both Medicare and commercial insurance), the diffusion of new technology, and high administrative costs are to blame and VBP does not solve them.
I have argued that while VBP may take some utilization out of the system, it cannot keep up with a broken price system that inflates from year to year no matter what and takes any savings from VBP away. Price reform is key.
(Article may require a subscription.)
#vbp #healthcarereform
KFF Briefers Cover Medicaid
Healthcare policy group KFF has published two new policy briefers on Medicaid. The first covers what to watch for in 2026. States begin implementing mandatory One Big Beautiful Bill Act (OBBBA) changes and grapple with budgetary issues due to less Medicaid funding. Restricting enrollment, benefits, and provider fees will need to be on the table.
The second dives deep on budgets at the state level and the coming Medicaid impacts, including the impacts of revenue raising and program funding due to provider tax limitations.
Additional article: https://www.kff.org/medicaid/medicaid-what-to-watch-in-2026/
#kff #medicaid #healthcare #coverage
https://www.kff.org/medicaid/medicaid-and-upcoming-state-budget-debates/
— Marc S. Ryan
