Parts of No Surprises QPA Rule Struck
A federal appeals court has ruled that the government’s methodology for calculating the qualifying payment amount (QPA) within the No Surprises Act’s arbitration process is partly unlawful. This could lead insurers to have to recalculate such future offers at higher rates. The court found that inclusion of so-called “ghost rates” in the calculation and excluding bonus and incentive payments did not meet the law.
The law heavily favors providers already. The move could mean higher benchmark payments in general over time. But it could also move the last best offers of plans up in the arbitration process. Would that sway some arbitrators to award to plans? So far, the awards are 85% in favor of plans and at payment amounts that are well higher than before the law went into effect. It is driving higher prices overall.
Additional articles: https://www.beckershospitalreview.com/legal-regulatory-issues/5th-circuit-strikes-down-parts-of-no-surprises-qpa-rule-rejects-air-ambulance-challenge/ and https://www.beckerspayer.com/policy-updates/the-never-ending-no-surprises-saga/
(Some articles may require a subscription.)
#nosurprisesact #providers #healthplans #transparency
https://www.modernhealthcare.com/legal/mh-no-surprises-act-payment-appeals-court
Health Plan Financials
More coverage on the recent Q2 financials, indicating the strong performance of most national players and continued challenges at other plans. The article signals some of the challenges ahead. I covered this last week at the blog tab: https://www.healthcarelabyrinth.com/are-insurers-turning-the-financial-corner-yes-but-there-is-more-work-to-be-done/
(Article may require a subscription.)
#healthplans #margins
https://www.modernhealthcare.com/insurance/mh-unitedhealthcare-cvs-humana-outlook
Biggest PBMs Losing Some Market Share
A new survey finds that the percentage of employers contracted with the three largest pharmacy benefit managers (PBMs) fell to 54.3% in 2026, down from 64.4% in 2025. Employers made changes due to higher-than-average costs and transparency arrangements with smaller PBMs that offered better protections. More than half of respondents working with one of the three largest PBMs are considering a change in the next three years.
Additional article: https://www.modernhealthcare.com/insurance/mh-pbm-optum-rx-cvs-caremark-express-scripts/
(Some articles may require a subscription.)
#pbms #drugpricing
https://www.beckerspayer.com/research-analysis/56-of-employers-using-big-3-pbms-consider-switch
Brookings Slams CMS’ Assumptions On Work Requirements
Brookings Institution health researchers are questioning assumptions made by the Trump administration in its new Medicaid work requirements rule. For example, one assumption is that 29% of affected beneficiaries will move into qualifying activities when work requirements hit.
Brookings policy expert Sherry Glied says that CMS made “complete random assumptions. They didn’t provide any — zero — justification for their assumptions.” Brookings’ Richard Frank added that: “If you’ve been around health economics for a while and read that literature, it was just totally clear that these guys were way off the reservation.”
The 29% assumption is more than six times larger than the largest estimate in any line of research the CMS could have used to estimate work requirements’ impact, they said.
#medicaid #workrequirements
ICHRAs Growing
While still a tiny part of overall coverage, the number of people covered by individual coverage health reimbursement arrangements (ICHRAs) doubled year over year and now have 500,000 enrollees, driven largely by a surge in adoption among larger employers. The data come from the HRA Council’s fifth annual report.
Gold plans represented the most popular metal tier selection on average across the 2023 to 2025 period, just ahead of Silver. About 81% of ICHRA employees elect to spend more than their employer’s allowance for better coverage. More than two-thirds of small businesses offering ICHRAs this year previously offered no health benefits.
In other news, Exchange plan Oscar Health expects between 250,000 and 300,000 of its members to be retroactively disenrolled in connection with program integrity initiatives. The Trump administration says millions are illegally enrolled. The expected disenrollments represent between 8% and 10% of Oscar’s total membership. Oscar believes that some of the members are wrongly classified as improper enrollments by the administration. See my blog on the subject today here: https://www.healthcarelabyrinth.com/the-exchange-enrollment-debate-the-truth-is-somewhere-in-the-middle/
Additional article: https://www.beckerspayer.com/payer/ichra/ichra-market-doubles-to-500000-enrollees-report/ and https://www.beckerspayer.com/payer/aca/oscar-flags-up-to-300k-aca-disenrollments-tied-to-cms-fraud-crackdown/
#ichras #healthcare #coverage
KFF Updates MA Stars Spending
Healthcare policy group KFF finds that federal spending related to the Medicare Advantage (MA) quality bonus program will reach at least $13.4 billion in 2026, up from $12.7 billion in 2025, and more than four times higher than in 2015.
KFF estimates that Star payments will be about $600 million higher in 2027 than they would have been if the Centers for Medicare and Medicaid Services (CMS) had not recalculated the Star ratings recently, with additional spending on higher rebate percentages outside of the quality bonus.
#stars #medicareadvantage #quality #cms
— Marc S. Ryan
