Another Model Deadline Extended
The Centers for Medicare & Medicaid Services (CMS) is extending the application deadline for drug manufacturers to apply to the GENErating cost Reductions fOr U.S. Medicaid (GENEROUS) Model. The deadline was extended by the agency to June 11 from April 30. CMS says the reason was due to overwhelming interest from prescription drug manufacturers. However, it cites that more time will help small to mid-sized firms to join. Participation agreement deadlines will be extended from June 30 to July 17. CMS is also extending the deadline for states to apply to the GENEROUS model from July 31 to September 10 and to finalize participation agreements from August 31 to September 30.
The program intends to have the federal government negotiate with drug makers to obtain a most-favored-nation (MFN) price. MFN drug pricing is also being set up in Medicare under the GLOBE and GUARD models.
Read my blog Monday on potholes at CMS with reform models: https://www.healthcarelabyrinth.com/cms-reform-models-hitting-some-potholes/
#drugpricing #trump #mfn
Business And Consumers Speak Out On Healthcare Costs
A new Mercer survey finds that a third of chief financial officers now view increased health benefit costs as a “top three” concern relative to other expenses. Mercer found that only one in four CFOs said they were able to absorb benefit cost increases without business impacts over the past two years. Respondents said the following occurred:
- Reduced spending on other benefits: 38%
- Slower wage growth: 36%
- Increased prices for products and services: 26%
- Layoffs and reduced hiring: 22%
- Reduced investment: 19%
As well, the latest healthcare policy group KFF tracking poll finds that 64% of adults are worried about being able to afford their healthcare. About three in 10 of those surveyed said they were “very worried” about the affordability of care.
Additional articles: https://www.fiercehealthcare.com/finance/only-1-4-healthcare-orgs-able-absorb-increasing-health-benefit-costs-without-impacting and https://www.kff.org/public-opinion/kff-health-tracking-poll-health-care-costs-and-the-midterms/
#healthcare #costs #employercoverage
Humana Beat The Street; Will Reduce Benefits for 2027
Humana earned $1.19 billion in profit for Q1, down slightly from the $1.2 billion reported in the prior year quarter. Humana also brought in $39.6 billion in revenue for the quarter, growing year over year from $32.1 billion. Both numbers beat The Street.
The company projects that its Medicare Advantage (MA) membership will grow by about 25% compared to 2025 and said performance in the program’s Star Ratings is a likely headwind in the coming year. Despite earlier saying it was bullish on MA in 2026 and growing membership dramatically, Humana announced that it will have to reduce benefits in 2027 to get to margins investors expect.
Additional article: https://www.fiercehealthcare.com/payers/humana-shares-fall-ma-star-ratings-headwinds-company-affirms-2026-outlook
(Some articles may require a subscription.)
#humana #healthplans #margins #medicareadvantage
https://www.modernhealthcare.com/insurance/mh-humana-medicare-advantage-benefit-cuts
PBMs Get In Biosimilar Game
Large pharmacy benefits managers (PBMs) are morphing from favoring brand biologics to having sister companies manufacture biosimilars. Companies such as CVS Caremark owner CVS Health, Optum Rx owner UnitedHealth Group and Express Scripts owner Cigna seek to harness demand for lower-cost versions of biologic drugs and bolster their profits. Critics say costs will be artificially high as these big PBMs chase away other competition.
(Article may require a subscription.)
#drugpricing #pbms #biosimilars
https://www.modernhealthcare.com/insurance/mh-pbm-private-label-biosimilars-drug-costs
Blues Report 2025 Results
Conflicting financial pictures emerging from Big Blues. Blue Cross and Blue Shield North Carolina reported a $497M loss in 2025. Blue Cross and Blue Shield of Tennessee reported a $168M profit in 2025. Earlier, Health Care Service Corporation, a multi-state Big Blue reported a loss of $1.9B loss in 2025.
Additional article: https://www.beckerspayer.com/financial/bcbs-north-carolina-posts-497m-loss-in-2025/
#healthplans #margins
https://www.beckerspayer.com/financial/bcbs-tennessee-posts-168m-profit-in-2025
Wakely Analyses Of Exchanges And MA Stars
Wakely recently released two analyses – one on Exchange enrollment and one on Medicare Advantage (MA) Stars ratings.
In the Exchanges, Wakely analyzed government data and concluded selections decreased by 5% in total for 2026, with new consumers decreasing by 13%. However, Wakely says enrollment in 2026 is likely to decrease in 2026 overall on average from 17% to 26% in total due to high premiums and enrollees unable to pay. It also noted significant metal and Cost Share Reduction (CSR) shifts as consumers are “buying down” to leaner coverage. Bronze plan selections increased 10%, from 30% to 40%.
In addition, Wakely says the removal of the EHO4all health equity reward and continuation of the reward factor in Medicare Advantage (MA) Star Ratings will preserve plan revenue overall. However, the elimination of 11 administrative measures will reduce overall Star Ratings. Wakely says the impact will vary widely, but the majority will experience a reduction in quality bonus payments due to lower Star Ratings. Between SY 2026 and SY 2029, Wakely estimates that the enrollment-weighted market average overall Star Rating will decline by approximately 0.24 Stars. This will translate into fewer contracts qualifying for bonus payments, resulting in a 1.2% decline in MA-Part D payments across the market.
Additional article: https://www.wakely.com/wp-content/uploads/2026/04/Wakely-Summary-2027-Final-Rule-Stars-Changes_Updated_2026-04-20.pdf
#healthcare #stars #quality #medicareadvantage #exchanges
https://www.wakely.com/blog/2026-aca-open-enrollment-what-happened/
— Marc S. Ryan
