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Aetna Delays And Changes Downcoding Policy

After major pushback from lawmakers and providers, Aetna is easing a controversial “downcoding” policy for inpatient Medicare Advantage (MA) claims. The insurer said the policy’s start date has been delayed to Jan. 1, 2026 and that its severity review would now apply to urgent or emergent inpatient hospital stays that include at least one midnight but fewer than five. As part of the reimbursement approach, Aetna will approve these inpatient stays without a medical necessity review and cover the claim at a rate that aligns with observation services. Stays of five or more midnights will not be subject to a severity review in the updated policy.

Additional articles: https://www.fiercehealthcare.com/payers/american-hospital-association-urges-aetna-rescind-new-inpatient-policy-payment and https://www.modernhealthcare.com/insurance/mh-aetna-medicare-advantage-downcoding-policy/

(Some articles may require a subscription.)

#aetna #hospitals #claimsdenials #priorauthorization

https://www.beckerspayer.com/payer/aetna-delays-new-inpatient-reimbursement-policy/

Healthcare Costs Continuing to Surge

WTW’s 2026 Global Medical Trends Report indicates that healthcare increases remain “significantly higher” than the 7.6% seen in 2024. Further, healthcare cost increases are projected to rise 9.6% in the U.S. in 2026, only a little less than the 9.7% experienced this year.

Globally, the average cost of health benefits is predicted to rise 10.3%, up from 10% in 2025 and 9.5% in 2024.

Employers add that they believe elevated costs will continue for more than three years, driven by medical costs, regional pressure on pharmacy and outpatient services, and global structural factors. About three-quarters said new medical technologies as the top reason for medical inflation, followed by the decline of public health systems (52%) and advancements in pharmaceuticals (49%).

Cancer tops the list of cost drivers globally.

#healthcare #costs

https://www.healthcaredive.com/news/us-healthcare-cost-increases-expected-to-fall-in-2026/805340

Government to Reopen – Finally!

The House passed the Senate bill to reopen government this evening on a vote of 222 to 209. Six Democrats joined the vast majority of Republicans to pass the bill. Two Republicans voted with Democrats. The bill extends some expiring healthcare programs and delays cutbacks. But it did not include an extension of enhanced Exchange premium subsidies. The Senate leader has promised a vote in mid-December, while the House speaker has yet to make a commitment.

Despite the Democrats’ focus on the subsidy extension, little has been proposed on healthcare reform by either party outside of President Trump’s efforts on drug pricing. Republicans are rumored to be compiling a reform plan that could be pared with some subsidy extension, but in the past the changes meant millions losing coverage.

In other news, hidden in the government funding bill was a provision that overrides budget sequestration rules that may have led to $500 billion in Medicare cuts over ten years.

Additional articles: https://www.modernhealthcare.com/politics-regulation/mh-house-stopgap-funding-bill-aca-subsidies/ and https://www.fiercehealthcare.com/regulatory/shutdown-has-highlighted-washingtons-retreat-big-ideas-healthcare and https://www.modernhealthcare.com/politics-regulation/mh-stopgap-funding-bill-medicare-cuts-shutdown/

#governmentshutdown #congress #trump #exchanges #healthcare #coverage #medicare #healthcarereform

https://thehill.com/homenews/house/5603344-house-bill-government-shutdown

With Government Shutdown Ending, GOP Struggles With Obamacare

With the government funding bill almost assuredly to pass the House Wednesday, the GOP will next have to turn to what to do with the expiring enhanced Exchange subsidies and perhaps some healthcare reform in general.

Senate Majority Leader John Thune, R-SD, promised a vote on the subsidies by mid-December, but House Speaker Mike Johnson, R-LA, refuses to make any commitment on a vote. Moderate GOPers in the Senate and about several dozen moderates in swing districts in the House GOP caucus want a vote and some sort of extension. Various potential compromises are being discussed including an income cap, minimum premiums, and an extension vs. permanency.

The GOP may also want to pass healthcare reform changes but have yet to truly put up a plan. Conservatives, such as Rep. Majorie Taylor Greene, R-GA, have been pressuring the Speaker to pass yet another budget bill with reductions and reforms. They have criticized the GOP leadership for having no plan.

The GOP has never crafted a healthcare plan that did not mean millions losing coverage. The party favors individual purchasing, health savings accounts, ICHRA health reimbursement, and alternative plans that fall short of comprehensive coverage.

The president this weekend proposed that subsidies that go to insurance companies go directly to those in need, but the treasury secretary had to quickly point out there is no real plan for this.

#healthcare #coverage #exchanges #obamacare #aca

https://thehill.com/newsletters/the-movement/5599435-shutdown-health-care-republicans

Trump Wants Healthcare Subsidies To Go To Individuals But Has No Detailed Plans

Over the weekend, President Donald Trump declared that his solution for the Exchange subsidy stalemate and high costs in healthcare generally is to have subsidies go directly to individuals to purchase healthcare. But Treasury Secretary Scott Bessent said Monday that there is really no formal plan. Apparently, it was just musings from the president, along with a frontal assault on what he called “money sucking insurance companies.”

The president’s social media post stated: “I am recommending to Senate Republicans that the Hundreds of Billions of Dollars currently being sent to money sucking Insurance Companies in order to save the bad Healthcare provided by ObamaCare, BE SENT DIRECTLY TO THE PEOPLE SO THAT THEY CAN PURCHASE THEIR OWN, MUCH BETTER, HEALTHCARE, and have money left over. In other words, take from the BIG, BAD Insurance Companies, give it to the people, and terminate, per Dollar spent, the worst Healthcare anywhere in the World, ObamaCare. Unrelated, we must still terminate the Filibuster!”

But of course, terminating Obamacare (the Medicaid expansion and Exchanges) would send millions onto the rolls of the uninsured. The subsidies would be meaningless for those unable to access healthcare via employer coverage, especially those with significant health risks. And the proposal does little to nothing on affordability itself.

Republicans are supposedly putting together a reform plan, including encouraging individual options and health savings accounts, banning Silver loading in the Exchanges perhaps by funding cost-sharing subsidies, and expanding employer-funded health reimbursement accounts to help consumers buy individually. The GOP also may expand short duration plans and association plans as well as further limit provider taxes and other spending in Medicaid.

The Affordable Care Act does need some reforms to bring more affordability, but the Republican plans remain a mishmash of prior proposals that fell short of comprehensive reform and coverage.

Additional articles: https://www.axios.com/2025/11/08/trump-affordable-care-act-subsidies-shutdown and https://www.modernhealthcare.com/politics-regulation/mh-republicans-aca-site-neutral-payments-shutdown/ and https://thehill.com/homenews/administration/5596505-donald-trump-filibuster-reform-health-insurance-democrats-government-shutdown/ and https://thehill.com/policy/healthcare/5597877-government-shutdown-aca-debate/?tbref=hp

(Some articles may require a subscription.)

#aca #obamacare #exchanges #medicaid #healthcare #coverage

https://www.cnbc.com/2025/11/08/trump-republicans-health-insurance.html

Government Funding Deal In Flux, But GOP To Push Democrats To Acquiesce This Weekend

While bipartisan talks continue, today saw the two parties argue over a government funding bill and the parties appear further apart in the Senate. Senate Minority Leader Chuck Schumer, D-NY, proposed a bill that would fund some parts of government for the year and others partially, enact some additional funding being negotiated between the parties, and provide a one-year extension of enhanced Exchange premium studies. Republicans rejected the Democratic proposal.

Instead, the Republicans will challenge Democrats to reject a bill based on the same bipartisan negotiations to fund some parts of government for the year and extend other funding to January. There would be no deal on subsidies. Senate Majority Leader John Thune, R-SD, has committed to a vote on subsidies later, but House Speaker Mike Johnson, R-LA, has refused to do so, and Democrats believe President Trump will also refuse a subsidy extension and continue his campaign to downsize government and lay off workers.

The GOP hopes that over the weeekend that eight Democratic senators will vote on the planned GOP measure to achieve the 60 votes needed for passage. The bill would then have to go to the House due to material changes.

Additional articles: https://www.medpagetoday.com/washington-watch/washington-watch/118374 and https://thehill.com/homenews/senate/5595759-senate-gop-democratic-offer-shutdown/ and https://thehill.com/homenews/senate/5595545-schumer-plan-government-shutdown/ and https://thehill.com/homenews/senate/5594333-government-shutdown-deal-democrats-trump/

#governmentshutdown #congress #trump #exchanges #healthcare #coverage

https://www.fiercehealthcare.com/regulatory/shutdown-tracker-cms-issues-billing-guidance-hhs-furloughs-32000-employees

Trump Announced GLP-1 Deals With Brand Drug Makers

The Trump administration announced two major drug-related reforms today.

The Centers for Medicare & Medicaid Services (CMS) announced a new model that aims to bring most-favored nation (MFN) pricing to the Medicaid space. Second, President Trump personally announced lower prices for self-pay and Medicare customers for GLP-1 and some other drugs.

CMS says it will launch the GENErating cost Reductions fOr U.S. Medicaid (GENEROUS) model. State Medicaid programs will be able to purchase certain drugs at prices that align with what is paid in other countries beginning in 2026. Through the model, CMS will negotiate with participating pharmaceutical companies to bring down prices.

In addition, Medicare will cover GLP-1 semaglutide and tirzepatide at much lower prices and this appears true for chronic conditions, these conditions with underlying obesity, and apparently obesity alone. “Until now, neither of these two popular drugs have been covered by Medicare for weight loss, and only rarely by Medicaid,” Trump said during a press conference in the Oval Office. “That ends starting today …. This will improve the health of millions and millions of Americans.” Medicare will pay $245 for semaglutide and tirzepatide, with $50 copays for the medicine for enrollees.

As well, in 2026, doses of Novo Nordisk and Eli Lilly’s blockbuster drugs for patients without insurance will be priced at $350 through TrumpRx for a month’s supply. Starter doses will be as low as $149 per month. They are currently well over $1,000 per month on a list basis. Starting doses of new pill versions of the treatments that will come to market will cost $149 a month.

There is confusion on whether GLP-1s indeed will be covered in Medicare for obesity alone and whether aspects of the announcement are mandatory or voluntary. In November 2024, the Biden administration proposed Medicare and Medicaid coverage of GLP-1s for obesity alone. The Trump administration did not finalize the rule, which reinterpreted obesity as a qualifying disease state in Medicare. The Trump administration argued at the time it would lead to huge cost increases at current prices.

But that may have changed with the new prices. Trump’s remarks and other officials seem to say that Medicare will be opened up to GLP-1 coverage for obesity alone. The government provided little details, however. Reports suggest that savings generated for existing prescriptions will be used to provide new coverage for GLP-1s to patients with obesity. A Novo-Nordisk press release says that Part D coverage for anti-obesity medicines will be enabled through a pilot program designed to cover a majoirty of Part D beneficiaries.” Does that voluntary program cover both extending the coverage to those with obesity alone as well as capping cost-sharing at $50 for everyone on the drug for any disease state? The latter copay issue would be similar to what Trump did in Trump 45 for insulin prices. Or, on the issue of coverage for obesity, will Trump do this via rule, effectively backtracking on striking down what Biden proposed.

Complicating all this is when will it begin. An Eli Lilly press release suggests the $50 cap in costs for enrollees begins as early as 2026. But benefit design and bids have long been put to bed.

Medicare was already expanding GLP-1 coverage from diabetes and heart disease to other disease states, such as prediabetes with obesity. Even with the discounts, liberal expansion of GLP-1 coverage could mean a huge surge in Medicare Part D costs. As well, note that the price is not nearly as low as other developed nations, which have prices below $200 and sometimes closer to $100 for a monthly supply.

Eli Lilly and Novo Nordisk also agreed to discount other medicines. Eli Lilly will provide Emgality at $299 per pen and Trulicity at $389 per month. Novo Nordisk will offer insulin products, including NovoLog and Tresiba, at $35 per month.

Both companies also committed to repatriating foreign revenue, applying MFN pricing to future drugs, and extending pricing to all state Medicaid programs. Novo Nordisk will invest an additional $10 billion in U.S. manufacturing, and Eli Lilly pledged at least $27 billion.

The agreement is separate from ongoing Medicare drug price negotiations.

In other news, a study by Epic Research found that 56% of semaglutide, 52% of liraglutide, and 55% of tirzepatide patients kept the weight off or lost additional weight after stopping GLP-1 use. The study tracked 188,722 patients who stopped taking the drugs after at least 90 days of use for treatment of obesity and had an initial weight loss of 5+ pounds. Complete weight regain occurred in 23% of semaglutide, 21% of tirzepatide, and 27% of liraglutide users at 24 months.

Additional articles: https://www.fiercehealthcare.com/regulatory/cms-unveils-new-model-aims-bring-most-favored-nation-pricing-medicaid and https://www.medpagetoday.com/publichealthpolicy/medicare/118344 and https://www.modernhealthcare.com/politics-regulation/mh-trump-eli-lilly-novo-nordisk-medicare-glp-1/ and https://www.beckershospitalreview.com/pharmacy/medicare-to-cover-glp-1s-under-trump-negotiated-pricing/ and https://www.beckershospitalreview.com/pharmacy/cms-launches-pilot-to-lower-medicaid-drug-costs-8-things-to-know/ and https://www.cms.gov/newsroom/press-releases/cms-announces-new-drug-payment-model-strengthen-medicaid-better-serve-vulnerable-americans and https://www.hhs.gov/press-room/cms-announces-new-drug-payment-model-to-better-serve-vulnerable-americans.html and https://thehill.com/policy/healthcare/5593083-trump-administration-glp-1-novo-nordisk-eli-lilly/ and https://www.epicresearch.org/articles/two-years-after-stopping-glp-1s-most-patients-sustain-at-least-some-weight-loss

(Some articles may require a subscription.)

#medicare #medicaid #partd #commercial #employergroup #gp1s #weightlossdrugs #drugpricing

https://www.healthcaredive.com/news/lilly-novo-trump-obesity-drug-pricing-deal-zepbound-wegovy/804937

Humana Reports Q3 Financial News

Medicare Advantage (MA)-dominant Humana reported Q3 financial news today. Humana, the second biggest MA player, slashed its earnings guidance as enrollment ticks above initial expectations during open enrollment. It now projects to have about 425,000 fewer Medicare MA enrollees next year, not 500,000 fewer as previously anticipated. Investors worry that these additional members, driven by generous benefits, will increase medical expense more than projected. Humana says it is confident in projections despite higher enrollment numbers but says it can throttle back enrollment with several levers if needed.

Operating expenses surged to $32.25 billion, up 11.75% year over year. Humana is spending more (hundreds of millions more) to better operations and increase Star ratings. Its Star Year 2026 rating actually dropped from a very low 25% of enrollment in 4 Star or greater plans to an even lower 20%.

Third-quarter net income declined 59.6% to $194 million. Revenue rose 11.1% to $32.6 billion. The medical loss ratio (MLR) rose to 91.1% from 89.1% a year ago. This was consistent with projections.

One analyst asked the burning question on Stars — why Humana didn’t crosswalk MA members out of one major contract suffering from low ratings to other contracts. Humana says that would be a short-term financial gain that could have negatives, including member attrition and hurt future Star performance. Humana says it will break up the master contract over time.

Additional articles: https://www.fiercehealthcare.com/payers/humana-slims-expectations-membership-losses-2025-425k and https://www.healthcaredive.com/news/humana-medicare-advantage-growth-confident-q3-2025/804661/ and https://www.beckerspayer.com/financial/humana-posts-195m-q3-profit/

(Some articles may require a subscription.)

#medicareadvantage #humana #margins #stars #quality

https://www.modernhealthcare.com/insurance/mh-humana-medicare-advantage-centerwell/

Is UnitedHealthcare Gaming Medical Expense Regulation?

A new study published in Health Affairs finds that UnitedHealthcare pays its owned providers at sister company Optum 17% more than those it does not own. And if United controls 25% or more of a market, that percentage increases to 61%. Researchers said the results suggest the company may be sidestepping government rules regarding calculation of medical expenses against premiums. If those rules are violated, rebates need to be sent to the government, employers, or individuals depending on the type of coverage. In effect, higher payments to owned providers would boost the so-called medical loss ratio (MLR) and more likely hit or exceed the required spending (usually 80% or 85%).

United says the study is wrong. And the study clearly has some limitations. It looked at just 14 CPT medical codes and about 385,000 transactions. But these were frequently performed and high-cost procedures in the commercial world. And to arrive at the over-reimbursement calculation, United payments were compared to what other large insurers, such as CVS’ Aetna, Cigna and Elevance Health, paid providers.

Notwithstanding United’s declarations to the contrary, the research would seem to be legitimate and reach a correct conclusion. It has long been a secret that vertically integrated health plans tend to sign lucrative deals with their own sister companies so as to inflate medical expense. It frees these organizations from a great deal of rebates and keeps the revenue in the family. It happens with payments to owned providers, at-risk payments to owned providers, higher payments to their own pharmacy benefits managers and specialty pharmacies, and payments to its own service entities. The good news is that transparency rules are now bringing some light to all this and congress is looking at the backroom deals.

Additional articles: https://www.healthcaredive.com/news/unitedhealthcare-pays-optum-doctors-more-than-other-doctors-study/804600/

#verticalintegration #healthplans #minimummlr #unitedhealthcare

https://www.fiercehealthcare.com/payers/study-suggests-unitedhealthcare-pays-optum-docs-more-other-providers

Government Shutdown End In Sight?

After bipartisan weekend talks, Senate Majority Leader John Thune, R-SD, said Monday that he is “optimistic” lawmakers can strike a deal to reopen the government by the end of the week. He added that a stopgap spending bill could fund government through January or later to allow time to mark up and pass appropriations bills. The House will have to re-pass the temporary funding bill as it expires on November 21. Insiders say that Democrats could give in on their position to include Exchange subsidy extensions if a bill is pre-negotiated, likely with the president, or if GOP leaders announce a commitment to hold an up or down vote on an extension.

Meanwhile, Rep. Marjorie Taylor Greene, R-GA, says Republicans deserve much of the blame for rising premiums, saying Republicans should have reformed the Affordable Care Act (ACA) sooner. “The Democrats passed Obamacare, but yet the Republicans have never done anything to correct the problems that exist with it. … And I don’t think it’s an easy thing to fix. … However, it’s something that we should have a plan for, and [House Speaker] Mike Johnson, for a month now, cannot give me a single policy idea. … And I’m angry about that.”

As well, four moderate House lawmakers, two on each side of the aisle, on Monday proposed a framework to temporarily extend the Exchange enhanced premium subsidies, including a sunset period and an income cap for high earners. 

Additional articles: https://thehill.com/homenews/senate/5587098-thune-shutdown-spending-bill/ and https://thehill.com/homenews/house/5584132-democrats-gop-end-shutdown/ and https://thehill.com/homenews/house/5584704-greene-maher-republicans-health-care-premiums-shutdown/

#governmentshutdown #trump #congress #exchanges #healthcare #coverage #aca #obamacare

https://thehill.com/policy/healthcare/5587204-obamacare-tax-credits-extension-proposal/?tbref=hp