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Proactive Enrollment Caps Could Be Used in MA in 2027

The Centers for Medicare and Medicaid Services (CMS) is now allowing Medicare Advantage (MA) plans to file for prospective enrollment caps in 2027 that could be used as a way to limit financial exposure. It could be yet another tool in the toolbox for plans seeking to stay in an area but fearful of too much risk. CMS says it will help stem further exits in areas.

It appears existing regulatory authority is being used, perhaps more expansively. Previously, CMS only approved caps after an insurer’s enrollment ballooned to a point at which members’ health and safety was jeopardized.

Network Health has applied for such a cap in 2027. Several protections exist in the regulation.

#medicareadvantage #enrollment

https://www.modernhealthcare.com/insurance/mh-medicare-advantage-enrollment-caps-2027-cms/

Prominent Health Plan, PBM, And Provider Fraud Lawsuits

A number of alleged fraud lawsuits have been filed recently, including the following:

The Villages (Fla.) Health, a primary and specialty care provider group, has agreed to pay $541.5 million to resolve allegations it violated the False Claims Act (FCA) by submitting improper Medicare Advantage (MA) diagnosis codes.

Similarly, Monogram Health agreed to pay $2.4 million to resolve allegations that it violated the FCA by submitting false diagnosis codes to increase payments in MA.

Maryland’s attorney general filed a lawsuit against UnitedHealth Group and Optum, seeking $380 million in damages stemming from alleged issues administering Medicaid behavioral health.

Florida’s attorney general sued Express Scripts and Prime Therapeutics, alleging arrangements between the two pharmacy benefits managers allowed Prime Therapeutics to improperly cut pharmacy payments by up to 20% and pass on savings to Express Scripts.

Additional articles: https://www.beckerspayer.com/legal/villages-health-to-pay-541-5m-to-settle-medicare-advantage-fraud-allegations/ and https://www.beckerspayer.com/legal/maryland-sues-unitedhealth-for-380m-over-medicaid-administration-issues/ and https://www.healthcaredive.com/news/the-villages-health-medicare-overbilling-settlement-doj-humana/828915/ and https://www.modernhealthcare.com/insurance/mh-express-scripts-prime-therapeutics-florida-antitrust/ and https://www.modernhealthcare.com/legal/mh-villages-health-system-doj-settlement/ and https://www.fiercehealthcare.com/hospitals/villages-health-reaches-541m-false-claims-act-settlement-doj

#healthplans #providers #pbms #regulations #fwa

https://www.justice.gov/opa/pr/medicare-advantage-provider-monogram-health-agrees-pay-24m-settle-false-claims-act-suit?utm_source=chatgpt.com

— Marc S. Ryan

Plans, Providers Urge Rejection Of State-Directed Payments Rule

Health plan and provider groups are joining together to oppose the Trump administration’s draft regulation implementing state-directed payment reforms and limitations in Medicaid. Changes were made in the One Big Beautiful Bill Act (OBBBA), but opponents say the draft rule goes well beyond what the statute outlines.

The plans and providers may be right about the rule exceeding statutory authority. At the same time, the use of state-directed payments have been abused and do need to be reined in.

#medicaid #obbba #coverage

https://www.modernhealthcare.com/politics-regulation/mh-cms-medicaid-state-directed-payments-rule-pushback/

Medicaid GLP-1 Program Getting Little Traction

President Donald Trump’s deal offering states discounted pricing on GLP-1 drugs for Medicaid patients is getting little traction. Only Indiana has publicly signed on, while 29 state Medicaid programs have said they will not participate and 14 more did not respond. States are citing budget costs if they joined.

#glp1s #weightlossdrugs

https://www.beckerspayer.com/payer/medicaid/states-reject-trumps-discounted-medicaid-glp-1-deal

Moody’s Calls Health Plan Recovery Uneven And Challenging

Bond rater and investment analyst Moody’s published a report on health plan finance and it echoes much of what I concluded from Q2 financial announcements — there are positive signs coming out of the results but pressures and challenges remain.

Overall, Moody’s says health plans surpassed investors’ expectations and most boosted their outlook, but high medical costs are still a key factor in recovery. Margin recovery and executing on financial plans to meet investor demands remains a challenge and is uneven across plans.

Interestingly, it notes that “… a significant portion of the quarter’s margin improvement reflected favorable prior-year reserve development and non-recurring items rather than solely underlying trend.”

Moody’s notes that Medicare Advantage (MA) is one of the biggest challenges, with exits from underperforming markets and retrenchment focused on higher margin populations. Products and benefits have been repriced. It opines that 2027 finalized MA rates could constrain the improvements.

Medicaid recovered somewhat but will see future impacts from the One Big Beautiful Bill Act (OBBBA) cuts.

My recent blog on the Q2 results and health plan recovery: https://www.healthcarelabyrinth.com/are-insurers-turning-the-financial-corner-yes-but-there-is-more-work-to-be-done/

My blog from Monday on the likelihood of MA going through retrenchment again in 2027: https://www.healthcarelabyrinth.com/medicare-advantage-retrenchment-is-not-over-2027-could-bring-another-tough-year/

#healthplans #margins #coverage

https://www.fiercehealthcare.com/payers/moodys-look-payers-diverging-paths-ma-aca-markets

— Marc S. Ryan

Scan Execs Frame What Needs To Be Done With Stars

A great Healthcare Forefront blog by Scan CEO Sachin Jain and his chief legal officer discussing the current state of Medicare Advantage (MA) Stars, the various litigation, what is wrong with the Centers for Medicare and Medicaid Services’ (CMS) approach, and what the agency should do about it.

They argue CMS has made the program such that sophisticated plans cannot reliably reconstruct how a score is produced. It notes the legal quandary CMS finds itself in post the Clover decision.

The Scan execs argue that CMS needs to step back and remake the system based on a smaller number of clinical measures and member experience. As they note, CMS is moving toward this with the SY 2029 restructure. CMS now needs to correct the legal and regulatory deficiencies.

#medicareadvantage #stars #quality #cms

https://www.healthaffairs.org/content/forefront/stars-docket-medicare-advantage-quality-ratings-trial

More Carriers To Reduce MA Footprint in 2027

Humana and Centene both announced they will reduce their Medicare Advantage (MA) footprint in 2027. Centene will exit in Oklahoma, Tennessee, and Hawaii, cut 158 counties and cancel 133 plans, impacting 340,000. Humana will reduce its county penetration and impact 600,000. All this is tied to a retrenchment to get to profitability.

#medicareadvantage #margins #enrollment

https://www.modernhealthcare.com/insurance/mh-centene-medicare-advantage-plans-states

Provider Wins In NSA Disputes Becoming Outlandish

More evidence that the terribly flawed No Surprises Act dispute process is getting more outlandish, yet lawmakers lack the courage to fix it. Meanwhile, awards continue to drive costs in the system in two ways – the sheer cost of the awards and driving up price points in the system overall.

A new federal analysis says disputes rose almost 75% to more than 2.5 million from 2024 to 2025. CMS originally projected just 17,000 cases a year when the law passed. Providers won 83.6% of disputes in Q4 2025, roughly consistent since 2023.

Provider groups of course claim the dollars awarded are merited. Health plans say providers are abusing the system and the process is incredibly slanted to providers.  A long-delayed reform rule is likely destined to do little to change the paradigm.

It is also true that a small subset of certain specialists are raking in the highest awards. Surgical and neurology procedures have resulted in a huge increase in reimbursements. Insurers paid a median award equal to 2,585% of the qualifying payment amount for neurology procedures in Q4, up from 1,262% during Q4 2023.

Arbitration processes are meant to be a 50-50 proposition – not 84-16. And to show how biased the process really is, plans offering five times the qualifying payment amount still lose about 75% of the time.

#nsa #nosurprisesact #transparency #providers #healthplans

https://www.modernhealthcare.com/providers/mh-no-surprises-act-billing-disputes-idr

— Marc S. Ryan

JD Power Finds Decline in MA Satisfaction

A new study by JD Power finds that satisfaction with Medicare Advantage (MA) plans has declined for a second year. Overall satisfaction was 611 on a 1,000-point scale, down 12 points from the 2025 report and 41 points from 2024. 

The study identified declines across the member experience, with the steepest declines over two years in how much the plan is saving time and money (down 51 points); level of trust (down 49 points); and coverage options to meet individuals’ needs (down by 47 points).

The decline is obviously related to major cutbacks in access and benefits as the industry grapples with realignment and margin recovery.

In other news, Modern Healthcare covers the Q2 financial recovery by plans and outlook for continued improvement. I covered this topic in a blog here: https://www.healthcarelabyrinth.com/are-insurers-turning-the-financial-corner-yes-but-there-is-more-work-to-be-done/ .

Additional article: https://www.fiercehealthcare.com/payers/jd-power-member-satisfaction-medicare-advantage-plans-continues-slide

#medicareadvantage #margins

https://www.modernhealthcare.com/insurance/mh-unitedhealth-humana-aetna-medicare-advantage-2027

Trump Reining In Medicaid Waivers, Further Complicating State Medicaid Budgets

The Centers for Medicare and Medicaid Services (CMS) is paring back on 1115 research and demonstration waivers. Critics say this could increase enrollee churn, undercut finances for providers, and impact innovation. States are already grappling with work requirements as well as reductions to provider taxes used to fund the state share or contribution.

The administration argues that the Medicaid footprint has grown considerably over the years, funded inappropriate areas, and has not lived up to budget neutrality.  The administration has defunded social needs waivers and will not renew continuous coverage enrollment.  

CMS has informally notified Arkansas that its private option Medicaid expansion under the Affordable Care Act of 2010 will not be renewed. Arkansas is seeking a two-year extension after CMS rejected its five-year renewal. It impacts 200,000 enrollees.

In other news, California’s Medicaid program, Medi-Cal, will reduce its asset limits 84% in July 2027. In 2022, California moved the asset limit from $2,000 to a ridiculous $130,000 for individuals and wanted to drop the asset test altogether at one time, which was approved by the Biden administration. But due to budget difficulties, the asset limit now will drop to $21,000 for singles.

Additional article: https://www.beckerspayer.com/payer/medicaid/medi-cal-plans-brace-for-devastating-asset-limit-crunch/

#medicaid #waivers #coverage

https://www.modernhealthcare.com/politics-regulation/mh-cms-medicaid-1115-waiver-states