Newsfeed

CMS Finalizes Sweeping Exchange Rule

The Centers for Medicare and Medicaid Services (CMS) finalized its sweeping 2027 Affordable Care Act and Exchange rule today. While a few items were not finalized, most of the major items that will dramatically change offerings were.

The agency says the rule is an effort to bring down premiums, increase choice, and address fraud. Critics say it will erode enrollment and benefits.

The changes include:

• Policies for tighter eligibility verification requirements, reformed marketing and enrollment practices, and fraud measures
• Extending a ban on a special enrollment period for those below 150% of poverty
• Expansion of access to catastrophic coverage due to hardship. This would apply to individuals who are ineligible for premium and cost-sharing reduction subsidies (those below 100% or above 250% of poverty) when they experience changes in their household income.
• Multi-year catastrophic coverage policies
• Value-based preventive benefits in multi-year coverage that will be covered pre-deductible.
• Non-network plans can qualify as essential benefit plans
• Changes to cost-sharing parameters to increase flexibility for issuers designing individual bronze and catastrophic plans.
• Repeal of standardized benefit options and no limits on non-standardized plans
• States get greater authority over plan oversight
• Lower user fees on plans to lower premiums
• Beginning in plan year 2028, states will be required to defray the cost of benefits they mandate that are in addition to essential benefits.

(Article may require a subscription.)

#exchanges #aca #obamacare #trump #regulations #coverage #healthcare

https://www.modernhealthcare.com/politics-regulation/mh-cms-aca-exchange-rule-2027-final

Internal CMS Memo Shows Growing Exchange Falloffs

NOTUS obtained an internal Centers for Medicare and Medicaid Services (CMS) memo that says more Americans are dropping out of Exchange coverage than usual. The memo says more than one in five people who enrolled in health insurance through the federal Exchanges during open enrollment and in the weeks following were dropped from coverage for failing to pay their first month’s premium. This rate is significantly higher than the rate from last year, which was 12%.

The administration attributes most of the drop to efforts to root out fraud. That could be some of it, but companies also report dropping enrollment since January due to non-payment. Premiums surged when enhanced subsidies lapsed. This occurred for those subsidized as well as more generally as companies increased rates across the board to mitigate an anticpated increase in risk and surging utilization costs.

(Article may require a subscription.)

#exchanges #coverage #healthcare

https://www.notus.org/healthcare/aca-healthcare-dropped-insurance-numbers-subsidies

Plans Launch New Ad Campaign On NSA Disputes

A new health plan ad campaign takes aim at the No Surprises Act (NSA) law and its arbitration component. It says that the dispute processes “create a ‘fox guarding the hen house’ dynamic.”

Data show that providers are far more likely to win (87% of the time) and earn significantly higher payouts than payments before the law. It is driving overall healthcare costs up.

Further, it is subject to abuse, with five organizations accounting for 63% of disputes in the first half of 2024: Team Health, SCP Health, Radiology Partners, AGS Health and HaloMD.

Plans have sued but it will take the courage of Congress to fix his problem.

#nosurprisesact #transparency

https://www.fiercehealthcare.com/payers/new-payer-backed-ad-campaign-pushes-no-surprises-act-idr-reform

Makary Resigns At FDA

Food and Drug Administration (FDA) Marty Makary, M.D, is out at the agency, having resigned under pressure from Health and Human Services (HHS) Secretary Robert F. Kennedy, Jr. The move was approved by the White House.

The last straw appeared to be Makary’s reluctance to approve fruit-flavored e-cigarettes given the potential for abuse by minors.

Critics argued that Makary lacked government experience and did not lead the agency well. Others say he rightfully pushed back on certain administration initiatives he deemed wrong-headed.

I won’t get into the saga, only to say that Makary was dealt a poor hand, with layoffs and huge cutbacks at a time of great political volatility for the agency. Such appointments don’t always work out for the principled person.

I am a supporter of Makary, who I have been connected with for over five years now. (He endorsed my book when it was published.) I was inspired to write based on several of his works and those of Uwe Reinhardt. Makary is a deep thinker and consummate professional. His works on surgery, healthcare, and reform are top-notch. He brings the unique perspective of a practicing physician and academic to healthcare reform. Makary would be better as a healthcare policy change agent more broadly.

That Makary drew scorn from all corners is likely a signal that he was actually a good pick. His speeding of drug development will be a lasting legacy as will his reforms on rare diseases. I know he will continue to influence the healthcare world for good.

Additional articles: https://www.fiercepharma.com/pharma/fda-commissioner-marty-makary-resigns-capping-turbulent-tenure and https://www.healthcaredive.com/news/makary-fda-commissioner-resign-trump/820008/ and https://www.medpagetoday.com/washington-watch/fdageneral/121232 and https://thehill.com/policy/healthcare/5875030-marty-makarys-tenure-as-head-of-fda-ends-with-difficulty/

(Some articles may require a subscription.)

#fda #makary #trump #hhs #rfkjr

https://www.modernhealthcare.com/politics-regulation/mh-trump-fda-marty-makary-resign

United Moving To Transparency For Its PBM

UnitedHealth Group Inc. said it will change its profit structure at pharmacy benefits manager (PBM) Optum Rx. The company handled about 1.7 billion prescriptions last year. Optum Rx plans to shift to a more transparent fee structure that gives clients clarity into payments the PBM gets from drug makers.

CVS Health Corp’s Caremark earlier said it would change how it pays pharmacies to make it simpler and more transparent. Cigna’s Express Scripts late last year said it will phase out rebate payments in many private health plans.

(Article may require a subscription.)

#pbms #drugpricing

https://www.modernhealthcare.com/insurance/mh-unitedhealth-optum-rx-pbm-model

Exchange Insurers Report On Program Challenges

First quarter results for insurers with Exchange lines of business had two trends. First, there generally was lower enrollment because people exited the market due to surging premiums and expiring subsidy enhancements. Second, people moving to less costly and trimmer Bronze and Catastrophic plans.

The health insurance companies expect aggregate Exchange enrollment will shrink by at least 20% over the course of the year as more drop out due to affordability.

Oscar Health bucked the trend in terms of enrollment growth.

Additional articles: https://www.fiercehealthcare.com/finance/aca-exchanges-dominated-q1-earnings-calls-heres-what-payer-health-system-execs-had-say

(Some articles may require a subscription.)

#exchanges #healthplans

https://www.modernhealthcare.com/insurance/mh-aca-enrollment-centene-molina-cigna-oscar

CMS Could Auto-Enroll Seniors In MA or ACOs

STAT reports that the Centers for Medicare and Medicaid Services (CMS) is currently mulling a plan that would automatically enroll beneficiaries into either Medicare Advantage (MA) plans or traditional Medicare Accountable Care Organizations (ACOs). The House GOP has shown interest in the proposal as have a number of right-leaning think tanks. The move would be consistent with CMS’ desire to radically expand value-based care (VBC) penetration in Medicare.

#medicareadvantage #acos #vbc

https://www.medpagetoday.com/publichealthpolicy/medicare/121161

CVS Health Beats The Street; Raises Guidance

CVS Health Beat The Street in its Q1 financial news and raised its full-year projections. Its Aetna insurance division has recovered well from a huge meltdown a few years ago. Revenue should reach at least $405 billion this year. It posed $2.9 billion in profit in Q1. Revenues also grew to $100.4 billion in Q1 2025.

Executives said that while the final 2027 Medicare Advantage (MA) rate notice does not meet financial expectations, Aetna is still on track for planned margin improvements by 2028.

Additional articles: https://www.fiercehealthcare.com/payers/cvs-health-beats-street-29b-q1-profit and https://www.modernhealthcare.com/insurance/mh-aetna-revenue-cvs-health-earnings-outlook/ and https://www.modernhealthcare.com/insurance/mh-cvs-health-earnings-outlook-aetna/ and https://www.beckerspayer.com/financial/cvs-health-reports-2-9b-in-q1-profit-as-aetna-strengthens/

#aetna #cvshealth #margins #medicareadvantage #healthplans

https://www.healthcaredive.com/news/cvs-hikes-outlook-aetna-improved-performance-q1-2026-earnings/819462

United Limiting PAs

UnitedHeathcare said it would eliminate prior authorization (PA) requirements for 30% of services that previously required payer approval. It plans to roll out the changes by the end of the year. Services seeing removal of PA will be outpatient surgeries, diagnostic tests, and chiropractic care.

I will have a blog on Thursday on ongoing PA reforms.

In other news, the California Hospital Association sued to stop Elevance Health from implementing a policy that would cut payments to hospitals that refer some members to out-of-network providers.

Additional articles: https://www.fiercehealthcare.com/payers/unitedhealthcare-reduce-prior-auth-requirements-30 and https://www.modernhealthcare.com/insurance/mh-unitedhealthcare-prior-authorization-cuts/

(Some articles may require a subscription.)

#unitedhealthcare #elevancehealth #priorauthorization #healthplans

https://www.modernhealthcare.com/insurance/mh-california-elevance-out-of-network-penalty-lawsuit/

ACCESS Model Examined

Fierce Healthcare dives deep into the Trump administration’s new Advancing Chronic Care with Effective Scalable Solutions (ACCESS) Model, which is a 10-year value-based-care (VBC) payment program to encourage the use of technology to treat chronic diseases. It teams technology companies with traditional Medicare fee-for-service (FFS) providers.

About 150 digital health companies were approved to participate in the first cohort, which launches as early as July 5. The Center for Medicare and Medicaid Innovation (CMMI) announced the model in December and pays recurring payments for technology used to treat diabetes, hypertension, chronic kidney disease, obesity, depression and anxiety. It then awards a VBC bonus if outcomes are met. This could be improvement or stability in disease states.

The ACCESS Model aligns with the Centers for Medicare and Medicaid Services’ (CMS) goal of having all traditional Medicare beneficiaries in an accountable care relationship by 2030. The model shifts away from remote patient monitoring (RPM) and chronic care management (CCM) billing codes that offer payments for specific activities. ACCESS encourages the use of AI and other emerging technologies at scale.

The tracks in the ACCESS Model include early Cardio-Kidney-Metabolic (hypertension, dyslipidemia, obesity, and prediabetes); Cardio-Kidney-Metabolic (diabetes, chronic kidney disease, atherosclerotic cardiovascular disease); Musculoskeletal (chronic musculoskeletal pain); and Behavioral Health (depression and anxiety). 

Rates were lower than the industry expected and fall below current billing models. The rates range from $90 to $420 per beneficiary per year (i.e., $7.50 to $35 per month), depending on model track. But it does include additional populations that may not usually be enrolled in traditional care coordination programs.

#access #vbc #medicare #cms

https://www.fiercehealthcare.com/health-tech/deeper-dive-access-model-whos-participating-potential-headwinds-and-how-it-could-spur