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Regional Plans Not Faring Well

Despite some studies suggesting regional plans are doing better than national payers during this financial downturn, HealthScape Advisors says regional nonprofit insurance companies are falling behind their larger competitors. It says that in 2024, 71% of regional nonprofit insurers ended the year with an operating loss. By comparison, 53% posted operating losses in 2023, and just 22% did in 2020.

In other news, Humana will not pay agents and brokers for enrolling new members in many of its wider-network Medicare Advantage (MA) products for 2026. There will be 288 plans across 46 states and the District of Columbia impacted, about 80% of which are Preferred Provider Organizations (PPOs).

Further, a bipartisan group of lawmakers has introduced legislation requiring MA plans to promptly pay out providers’ claims, with up to a $25,000 fine and interest accrual. Plans would have a 14-day deadline to pay electronically submitted, in-network claims and a 30-day requirement for paper or out-of-network claims. Penalties would hit if 95% of “clean claims” were not paid timely.

Last, more MA contraction is expected and this will fall again on the amount and types of supplemental benefits. This could even impact more traditional benefit add-ons, such as dental.

Additional article: https://www.modernhealthcare.com/insurance/mh-humana-medicare-advantage-commissions-2026/ and https://www.fiercehealthcare.com/regulatory/bipartisan-bill-introduced-require-medicare-advantage-plans-promptly-pay-claims and https://www.modernhealthcare.com/insurance/mh-medicare-advantage-supplemental-benefits-2026/

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#medicareadvantage #healthplans #margins #marketing #claimsdenials #supplementalbenefits

https://www.modernhealthcare.com/insurance/mh-regional-nonprofit-insurance-healthscape-advisors/

C-SNPs Could Impact Dual Integration

While Medicare Advantage (MA) Dual Eligible Special Needs Plans (D-SNP) membership is growing rapidly, a new Health Affairs Forefront blog calls out that growth in Chronic Care SNPs (C-SNP) could actually create barriers to greater integration of Medicare and Medicaid.

The authors note the huge growth in C-SNP enrollment over the past few years. C-SNP product offerings have grown from 303 in 2024 to 372 in 2025. The total number of Medicare beneficiaries enrolled in C-SNPs has increased from 629,560 to 1,069,660 in that timeframe. In 2016, there were only 137 C-SNPs with 315,200 beneficiaries.

The authors note that in 2025 there are now 125,638 full-benefit dual eligible individuals and 86,815 partial dual eligibles in C-SNPs. About 28% of the full-benefit dual eligible beneficiaries were previously enrolled in a plan that offered some form of integration in the prior year.

The authors propose a few reforms to ensure dual integration is not scuttled, including applying the SNP “look-alike” regulation to C-SNPs as well. By 2026, this would potentially translate to terminations of about 15% of the C-SNPs with at least 100 enrollees. 

I understand the point being made, but I do not see these trends as fundamentally impacting the ultimate progress toward integration of the two public healthcare programs. I would stand more for choice for beneficiaries. Some are attracted to benefits to address their chronic conditions, while others are attracted to plans that truly integrate care between Medicare and Medicaid.

#medicareadvantage #snps #dualeligbles

https://www.healthaffairs.org/content/forefront/growth-c-snps-may-jeopardizing-medicare-medicaid-integration

Report Says MA Had $5.7B Underwriting Loss in 2024

Credit rating agency AM Best says that Medicare Advantage (MA) plans had a collective underwriting loss of $5.7B in 2024. From 2019 to 2022, MA made up 40% of underwriting gains and dropped to 20% in 2023. The agency said the losses came from the v28 risk adjustment model (being phased in from 2024 to 2026), lower Star ratings bonus revenue, and high utilization, inflation, and medical costs. About 3 out of 4 insurers with an MA concentration had a loss last year.

#medicareadvantage #margins

https://www.beckerspayer.com/payer/medicare-advantage/ma-struggles-cited-in-2024-5-7b-underwriting-loss-report

PwC Highlights AI-Driven Change In Healthcare

A blockbuster report from management consultant PwC predicts that $1 trillion of national healthcare spending could go to digital-first, personalized medical care. PwC also says healthcare is in the process of a monumental shift to artificial-intelligence-driven, consumer-centric healthcare services, which could mean simplified care models emerge that lower costs and increase quality.

PwC notes that healthcare spending is expected to grow to $8.6 trillion by 2035, hitting 20% of gross domestic product. And this means health plan and provider executives must rethink care delivery.

In terms of payers, PwC notes that medical cost trends are nearing double digits and that payers will be expected to deliver far more with far less. It says AI and other technologies can help build capabilities to deliver medical value and actively manage population risk within the plan and with provider partners. It says payers will increasingly serve as data clearinghouses. Automation will be key to reduce costs as well and free up resources for investment into additional emerging technologies.

 #ai #healthplans #providers #technology #quality

https://www.fiercehealthcare.com/health-tech/2035-1t-healthcare-spend-will-shift-digital-first-ai-driven-healthcare-system-pwc

Government Funding Bill Fails

A government shutdown is coming closer to reality. A stop gap funding measure through November 21 passed the House on a vote of 217-212 but failed to achieve 60 votes in the Senate. Almost all Democrats and two Republicans voted together and the bill failed in the upper chamber by a vote of 44-48. Democratic Sen. John Fetterman, PA, voted with most Republicans in favor, while GOP Sens. Lisa Murkowski, AK, and Dr. Rand Paul, KY, voted with Democrats.

The House is expected to be out until two days before funding expires but may now have to come back early. The measure included many critical healthcare funding and policy extensions.

Additional articles: https://www.modernhealthcare.com/politics-regulation/telehealth-medicaid-dsh-stopgap-funding-bill/ and https://thehill.com/homenews/senate/5512606-government-shutdown-senate-funding-bill/

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#governmentshutdown #congress #ffy2026 #healthcare

https://www.fiercehealthcare.com/regulatory/republicans-unveil-7-week-stopgap-hospital-funding-telehealth-extensions-no-aca-premiums

Provider Directory Rule For Medicare Advantage

Medicare Advantage (MA) insurers will be required to submit provider directories to the Centers for Medicare and Medicaid Services (CMS) next year under a final rule issued Thursday. The provider information will be added to the Medicare Plan Finder. CMS will issue an operational guide to outline how to prepare and submit the directory.

MA plans will have to submit their network lists by Jan. 1 and then once a year. Updates must be made every 30 days to reflect changes in provider participation. Insurers will not have to attest that they meet network adequacy standards.

(Article may require a subscription.)

#medicareadvantage #providers #cms

https://www.modernhealthcare.com/politics-regulation/mh-medicare-advantage-plans-provider-directories-2026

Stars Drama Begins Early

The Centers for Medicare and Medicaid Services (CMS) will release SY 2026 results in October but appears to have botched part of the rollout. In Plan Preview 2, the agency provided insurers with a private preview of their individual ratings but may have accidentally disclosed every company’s preliminary ratings in the file. It is unknown if every plan got the ultimate sneak peek or not. CMS promptly pulled the electronic data, told plans to delete any download, and reuploaded just what it should have for each plan. It also has instructed plans not to make Stars public before October’s announcement after some did so. This led to some plans seeing increases in stock, while others who did not comment saw their stocks fall.

(Article may require a subscription.)

#stars #quality #medicareadvantage

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

Government Funding Stopgap

House Republicans will vote this week on a shorter, 7-week funding resolution for FFY 2026 (which begins October 1) that includes some critical healthcare extensions, but nothing on extending the Exchange premium subsidy enhancements. The bill would need a simple majority in the House but 60 votes in the Senate.

Congressional Democrats have suggested they may not support the measure unless it includes greater healthcare funding, including a rollback of some budget reconciliation bill cuts and extension of the subsidies.

Additional articles: https://www.fiercehealthcare.com/regulatory/republicans-unveil-7-week-stopgap-hospital-funding-telehealth-extensions-no-aca-premiums and https://www.beckershospitalreview.com/finance/aca-subsidy-extension-left-out-of-7-week-stopgap-funding-bill/

(Some articles may require a subscription.)

#governmentshutdown #congress #healthcare

https://www.modernhealthcare.com/politics-regulation/mh-house-spending-bill-aca-subsidies-mike-johnson

Trump Marketing Curbs Worry Brand Drug Makers

President Trump’s order to curb advertising for pharmaceutical drugs on television is creating anxiety for brand drug makers, advertising firms, and broadcasters. They say it could pose an existential threat to them. Media companies brought in $5 billion in advertising revenue from pharmaceutical companies in 2024.

The order does not outright ban direct-to-consumer advertising of drugs. Trump does not have the authority to do that, but health chief Robert F. Kennedy, Jr. wants to ban them. But the administration is using its executive and regulatory authority to ensure “transparency and accuracy” in direct-to-consumer advertising, including requiring greater disclosures of side effects in television and other ads. The administration also has sent cease-and-desist letters to some large drug manufacturers to combat “egregious violations demonstrating harm” in the marketing of high-cost prescription drugs.

The president is absolutely right on this one.

#drugpricing #marketing #branddrugmakers

https://thehill.com/policy/healthcare/5500949-trump-administration-pharma-advertising-curbs

Study Says Big Health Plans Will Continue Growth

A new analysis from Morningstar has a fairly optimistic view of big health plan growth over the next decade but notes some headwinds. It says big plans will continue to grow market share.

The study says Aetna, Centene, Cigna, Elevance Health, Humana and UnitedHealthcare will insure 56% of Americans by 2034. They had 41% in 2014 and 52% in 2024, so growth will be far more measured. United and Elevance will continue to lead the way.

The study notes these plans have some critical competitive advantages and that there is continued outsourcing of government program lives. Headwinds noted, though, are elevated utilization impacting profits, increased uninsured rates due to the budget reconciliation healthcare cuts, and new regulatory scrutiny. The last headwind includes prior authorization reforms, claims scrutiny, and risk adjustment reform. A possible headwind may be a move to have vertically integrated firms with health plans shed pharmacy benefits managers (PBMs). While reform of PBMs is likely, such disposition is less likely.

I am perhaps a little more pessimistic about big plan prospects. I think regulatory pressure could be far worse than expected and big plans may battle big time with provider entities and regional plans in the future. But yes, the big guys have a lot of advantages.

#healthplans #margins

https://www.fiercehealthcare.com/payers/morningstar-major-payers-are-set-grow-market-share-over-next-decade-headwinds-await-too