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340B Program Reform Coming

The Trump administration indicated in several drug price reform announcements it would seek to reform the 340B drug discount program. Now, it is proposing a pilot to go down the reform path. The Health Resources and Services Administration (HRSA) is launching a voluntary program to test drug makers paying rebates versus issuing discounts upfront to the qualifying providers, which include some hospitals, federally qualified health centers, and other safety-net providers. The pilot will cover just a small subset of drugs, including those for diabetes, rheumatoid arthritis, and heart failure.

Some brand drug makers attempted to convert to rebates but were stopped by the Biden administration. The Trump administration appears on board, although hospitals and other providers oppose the changes. But 340B badly needs reforms as the drug discounts are not truly being passed on by most providers, who pocket the discounts.

Additional articles: https://www.modernhealthcare.com/politics-regulation/mh-hrsa-340b-rebate-pilot-program-2026

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#340b #drugpricing #hospitals #branddrugmakers

https://www.fiercehealthcare.com/providers/hhs-will-demo-drugmakers-340b-rebate-model-limited-pilot-program

More Insurer Financial News

Medicare Advantage-dominant insurer Humana had better financial news than most insurers these days, but perhaps because of its earlier bad reports and its ongoing efforts to right its financial ship. Humana slightly raised its guidance on earnings, although it did have a decline in net income in Q2. Humana reported a net income of $545 million in the second quarter, down from a net income of $679 million during the same period last year.

Lower MA revenue and high utilization spend continues to challenge Humana. The medical loss ratio was reported as 89.7%, high but in line with forecasts. Its Medicaid financials bucked trends. Its pharmacy unit was a bright spot.

Humana says its projected loss in membership in MA will be lower than previously forecast – 500,000 vs. 550,000.

In other news, Fitch affirmed UnitedHealth Group’s “AA-” rating July 30 but revised the company’s outlook to negative from stable. 

Alignment Healthcare posted its first quarterly profit and raised its full-year membership, revenue, adjusted profit and adjusted EBITDA outlooks.

Additional articles: https://www.modernhealthcare.com/insurance/mh-humana-medicare-advantage-outlook-earnings/ and https://www.healthcaredive.com/news/humana-2025-guidance-raise-medicare-advantage-pharmacy/756257/ and https://www.beckerspayer.com/payer/fitch-revises-unitedhealths-outlook-to-negative/ and https://www.beckerspayer.com/payer/medicare-advantage/alignment-healthcare-posts-first-profit/ and https://www.beckerspayer.com/payer/humana-posts-545m-q2-profit-raises-2025-outlook/

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#healthplans #margins #humana #unitedhealthcare #alignment #medicareadvantage #medicaid

https://www.fiercehealthcare.com/payers/humana-improves-outlook-revenue-beats-estimates-q2

UnitedHealth Group’s Financial Woes

UnitedHealth Group painted a bleak picture in its revised outlook for 2025. It significantly downgraded its projections for 2025 and reported a steep drop in earnings per share. Net income declined 19% to $3.4 billion.

United says it will deemphasize sales of Medicare Advantage (MA) PPOs, eliminate unprofitable MA plans in 2026 that cover more than 600,000 people, and may exit some Exchange markets in 2026.

United is seeing its MA costs spike well over forecast and they could go even higher, to as much as 10%. While most plans are hurting in MA, United’s problems seemingly came out of the blue and are right now worse than others. Costs are high in other business lines, too. Its normally strong services unit, Optum, also is feeling the pinch.

And given its continuing financial woes, Humana is offering certain employees voluntary early retirement buyouts. Employees age 50 or older with at least three years of service are eligible for the program, although those working in certain business-critical areas will be ineligible.

Additional articles: https://www.modernhealthcare.com/insurance/mh-humana-buyouts-voluntary-early-retirement/ and https://www.modernhealthcare.com/insurance/mh-unitedhealth-group-q2-earnings-guidance/ and https://www.healthcaredive.com/news/unitedhealth-2025-outlook-lower-earnings/754243/ and https://www.beckerspayer.com/payer/unitedhealth-group-sets-new-earnings-guidance-amid-19-q2-profit-dip/ and https://thehill.com/policy/healthcare/unitedhealth-earnings/

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#unitedhealthcare #medicareadvantage #humana #margins #layoffs

https://www.fiercehealthcare.com/payers/unitedhealth-cuts-2025-outlook-elevated-medical-costs-continue-sting

CMS Reins In Part D PDP Premium Stabilization Program

The Centers for Medicare & Medicaid Services (CMS) released preliminary technical Medicare Part D bid information for contract year 2026. It released the national average monthly bid amount (NAMBA) and base beneficiary, which are used in bid preparation. CMS also announced it was again funding a special premium stabilization demonstration started in 2025 to keep premiums from rising dramatically.

The culprit for rising premiums is largely the passage of cost-sharing limits in Part D in the Democrats’ Inflation Reduction Act. The Democrats did not adequately fund the changes and therefore pushed many of the costs to plans, which then had to increase premiums and cost-sharing and make other reductions. The IRA changes have badly impacted the financial stability of the standalone Part D offerings (PDPs).

For 2026, the generosity of the demonstration will be less. In 2026, CMS is reducing the uniform base beneficiary premium reduction from $15 to $10, increasing the increase limit on a plan’s total Part D premium from $35 to $50, and eliminating the narrowed risk corridor thresholds. While PDP enrollees saw less offerings and higher costs in 2025, they will likely see more of this in 2026.

In other news, healthcare policy group KFF published a review of 2025 Medicare Advantage (MA) plans. A key finding: In 2025, more than three quarters (76%) of enrollees in individual MA plans with prescription drug coverage pay no premium other than the Medicare Part B premium.

Further, KFF also published a review of 2025 MA enrollment so far. More than half (54%) of eligible Medicare beneficiaries are enrolled in Medicare Advantage in 2025. In 2025, one in five (21%) Medicare Advantage enrollees is in a special needs plan (SNP), reflecting a steady increase in recent years. Slightly less than one in five (17% or about 5.7 million) Medicare Advantage enrollees are in a group plan offered to retirees by an employer or union.

Additional articles: https://www.kff.org/medicare/issue-brief/medicare-advantage-premiums-out-of-pocket-limits-supplemental-benefits-and-prior-authorization/ and https://www.kff.org/medicare/issue-brief/medicare-advantage-enrollment-update-and-key-trends/

#medicareadvantage #partd #pdp #specialneedsplans #snps

https://www.cms.gov/newsroom/fact-sheets/2026-medicare-part-d-bid-information-and-part-d-premium-stabilization-demonstration-parameters

Centene Reports Huge Loss in Q2

After pulling its earnings guidance several weeks ago, Centene announced today a $253 million loss in the second quarter as it navigates significant cost pressures. Financials will be challenging in 2026 due to Exchange and Medicaid reductions in the recent budget bill. Its medical loss ratio (MLR) was 93%. It also received lower risk adjustment transfers in the Exchange than anticipated.

Through the first six months of the year, the company brought in $95.4 billion in revenue and $1.05 billion in profit. Centene will update rates for the Exchange given higher adversity and the impact of the budget bill. It also hopes for higher Medicaid rates.

Centene is the largest Exchange plan, with 5.8 million members in 29 states, and the largest Medicaid plan, with 12.8 million members in 30 states.

Additional articles: https://www.fiercehealthcare.com/payers/centene-posts-253m-loss-amid-aca-marketplace-woes and https://www.modernhealthcare.com/insurance/mh-centene-earnings-medicaid-cuts-aca-market/ and https://www.beckerspayer.com/payer/centene-posts-253m-loss-in-q2/

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#centene #medicaid #exchanges #margins

https://www.healthcaredive.com/news/centene-q2-2025-loss-medicaid-aca/754014

Could Bipartisan Healthcare Reforms Be In The Making?

Senate Republicans say they are working on a bipartisan healthcare package to lower drug and health insurance costs. Democrats say they have not been brought into the process and are skeptical.

Sen. Bill Cassidy, R-LA, who leads the HELP Committee, is leading the talks, with pharmacy benefit managers reform and stopping upcoding practices in the Medicare Advantage (MA) risk adjustment program at the top of the list of reforms. Further, a group of Republican senators, including Lisa Murkowski of Alaska, are pushing to extend the expiring Exchange enhanced premium subsidies.

It appears that even conservative Senate Finance Chair Michael D. Crapo, R-Idaho, who chairs the Senate Finance Committee, is involved.

#healthcare #riskadjustment #medicareadvanage #pbms #drugpricing

https://rollcall.com/2025/07/23/republicans-plan-bipartisan-health-package-as-democrats-demur

With Friends Like These: No Love From GOP For Medicare Advantage

At a House Ways and Means Committee’s joint oversight and health subcommittee hearing, GOP lawmakers declared that the Medicare Advantage (MA) program needs an overhaul and private plans need to be reined in. The primary complaints were risk adjustment upcoding and prior authorization abuses. They also argued MA is not saving money as promised.

The hearing was contentious and could lead to either accelerated reforms from the Centers for Medicare and Medicaid Services (CMS) or possible inclusion of cuts in a future budget bill. But admittedly, so far Congress has not wanted to pull the trigger on MA reforms given the popularity among seniors.

In other news, a good article on the Trump administration proposal to begin some site neutral payment reform in Medicare. Some hospital-owned outpatient facilities (just off-campus outpatient facilities) would be paid the same to administer medications as physicians. CMS projects that Medicare would save $210 million and that beneficiaries would save $70 million in out-of-pocket costs next year. Clinic visits at on-campus outpatient departments could be the next area of reform.

These are baby steps. Congress is working on broader measures. Congressional policy arm MedPAC proposes very deep changes. Of course, hospitals will fight all site neutral measures because they simply do not want to reform and be efficient. But the time seems to be coming – finally.

Site neutral on Medicare fee-for-service (FFS) would help MA and commercial products as well.

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Additional articles: https://www.modernhealthcare.com/politics-regulation/mh-medicare-advantage-house-hearing-upcoding/ and https://www.modernhealthcare.com/politics-regulation/mh-site-neutral-payment-cms-2026/

#hospitals #medicare #siteneutral

https://www.healthcaredive.com/news/medicare-advantage-house-hearing-upcoding-prior-auth/753726

Oscar Health Slashes Earnings Guidance

The trend continues of large health plans surprising The Street with major slashes in guidance with little or no notice. While its Q2 investor call is not until August 6, Oscar Health announced today it is slashing its full-year guidance by about half a billion dollars. The insurer expects a loss from operations of $200 million to $300 million just months after estimating earnings from operations of $225 million to $275 million. Elevated utilization is a big culprit. Oscar’s medical loss ratio is climbing to between 86% and 87%, more than 5% higher than initially forecast.

Oscar had an operating loss of about $230 million in Q2, when analysts expected an operating profit of $55.5 million.

Oscar is a 100% Exchange plan. Revenue and margin concerns likely will continue given the expiration of the enhanced premium subsidies and enrollment tightening in a new rule and the budget reconciliation bill. Enrollment is slated to drop in 2026.

Additional articles: https://www.fiercehealthcare.com/payers/oscar-health-cuts-full-year-guidance-estimates-2025-loss-aca-marketplace-stumbles and https://www.modernhealthcare.com/insurance/mh-oscar-health-aca-marketplace-obamacare/

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#oscar #exchanges #healthplans #margins

https://www.beckerspayer.com/payer/oscar-health-is-latest-insurer-to-cut-earnings-guidance/

Final Budget Score In From CBO: 10 Million To Lose Coverage

The One Big Beautiful Bill Act that President Donald Trump signed into law on Independence Day will add $3.4 trillion to the national debt from 2025 to 2034. This is from the final scoring of the bill from the Congressional Budget Office (CBO). The estimated deficit rise reflects $1.1 trillion in cuts to direct spending and a $4.5 trillion government revenue loss due to extended and new tax cuts.

CBO also projects the number of uninsured individuals will increase by 10 million by 2034 due to the Medicaid and Exchange reductions in the bill. This is about 2 million less than previously estimated due to some provisions being ruled unallowable by the Senate parliamentarian. Adding the expected 4.2 million to lose coverage when the enhanced Exchnage subsidies expire December 31 as well the 900,000 to lose coverage due to the just finalized Exchange rule, a total of just over 15 million will lose coverage as opposed to about 17 million.

Healthcare cuts are about $1.1 trillion over ten years, with $964 billion cut from Medicaid and $124 billion from the Exchanges.

In terms of Medicaid, limitations, and phasedown on provider taxes as well as limits on state directed payments save $392 billion and work requirements save $326 billion.

In addition, more than half of Americans — 57 percent — said in a new CBS/YouGov poll that they think the GOP’s budget bill will increase their health-care costs.

Additional articles: https://www.modernhealthcare.com/politics-regulation/trump-tax-law-medicaid-cbo/ and https://thehill.com/business/5412262-biden-bill-adds-3-4-trillion-deficits/?tbref=hp and https://thehill.com/policy/healthcare/5411435-gop-megabill-health-care-costs-survey/

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#budgetreconciliation #trump #congress #spending #medicaid #coverage #exchanges

https://www.beckershospitalreview.com/hospital-management-administration/one-big-beautiful-bill-to-add-3-4t-in-debt-cbo

Humana Loses Stars Lawsuit

Humana’s lawsuit on Star calculations was thrown out of court this week. The judge indicated that the plan did not exhaust internal appeals processes at the time of the filing and thus the suit did not have standing. The suit could be refiled, though. The Centers for Medicare and Medicaid Services (CMS) later rejected Humana’s appeal.

Humana’s suit was far-reaching and pointed. It said CMS did not follow its own regulations in its methodology for calculating ratings and said the agency does not provide plans the necessary data to calculate aspects of Star ratings. As an example, Humana said it could not replicate 60% of CMS’ cut point calculations.

Humana’s average Star score fell from 4.37 in 2024 to 3.63 for 2025.

Despite the lawsuit outcome, Humana is not wrong in its premise that inadequate data and a lack of transparency pervades the Star process. While the agency has gotten better about releasing and explaining aspects of the complex Star calculations, aspects remain a black box.

Additional articles: https://www.modernhealthcare.com/insurance/mh-humana-medicare-advantage-lawsuit-dismissed/ and https://www.beckerspayer.com/legal/judge-dismisses-humanas-medicare-advantage-star-ratings-lawsuit/ and https://www.healthcaredive.com/news/humana-medicare-advantage-star-ratings-lawsuit-dismissed/753455/

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#stars #cms #humana #medicareadvantage #quality

https://www.fiercehealthcare.com/payers/humana-joins-chorus-lawsuits-over-sinking-star-ratings