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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.

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#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

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#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/

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#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

Alignment Posts Q1 2026 Profit

Medicare Advantage (MA) plan Alignment Healthcare reported Q1 2026 revenue of $1.2 billion, a 33% increase from Q1 2025. MA membership reached 284,800 at the end of Q1, up 30.9% from Q1 2025. The insurer posted net income of $11.4 million, compared to a net loss of $9.4 million in Q1 2025. The company’s medical loss ratio (MLR) was 88.2%. The company raised its guidance for the year.

#medicareadvantage #alignment #margins

https://www.beckerspayer.com/payer/medicare-advantage/alignment-posts-11m-profit-in-q1

Cigna Beats The Street; Will Exit Exchanges

The Cigna Group beat The Street on both earnings and revenue in Q1 2026, posting $1.65 billion in profit. That’s up from $1.3 billion in Q1 2025. Revenues in the quarter were $68.5 billion, up from $65.5 billion haul in Q1 2025. Cigna’s medical loss ratio (MLR) decreased from 82.2% to 79.8%. Cigna is predominantly commercial.

But Cigna will exit the individual market for the 2027 plan year given troubles with membership and risk. And the company is likely to sell its company EviCore, which specializes in prior authorization services. Its Express Script PBM revenue was down given the transition to net pricing.

Additional articles: https://www.fiercehealthcare.com/payers/cigna-posts-165b-profit-q1-earnings-beat and https://www.modernhealthcare.com/insurance/mh-cigna-aca-exchanges-2027/ and https://www.healthcaredive.com/news/cigna-exit-aca-exchanges-despite-q1-2026-profit-growth-ci/818873/ and https://www.beckerspayer.com/financial/cigna-to-exit-aca-individual-business-posts-1-65b-q1-profit/

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#healthplans #margins #cigna

https://www.modernhealthcare.com/insurance/mh-cigna-earnings-outlook-evernorth-health

Another Model Deadline Extended

The Centers for Medicare & Medicaid Services (CMS) is extending the application deadline for drug manufacturers to apply to the GENErating cost Reductions fOr U.S. Medicaid (GENEROUS) Model. The deadline was extended by the agency to June 11 from April 30. CMS says the reason was due to overwhelming interest from prescription drug manufacturers. However, it cites that more time will help small to mid-sized firms to join. Participation agreement deadlines will be extended from June 30 to July 17. CMS is also extending the deadline for states to apply to the GENEROUS model from July 31 to September 10 and to finalize participation agreements from August 31 to September 30.

The program intends to have the federal government negotiate with drug makers to obtain a most-favored-nation (MFN) price. MFN drug pricing is also being set up in Medicare under the GLOBE and GUARD models.

Read my blog Monday on potholes at CMS with reform models: https://www.healthcarelabyrinth.com/cms-reform-models-hitting-some-potholes/

#drugpricing #trump #mfn

https://www.cms.gov/newsroom/news-alert/cms-extends-deadlines-generous-model-applications-drug-manufacturers-states

Site Neutral Stunner On Capitol Hill

Health system CEOs faced a grilling on a range of hospital issues today on Capitol Hill, but in a stunning turn of events the executives said that they are willing to discuss reasonable changes to their long-standing opposition to site neural payments in Medicare.

Under site neutral, the same services at all locations are paid the same rate, which would drop hospital payments dramatically. What emerged was some consensus on moves to site neutral that would recognize hospital differences in some cases and changes that might be phased in so as not to undermine finances at health systems.

Lawmakers, mostly on the GOP side, otherwise accused health systems of driving high costs and reducing competition. Democrats focused on the cuts in the One Big Beautiful Bill (OBBBA).

The Trump administration finalized another small step on site neutrality, but Capitol Hill has always been stymied by a strong hospital lobby opposition. It was truly a watershed event.

Additional articles: https://www.fiercehealthcare.com/providers/capitol-hill-health-system-ceos-agree-rational-reworking-site-neutral-payments and https://thehill.com/homenews/house/5853987-gop-hearing-hospital-costs/

(Some articles may require a subscription.)

#hospitals #antitrust #mergers #acquisitions #siteneutral

https://www.modernhealthcare.com/politics-regulation/mh-congress-hca-commonspirit-new-york-presbyterian-ceos