Newsfeed

Elevance Gets A Reprieve

Elevance Health avoided sanctions for now, including an enrollment and marketing freeze, after the Centers for Medicare and Medicaid Services (CMS) granted the Medicare Advantage (MA) plan an extension to make up for incorrect risk adjustment data reporting. Elevance has until May 30 to remediate the issues.

At the same time, a bipartisan group of senators is urging CMS to work with Congress to crack down on overpayments in MA.

Further, a lawsuit alleging Elevance Health’s Carelon Behavioral Health misled beneficiaries about the scope of its provider network was allowed to move forward by a judge.

Additional article: https://www.healthcaredive.com/news/elevance-sidesteps-medicare-advantage-sanctions-cms/816324/ and https://www.fiercehealthcare.com/payers/blue-cross-plan-accused-perpetrated-fraud-ghost-network-class-action-lawsuit and https://www.modernhealthcare.com/insurance/mh-carelon-behavorial-ghost-network-lawsuit-elevance/

(Some articles may require a subscription.)

#medicareadvantage #riskadjustment #overpayments #elevancehealth

https://www.healthcaredive.com/news/bipartisan-senators-cms-crack-down-medicare-advantage-overpayments-upcoding/816336

Gallup Finds Healthcare Affordability Tops Concern List

A new Gallup Poll finds that Americans are more concerned about the availability and cost of healthcare than any other domestic issue. It is now issue number 1 in Americans’ minds. This has not happened since 2020.

About 61% of the 1,000 adults surveyed said they worry a “great deal” about accessing and affording healthcare, while 23% expressed a “fair amount” of concern. About 51% of respondents said they were concerned a “great deal” about the economy and 50% said the same about inflation.

The change comes as premiums surge throughout healthcare and enhanced Exchange subsidies expired.

In other news, healthcare tech company Cedar surveyed 4,150 patients across the U.S. and analyzed 1.5 billion patient interactions. Nearly 40% of healthcare collections now come from uninsured patients, up 54% in the past three years.

Also, states are paying contractors such as Deloitte, Accenture, and Optum millions of dollars to help them comply with the One Big Beautiful Bill Act (OBBBA) new mandates, including work requirements in Medicaid.

Additional articles: https://www.fiercehealthcare.com/finance/uninsured-patients-drive-nearly-40-healthcare-collections-cedar-survey and https://www.fiercehealthcare.com/regulatory/states-pay-deloitte-others-millions-comply-trump-law-cut-medicaid-rolls

#healthcare #coverage #uninsured #medicaid #workrequirements

https://thehill.com/policy/healthcare/5808929-healthcare-concerns-top-issue

CMS Announces Final Exchange Enrollment

The Centers for Medicare and Medicaid Services (CMS) announced final Exchange enrollment nationwide as well as premium hike statistics. Total enrollment fell nationwide from 24.3 million in 2025 to 23.1 million in 2026. This is far less than anticipated, but some say rolls will slip further due to the inability to afford the surges in premiums as well as lower subsidies. Current 2026 enrollment is still 1.7 million higher than in 2024.

About 15.8 million enrollees obtained coverage through the HealthCare.gov platform, while 7.4 million were enrolled through a state-based Exchange. New customers dropped 13% year over year. Enrollees with an advanced payment premium tax credit dipped from 92% to 87%, while the portion with cost-sharing reductions dropped from 51% to 37%. The latter figure may indicate that many low-income individuals dropped coverage.

Average premiums increased 58% for those on subsidies because enhancements expired. This is lower than a healthcare policy group projection that premiums would jump 114%. KFF indicated its projection was based on everyone staying in current plans. Consumers are paying on average $780 per year more for coverage in 2026.

As CMS noted, enrollment in low-premium, high-deductible bronze plans jumped due to premium surges. Enrollment in bronze plans jumped from 30% in 2025 to 40% in 2026. Silver plans dropped from 56% in 2025 to 43% in 2026.

Additional articles: https://www.fiercehealthcare.com/payers/cms-years-open-enrollment-brought-fewer-signups-higher-premiums-fewer-silver-sign-ups and https://www.healthcaredive.com/news/aca-premiums-enrollment-bronze-plans-2026-cms-data/816067/

(Some articles may require a subscription.)

#exchanges #coverage #healthcare

https://www.modernhealthcare.com/insurance/mh-aca-customers-2026-cms-data/

State Hospital Price Caps

Modern Healthcare has a good article on various state initiatives to regulate hospital prices. Proposals range from hard caps to looser standards. Coincidentally, I had a blog on Thursday covering many of the same states and initiatives. Check it out here: https://www.healthcarelabyrinth.com/states-attack-healthcare-costs-and-hospital-prices/

In related news, healthcare policy group KFF issued a briefer on hospital competition in the U.S. The analysis examines the competitiveness of markets for hospital care based on RAND Hospital Data and American Hospital Association (AHA) survey data. 

It found that one or two health systems controlled the entire market for inpatient hospital care in nearly half (47%) of metropolitan areas in 2024. In more than four of five metropolitan areas (83%), one or two health systems controlled more than 75% of the market. Nearly all (97% of) metropolitan areas had highly concentrated markets for inpatient hospital care.

KFF also says that most hospital markets in metropolitan areas (80%) became less competitive from 2015 to 2024 or were controlled by one health system over that entire period.

Additional article: https://www.kff.org/health-costs/one-or-two-health-systems-controlled-the-entire-market-for-inpatient-hospital-care-in-nearly-half-of-metropolitan-areas/

(Some articles may require a subscription.)

#hospitals #rates #coverage #healthcare

https://www.modernhealthcare.com/providers/mh-hospital-price-cap-legislation-indiana-vermont

GOP May Run Another Reconciliation Bill

Republicans may run another budget reconciliation bill to advance a number of President Donald Trump’s stalled priorities, including funding for the war, a voting bill, and to fund the Department of Homeland Security. Within the bill likely will be more healthcare cuts to meet spending rule and deficit mandates. Not all of the initiatives would pass the Byrd rule, which limits what can be in such a bill.

Among the healthcare cuts that could be included are:

• Implementing aggressive site neutrality in Medicare.
• Funding cost-sharing reductions in the Exchanges (to save on premium tax credits).
• Further reining in Medicaid eligibility for some populations.
• Aspects of Trump’s healthcare plan, including expanding ICHRA reimbursement and small business healthcare tax credits, Exchange benefit package changes, replacing Exchange subsidies with Health Savings Account (HSA) contributions, and codifying TrumpRx.
• Requiring greater price transparency from health insurance companies and providers.

(Article may require a subscription.)

#congress #trump #reconciliation #exchange #coverage

https://www.modernhealthcare.com/politics-regulation/mh-gop-budget-reconciliation-bill-medicaid-aca

Senate Deal On Private Coverage Insulin Costs

Sens. Jeanne Shaheen, D-NH, Susan Collins, R-ME, Raphael Warnock, D-GA, and John Kennedy, R-LA, reached a deal to limit out-of-pocket costs for people with diabetes by waiving any deductibles and limiting cost sharing to the lesser of $35 or 25 percent of the list price per month. This could lead to the passage of the legislation in the upper chamber.

The bill would also require pharmacy benefit managers (PBMs) to pass through 100% of insulin rebates and other compensation to insurers. A pilot program in 10 states would also be set up to identify uninsured people with diabetes and providing them with $35 monthly insulin.

#drugpricing #insulin #diabetes

https://thehill.com/policy/healthcare/5800233-insulin-cost-cap-legislation

CVS Health To Settle PBM Lawsuit With FTC

CVS Health’s Caremark has become the second of the Big 3 pharmacy benefit managers (PBMs) to reach a settlement with the Federal Trade Commission (FTC) over insulin pricing. A court document filed Monday indicates the parties have requested that the matter be withdrawn “for the purpose of considering a proposed consent agreement.”

No details on the settlement were made public, but the concessions likely mirror the far-reaching elements agreed to earlier by Cigna’s Express Scripts PBM. United’s OptumRx PBM will undoubtedly have to settle too.

Additional articles: https://www.fiercehealthcare.com/payers/cvs-caremark-ftc-reach-settlement-insulin-pricing-case and https://www.healthcaredive.com/news/cvs-caremark-ftc-proposed-settlement-insulin-lawsuit/815581/

(Some articles may require a subscription.)

#ftc #cvshealth #pbms #insulin #drugpricing

https://www.modernhealthcare.com/politics-regulation/mh-cvs-health-ftc-insulin-rebate-lawsuit/

Two Major Medicare Advantage Developments

Two major Medicare Advantage (MA) developments today.

Modern Healthcare reports that MA plans are pushing the Centers for Medicare and Medicaid Services (CMS) to change the $40 per member per month total beneficiary cost threshold that has been in place since 2024. Plans say this is needed so as to allow scaling back benefits more to respond to rising costs and paltry rate hikes.

The 2027 proposed hike is roughly flat due to several changes in how risk adjustment will be applied. It could increase some (say to between 2% and 3%) but the final hike will not be near the cost growth in the program (that was as much as 9% coming into the year) or the over 5% hike last year.

Plans have been reducing geographic footprints, shuttering expensive Preferred Provider Organization (PPO) products, and reducing benefits the past few years. But benefit reductions are constrained by the $40 benefit cost threshold. And plans know they will need to pare benefits again in 2027.

Humana and Scan are two big plans that have seen enrollment jump tremendously and are among plans asking for the change. The cap on total beneficiary cost was introduced in 2012 and is meant to be a consumer protection but does not appear to be keeping up with the huge trend in the program. In February, CMS proposed maintaining the $40 per member per month total beneficiary cost threshold that has been in place since 2024. The agency intends to finalize it in April.

Meanwhile, President Trump’s Medicare director said CMS may consider default enrollment of new Medicare beneficiaries. The proposal could automatically enroll beneficiaries into MA or traditional Medicare accountable care organizations (ACOs). Individuals could then opt out to different coverage. Right now, people who don’t make a choice are covered by traditional Medicare.

Additional article: https://www.statnews.com/2026/03/20/medicare-advantage-default-enrollment-chris-klomp-project-2025/

(Articles may require a subscription.)

#medicareadvantage #coverage #cms #healthplans #medicare

https://www.modernhealthcare.com/insurance/mh-cms-medicare-advantage-benefits-humana-scan

Read My Lips — No New Faxes: CMS Finalizes Electronic Exchange Rule

The Centers for Medicare & Medicaid Services (CMS) finalized a new healthcare and electronic processes rule that is aimed at slashing wasteful spending and antiquated paperwork. The rule establishes national standards for the electronic exchange of clinical documentation used to support healthcare claims. CMS says the initiative will help end faxing and mailing in favor of electronic transactions. The agency hails the change as a way to reduce providers’ administrative burden. CMS says the rule will reduce costs, save time, ensure faster care delivery, and enhance security and efficiency.

CMS says the “Administrative Simplification; Adoption of Standards for Health Care Claims Attachments Transactions and Electronic Signatures Final Rule” is projected to save the healthcare industry $781 million annually. The standards adopted apply to any Health Insurance Portability and Accountability Act (HIPAA)-covered entities, including health plans, healthcare clearinghouses, and healthcare providers. Covered entities must comply by May 26, 2028.

Additional article: https://www.cms.gov/newsroom/press-releases/cms-rule-phases-out-fax-machines-snail-mail-save-taxpayers-781-98-million-year

#cms #healthplans #providers #interoperability #priorauthorization #claimsdenials

https://www.cms.gov/newsroom/fact-sheets/administrative-simplification-adoption-standards-health-care-claims-attachments-transactions

Senate Dems Unveil Healthcare Agenda If They Take Over

Twelve Democratic senators signed a letter detailing their plan for health insurance reforms they will pursue if they take back the Senate. They want to focus on affordability, reduce barriers to insurance, and hold insurance companies accountable. The Democrats said Republicans were responsible for recent healthcare cuts, including the expiration of enhanced subsidies in the Exchanges and Medicaid and Exchange cuts. They would undo the reductions.

Democratics want more affordable coverage, smoother enrollment — through “a one-stop shop” — and wider offerings for lower-income people. They would extend coverage to those in states that did not expand Medicaid and want a “Medicare-type” public option for all Americans. They also want to turn back recent changes on skimpier policies and standardize plans. In addition, they would focus on price transparency, prior authorization, and medical loss ratio gaming reforms.

Vertical integration reform of insurers, pharmacy benefits managers, and more would be a priority as well.

Additional articles: https://www.fiercehealthcare.com/regulatory/democratic-senators-detail-plans-take-big-insurance and https://www.modernhealthcare.com/politics-regulation/mh-democrats-trump-tax-law-aca-subsidies/

(Some articles may require a subscription.)

#healthcare #coverage #democrats #midterms

https://www.beckerspayer.com/policy-updates/senate-democrats-lay-out-health-insurance-reform-agenda-and-put-industry-on-notice/

— Marc S. Ryan