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More Brand Drug Makers Scramble To Make Deals With Trump

Big brand drug makers are scrambling to make deals with President Trump after Pfizer scored White House praise for making drug price concessions. Some of the other firms are upset with Pfizer as it increases pressure on them to cut deals as well. The White House says agreements could be announced as soon as this week, but the timing could slip.

I have a blog coming tomorrow on drug price reform so far this year and why the brand drug makers are hoodwinking Trump and his advisors with these deals. See it at the blog tab tomorrow.

In other news, a federal appeals court unanimously rejected a Novo Nordisk challenge to Medicare’s drug price negotiation program for 2025 negotiations. The ruling will allow the government to lump together products with the same ingredients for the purpose of choosing drugs for negotiation. Novo Nordisk argues the government was limited to negotiating 15 drugs and could not bundle some together, such as insulins and GLP-1 weight loss drugs.

Judges have ruled against drug makers and their supporters at least 15 times since the Medicare drug negotiation law came into effect.

Final guidance for the third round of Medicare drug price negotiations (2026 negotiations for 2028 prices) was also announced and Health Affairs Forefront blog does a good job outlining it. The 2025 negotiation results for 2027 pricing of 15 drugs will come out in late November.

Additional articles: https://www.statnews.com/2025/10/07/appeals-court-ruling-medicare-price-negotiations-novo-nordisk/ and https://www.healthaffairs.org/content/forefront/administration-releases-medicare-drug-price-negotiation-program-final-guidance-2028

(Some articles may require a subscription.)

#drugpricing #branddrugmakers #ira #trump

https://www.statnews.com/2025/10/07/trump-drug-pricing-deals-with-pharma-companies-after-pfizer/

Medicare Part D Program For 2026 Analyzed

Healthcare policy group KFF does its usual fabulous job analyzing Medicare Part D. In its new briefer, KFF sends a bit of a cautionary tale. While choice continues to exist in standalone Part D (PDP), the program continues to face financial headwinds and contract.

KFF finds:

• In 2026, beneficiaries in each state will have a choice of between 8 and 12 PDPs as well as Medicare Advantage (MA) Part D plans.
• A total of 360 PDPs will be offered by 17 different parent organizations across the 34 PDP regions nationwide (excluding 7 PDPs in the territories), a 22% decrease from 2025.
• Roughly the same number of PDPs will be available for enrollment of Part D Low-Income Subsidy (LIS) beneficiaries for no premium. These are called “benchmark” plans. But just 1 to 4 PDPs will be available across states.
• The 2026 Part D base beneficiary premium will be $38.99, a 6% increase from 2025. 
• Actual monthly premiums paid by Part D enrollees in stand-alone PDPs in 2026 will vary considerably, ranging from $0 to $100 or more in most regions.

A series of misguided cost-sharing reductions made by Democrats in the Inflation Reduction Act has created a difficult financial environment for Part D, causing plan exits and eroded benefits. The total number of stand-alone drug plans available in 2026 will fall for the third year in a row, as plan sponsors scale back their PDP offerings. But plans did their best to keep premiums low to avoid even greater concerns. Consumers likely will see higher costs within the benefit design. The big question is what will happen if and when the special premium stabilization program expires.

Additional articles: https://www.kff.org/medicare/a-current-snapshot-of-the-medicare-part-d-prescription-drug-benefit/ and https://www.kff.org/medicare/medicare-part-d-premiums-are-decreasing-for-many-stand-alone-drug-plans-in-a-number-of-states-in-2026/

#medicare #partd #pdp #medicareadvantage

https://www.fiercehealthcare.com/payers/stable-premiums-plan-exits-look-current-state-medicare-part-d

Government Shutdown Continues: Trump and Oz Signal Openness On ACA Credits

Democrats again voted down a GOP government funding bill on a fifth attempt. The same three Democratic caucus members supported the measure, but it fell short of the 60 votes needed to pass in the Senate.

Democrats are seeking to tag the government closure as a healthcare shutdown, arguing business cannot resume unless expiring Exchange premium enhancements are extended and other healthcare cuts are rescinded. Polls seem to show that Republicans are being blamed more for the shutdown than the Democrats, but the split is razor thin at 52-49. A healthcare policy group KFF poll also finds that more than three-quarters of Americans want the tax credit enhancements to continue. And about 3 in 4 people said they will blame Trump or the GOP if they end.

Republicans and Democrats both appear to be unrelenting in their position, but both President Trump and Centers for Medicare and Medicaid Services (CMS) Administrator Dr. Mehmet Oz signaled they are willing to consider healthcare changes. President Trump indicated he was willing to making a deal with Democrats on healthcare but indicated he is not saying it will happen.

A new KFF analysis also finds that 80% of all premium tax credits benefited enrollees in states Trump won. In part this is because more red or reddish states have not expanded Medicaid and the previously uninsured are more reliant on the Exchanges.

Republicans take the position that they have about three months to negotiate an extension if they want to, but the truth is that open enrollment begins for most Nov 1. And premium hikes due to the subsidy enhancement expiration would need to be public by then. This could chill re-enrollment.

Oz called out his concerns with fraudulent enrollments but said that premium rates from the health plans could be adjusted before the new year. While some moderate Republicans are sympathetic to an extension, conservatives are urging leaders not to go wobbly on the Obamacare issue.

Additional articles: https://thehill.com/homenews/administration/5540415-trump-republicans-shutdown-cbs-poll/?tbref=hp and  https://www.kff.org/quick-take/more-than-half-of-aca-marketplace-enrollees-live-in-republican-congressional-districts/ and https://www.kff.org/quick-take/if-enhanced-aca-tax-credits-expire-older-marketplace-enrollees-face-steepest-premium-hikes/ and https://thehill.com/policy/healthcare/5538167-congress-aca-tax-credit-increase/ and https://thehill.com/homenews/house/5540430-mike-johnson-shutdown-obamacare-subsidies/ and https://thehill.com/homenews/house/5540836-chip-roy-obamacare-shutdown/?tbref=hp and https://thehill.com/policy/healthcare/5541610-trump-democrats-healthcare-deal/

#governmentshutdown #congress #trump #healthcare #coverage #exchanges #oz

https://www.fiercehealthcare.com/regulatory/oz-urges-legislators-end-shutdown-then-negotiate-aca-subsidies

— Marc S. Ryan

SNP Benefits Continue Growth

As more becomes known about Medicare Advantage (MA) 2026 benefits, one trend continues. Special Needs Plan (SNP) investments remain strong. Despite notable MA contraction overall again, SNP benefit packages kept growing for 2026. SNP benefit offerings will grow overall by 33%. Regular MA plans will see a contraction of 9%, with Institutional or I-SNPs dropping 6%. Dual Eligible or D-SNPs will grow by 15% and Chronic Care or C-SNP packages by 42%. D-SNPs still dominate overall numbers in terms of benefit packages and enrollment.

Investments in C-SNPs are occurring as a hedge. C-SNPs carry increased regulatory requirements, but not to the extent of D-SNPs, which are undergoing major integration between the Medicare and Medicaid programs. The growth also is occurring because the ability to have too many SNP “look-alikes” was reined in through a recent rule.

There are a few plans behind this major growth in C-SNPs. Devoted Health is responsible for about half of the C-SNPs growth. They had four C-SNPs in three states and 13 counties in 2025. Now, the plan will have 29 C-SNPs in 978 counties for 2026. Aetna will have 46 plans in 18 states and 242 counties, up from six in two states and 18 counties. Humana will have 74 plans in 26 states and 1,089 counties, up from 64 in 24 states and 1,048 counties. UnitedHealthcare has 97 C-SNPs in 41 states and 2,086 counties for 2026, down slightly from 100 in 42 states and 2,094 counties.

Benefits were trimmed in most SNP plans from 2025 (especially supplemental benefits), but some plans also enhanced benefits.

In other news, here is a partial list of plans that exited MA for 2026:

— Michigan Medicine

— Ochsner Health

— Blue Cross Blue Shield Vermont

— Carle Health, which had Health Alliance and FirstCarolinaCare plans.

— UCare, which had 158,000 MA members across Minnesota and parts of western Wisconsin.

— Samaritan Health Plans, with the exception of D-SNPs.

Additional article: https://www.beckerspayer.com/payer/medicare-advantage/7-insurers-fully-exiting-medicare-advantage/

(Some articles may require a subscription.

#medicareadvantage #specialneedsplans #snps

https://www.modernhealthcare.com/insurance/aetna-devoted-health-medicare-advantage-snps-expand-for-2026

Humana Reports No Progress On Dismal Star Ratings

A shocker announcement today. Humana, the second largest Medicare Advantage (MA) health plan, told regulators and investors that its Star ratings remained largely steady and did not recover from a catastrophic low. What’s more, based on how enrollment looks to pan out in 2026, its percentage of members in 4 Star or greater plans will drop from 25% in 2025 to 20% in 2026. Historically, Humana has been a high performer. In 2024, it had 94% of members in 4 Star or greater plans.

The collapse of Star ratings for Humana in 2025 and now 2026 has cost billions in annual revenue. A good share of the drop in 2025 resulted from a lower Star rating in a nationwide contract with millions of enrollees. Humana was said to be addressing the concentration of enrollees in that one contract but apparently the time was too short to meaningfully impact ratings.

Humana said that the poor performance was in line with expectations and that its financial outlook has not changed.

The nation’s largest MA plan, UnitedHealthcare, saw a rebound in ratings for 2026, but Humana in the number 2 spot did not. I had predicted a modest recovery in Star overall for the industry from 2025. But with Humana’s performance, a recovery, if any, will be small.

Additional article: https://www.fiercehealthcare.com/payers/humana-says-20-members-ma-plans-four-plus-stars-2026 and https://www.healthcaredive.com/news/humana-2026-medicare-advantage-star-ratings-slip/801839/ and https://www.beckerspayer.com/payer/medicare-advantage/1-in-5-members-in-4-star-ma-plans-humana/

(Some articles may require a subscription.)

#medicareadvantage #stars #quality #cms #humana

https://www.modernhealthcare.com/insurance/mh-humana-medicare-advantage-plans-members-cms/

Glimpse At MA Plan Contraction for 2026

The Medicare Plan Finder for Medicare plans went live today and gave us a glimpse of the plan contractions in Medicare Advantage (MA) for 2026. The recent release of the so-called landscape files did so as well.

The number of plans nationwide remained about stable at 5,600 products, but this is a net of expansions and contractions. Major health plans contracted in a number of areas and especially contracted the Preferred Provider Organization (PPO) product.

An ATI Advisory analysis says individual MA plans will decrease 9% compared with 2025. Individual excludes Special Needs Plans (SNPs) and employer group MA. Individual Health Maintenance Organizations (HMOs) and SNPs grew.  Chronic Care SNPs are up 42% from 2025.

United county penetration is down 4% nationally, while Humana is down about 6.8% and Aetna down 4.4%. Both Elevance Health and Centene are expanding coverage, up 2.7% and 2.8%, respectively. United had said contraction would impact 600,000 enrollees.

In other news, disputes between plans and providers are up. FTI Consulting says there were 79 confirmed contract disputes between insurers and providers this year as of Sept. 1. Half related to MA, and 20% were unresolved at the beginning of September.

Further, a new survey shows that confusion and concerns of Medicare beneficiaries as open enrollment begins.

Additional articles: https://www.modernhealthcare.com/insurance/mh-aetna-unitedhealth-humana-medicare-advantage-plans-2026/ and https://www.modernhealthcare.com/insurance/mh-insurer-health-system-network-contract-splits-ramp-up/ and https://www.beckerspayer.com/payer/confusion-among-medicare-open-enrollees-9-things-to-know/ and https://www.beckerspayer.com/payer/insurers-launch-2026-medicare-plans/ and https://www.beckerspayer.com/payer/medicare-advantage/big-ma-market-exits-are-not-fazing-all-insurers/

(Some articles may require a subscription.)

#medicareadvantage #enrollment #2026 #providers

https://www.fiercehealthcare.com/payers/look-insurers-medicare-advantage-plans-2026

Trump Delivering On Drug Price Reductions?

President Donald Trump came out swinging a few months ago by promising drug price reductions for Americans. And while his policymaking can be seen as messy, in this case it seems to be paying dividends. After recently announcing 100% tariffs on brand drugs, at least one big maker has come to the table with some concessions. Pfizer agreed to provide all of its prescription drugs in the Medicaid program at Trump’s desired most-favored-nation (MFN) drug pricing (where the U.S. would get the lowest price given in any developed country). Pfizer also agreed to offer many of its drugs at a significant discount direct to consumer. Savings will be as high as 85% and be about 50% on average.

The administration indicates other deals are in the works. The White House also announced it was rolling out a direct-to-consumer website with medications at discounted prices. The new website is called TrumpRx. In return, Pfizer said it will be given a three-year “grace period” from tariffs. 

I do give credit to Trump for beginning to move usually intractable Big Pharma, whose gospel almost always has been to be intransigent and wait out administrations. But I have some fundamental questions. First, is it real and holistic drug price reform that saves consumers and the system? Second, will it derive more benefits faster than the Medicare drug price negotiations? So far, I am not sure. Medicaid is already deeply discounted through a rebate program. The deal is with one drug maker and most Americans would have to go direct to consumer to get discounts on a subset of drugs. Most will stay with insurance, which is not part of the deal. Discounts appear to be on average a little more than what net pricing after rebates are right now, but are not earth-shattering. Is this more PR from Big Pharma to avoid real change? Did Trump get hoodwinked? Stay tuned for my analysis in a coming blog.

Additional articles: https://www.fiercehealthcare.com/providers/white-house-announces-new-prescription-drug-website-trumprx and https://www.modernhealthcare.com/insurance/mh-phrma-discount-drug-website-trump-deadline/ and https://thehill.com/policy/healthcare/5528960-trump-pfizer-drug-prices/ and https://thehill.com/policy/healthcare/5527702-trumps-deadline-on-drug-prices-arrives-what-next/

(Some articles may require a subscription.)

#trump #drugpricing #branddrugmakers #tariffs

https://www.fiercepharma.com/pharma/pfizer-plans-offer-price-concessions-trumps-most-favored-nation-push-reports

2026 Medicare Advantage Fallout

Despite the announcement of a stable Medicare Advantage (MA) environment in 2026 by the Centers for Medicare and Medicaid Services (CMS) last week, more predictions that 2026 could be a rocky road for both plans and enrollees. Modern Healthcare has a good article on the possible impacts. It says UnitedHealthcare, Humana, Aetna and Elevance Health have all canceled products. Many are announcing elimination of broker commissions for some products and trimmed benefits and networks. There also have been plan pullouts.

Deft Research says a record 9.8 million, or 28%, could switch plans, compared with 23% in 2025. This is not those forced to switch due to plan terminations. Some plans, though, are expanding. And investments will continue to be made in Special Needs Plans (SNPs). Humana says it will maintain supplemental benefit investments.

At the same time, at least 29 health systems are dropping MA plans in 2026. Among the most commonly cited reasons for terminations are excessive prior authorization denial rates and slow payments from insurers.

In other news, Humana’s refiled lawsuit on its SY 2025 Star ratings is back in front of a court. The case now centers on CMS’ decision on call center metrics. Humana wants a quick decision – before October 15 open enrollment.

Additional articles: https://www.beckershospitalreview.com/finance/20-health-systems-dropping-medicare-advantage-plans-2025/ and https://insurancenewsnet.com/innarticle/humana-suit-3-phone-disconnects-could-cost-insurer-billions-in-revenue

(Some articles may require a subscription.)

#medicareadvantage #star #cms #quality #enrollment #hosptials

https://www.modernhealthcare.com/insurance/mh-aetna-elevance-unitedhealth-medicare-advantage-2026/

Federal Judge Strikes Risk Adjustment Audit Rule

A federal court has vacated the 2023 Medicare Advantage (MA) Risk Adjustment Rule finalized during the Biden years. The court nullified the entire rule not just portions of it. I will write more on this in a blog in coming days.

Humana challenged the rule in September 2023 on several grounds:

• The lack of a fee-for-service (FFS) adjuster, a mainstay of prior audits to ensure consistency between MA and traditional Medicare. Humana said the methodology held private Medicare insurers to a higher standard than the fee-for-service program.
• Imposition of extrapolation, where the audit is on a sample but penalties are calculated across all membership or a portion of membership.
• Retroactive recoupments on years long closed.

 The court found that the Centers for Medicare and Medicaid Services (CMS) did not follow the procedural requirements of the Administrative Procedures Act. There were inadequate notice requirements. CMS did not justify its decisions via the comment period, either. Because of the potential harm to plans, the court vacated the rule entirely.

The harm really would have been pronounced via retroactive application. Books are closed for prior periods for MA plans. Plans never even had a chance to reserve dollars for potential recoupments as the new rule was published years later. Indeed, CMS said the rule would result in insurers returning $4.7 billion to the agency between 2023 and 2032. I would argue the amount would have been much greater with the new targeted, 100% annual audit approach the Trump administration announced.

The decision here perhaps rivals what occurred in 2024 on Star ratings when a number of plans challenged CMS on guardrail application when Tukey was introduced. These plans said CMS ignored existing rules. Courts agreed.

The court decision pretty much throws 100% risk adjustment audits out the window. Decisions would easily be challenged based on the fact that no rule to conduct the audits now exists. I do not think CMS can carry out such far-reaching audits on general regulatory authority, especially with extrapolation and other features. They certainly cannot recoup for prior years unless there is evidence of fraud or other legal violations.

While I am a supporter of CMS overall, the Star lawsuit and this one shows how regulatory agencies can become too powerful and ignore procedures and due process. It is important for plans to push back as they did with the Star suit and risk adjustment audits. While the Trump administration could appeal the decision, it seems pretty clear that the appellate level or the Supreme Court would likely side with the district court. We are now in a post-Chevron world. The Supreme Court’s decision in that case was far-reaching.

Kudos to Humana for having the courage to lead this risk adjustment audit fight. Challenging CMS on such a threshold issue has to be hard. And Humana’s life blood is MA. Without the program, Humana does not exist as we know it. There surely was fear of reprisal when the suit was filed, but the leadership of former CEO Bruce Broussard and current CEO Jim Rechtin was key here. All MA plans owe them a debt of gratitude.

MA plans should see this only as a brief respite. CMS in time will come back on this. It seems serious on risk adjustment recoupment and reform. CMS can put a reasonable rule in place over time by following the rules. Congress now could also act, which may or may not be good for MA.

Additional articles: https://www.modernhealthcare.com/insurance/mh-medicare-advantage-audit-rule-radv-lawsuit/ and https://www.healthcaredive.com/news/judge-vacates-cms-medicare-advantage-audit-rule-humana/761219/ and https://www.beckerspayer.com/legal/judge-sides-with-humana-tosses-medicare-advantage-audit-rule/

(Some articles may require a subscription.)

#medicareadvantage #cms #radv #riskadjustment #overpayments

https://www.fiercehealthcare.com/payers/federal-judge-strikes-down-2023-radv-audit-overhaul-win-medicare-advantage-plans

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/

(Some articles may require a subscription.)

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

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