Newsfeed

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. It seems serious on risk adjustment recoupment and reform. CMS could continue the RADV process despite no underlying rule that will stand the test of time. 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/

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/

(Some articles may require a subscription.)

#governmentshutdown #congress #ffy2026 #healthcare

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