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Provider Directory Rule For Medicare Advantage

Medicare Advantage (MA) insurers will be required to submit provider directories to the Centers for Medicare and Medicaid Services (CMS) next year under a final rule issued Thursday. The provider information will be added to the Medicare Plan Finder. CMS will issue an operational guide to outline how to prepare and submit the directory.

MA plans will have to submit their network lists by Jan. 1 and then once a year. Updates must be made every 30 days to reflect changes in provider participation. Insurers will not have to attest that they meet network adequacy standards.

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#medicareadvantage #providers #cms

https://www.modernhealthcare.com/politics-regulation/mh-medicare-advantage-plans-provider-directories-2026

Stars Drama Begins Early

The Centers for Medicare and Medicaid Services (CMS) will release SY 2026 results in October but appears to have botched part of the rollout. In Plan Preview 2, the agency provided insurers with a private preview of their individual ratings but may have accidentally disclosed every company’s preliminary ratings in the file. It is unknown if every plan got the ultimate sneak peek or not. CMS promptly pulled the electronic data, told plans to delete any download, and reuploaded just what it should have for each plan. It also has instructed plans not to make Stars public before October’s announcement after some did so. This led to some plans seeing increases in stock, while others who did not comment saw their stocks fall.

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#stars #quality #medicareadvantage

https://www.modernhealthcare.com/insurance/mh-unitedhealth-humana-centene-aetna-medicare-advantage-stars

Government Funding Stopgap

House Republicans will vote this week on a shorter, 7-week funding resolution for FFY 2026 (which begins October 1) that includes some critical healthcare extensions, but nothing on extending the Exchange premium subsidy enhancements. The bill would need a simple majority in the House but 60 votes in the Senate.

Congressional Democrats have suggested they may not support the measure unless it includes greater healthcare funding, including a rollback of some budget reconciliation bill cuts and extension of the subsidies.

Additional articles: https://www.fiercehealthcare.com/regulatory/republicans-unveil-7-week-stopgap-hospital-funding-telehealth-extensions-no-aca-premiums and https://www.beckershospitalreview.com/finance/aca-subsidy-extension-left-out-of-7-week-stopgap-funding-bill/

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#governmentshutdown #congress #healthcare

https://www.modernhealthcare.com/politics-regulation/mh-house-spending-bill-aca-subsidies-mike-johnson

Trump Marketing Curbs Worry Brand Drug Makers

President Trump’s order to curb advertising for pharmaceutical drugs on television is creating anxiety for brand drug makers, advertising firms, and broadcasters. They say it could pose an existential threat to them. Media companies brought in $5 billion in advertising revenue from pharmaceutical companies in 2024.

The order does not outright ban direct-to-consumer advertising of drugs. Trump does not have the authority to do that, but health chief Robert F. Kennedy, Jr. wants to ban them. But the administration is using its executive and regulatory authority to ensure “transparency and accuracy” in direct-to-consumer advertising, including requiring greater disclosures of side effects in television and other ads. The administration also has sent cease-and-desist letters to some large drug manufacturers to combat “egregious violations demonstrating harm” in the marketing of high-cost prescription drugs.

The president is absolutely right on this one.

#drugpricing #marketing #branddrugmakers

https://thehill.com/policy/healthcare/5500949-trump-administration-pharma-advertising-curbs

Study Says Big Health Plans Will Continue Growth

A new analysis from Morningstar has a fairly optimistic view of big health plan growth over the next decade but notes some headwinds. It says big plans will continue to grow market share.

The study says Aetna, Centene, Cigna, Elevance Health, Humana and UnitedHealthcare will insure 56% of Americans by 2034. They had 41% in 2014 and 52% in 2024, so growth will be far more measured. United and Elevance will continue to lead the way.

The study notes these plans have some critical competitive advantages and that there is continued outsourcing of government program lives. Headwinds noted, though, are elevated utilization impacting profits, increased uninsured rates due to the budget reconciliation healthcare cuts, and new regulatory scrutiny. The last headwind includes prior authorization reforms, claims scrutiny, and risk adjustment reform. A possible headwind may be a move to have vertically integrated firms with health plans shed pharmacy benefits managers (PBMs). While reform of PBMs is likely, such disposition is less likely.

I am perhaps a little more pessimistic about big plan prospects. I think regulatory pressure could be far worse than expected and big plans may battle big time with provider entities and regional plans in the future. But yes, the big guys have a lot of advantages.

#healthplans #margins

https://www.fiercehealthcare.com/payers/morningstar-major-payers-are-set-grow-market-share-over-next-decade-headwinds-await-too

Assessing Premium Subsidy Extension

Modern Healthcare does a good job assessing the prospects of extending the enhanced premium subsidies for at least one year. There are a group of moderates seeking the extension but conservatives in each house seem to be very uninterested. House Speaker Mike Johnson, R-LA, is saying it is on the table but is non-committal.  The wild card is whether Democrats will demand the extension as part of some grand funding compromise on keeping the government open. But would that actually work against them politically in the midterms?

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#exchanges #budgetreconciliation #obbba

https://www.modernhealthcare.com/politics-regulation/mh-aca-subsidies-gop-expiring-2026

Uninsured Rate Remains Steady

Healthcare policy group KFF finds that the uninsured rate held steady at 8.0% in 2024 and remains near a historic low. The analysis uses new data from the Census Bureau and matches other findings. While Medicaid redeterminations meant losses there, private sector and Exchange coverage did pick up most of the losses. As the Medicaid continuous enrollment policy came to an end, states resumed Medicaid redeterminations. Medicaid coverage dropped by 1.3 percentage points from 2023 to 2024 while private coverage increased by 0.7 percentage points, including a 0.5 percentage point increase in direct purchase coverage.

In another analysis of Exchange coverage, KFF also found that 48% of adults under age 65 enrolled in individual market (direct purchase) coverage are either employed by a small business with fewer than 25 workers, self-employed entrepreneurs, or small business owners.

KFF also published key facts about Medicaid, including that over 70% of Medicaid spending pays for hospital services and long-term care.

Additional article: https://www.kff.org/medicaid/5-key-facts-about-medicaids-share-of-national-health-spending/ and https://www.kff.org/quick-take/2024-uninsured-rate-held-steady-as-aca-marketplace-enrollment-offset-medicaid-declines/

#uninsured #coverage #employercoverage #exchanges #medicaid

https://www.kff.org/affordable-care-act/about-half-of-adults-with-aca-marketplace-coverage-are-small-business-owners-employees-or-self-employed/

United Cuts Commissions In MA But Predicts Stars Improvement

Troubled UnitedHealthcare is ceasing or cutting commissions on new sales of more of its products. This will impact 18% of its products for 2026. United will pay only partial commissions for another 2% of its MA products. The insurer will continue to compensate brokers for renewals. United will not pay for new enrollments into its Institutional Special Needs Plans and will continue to zero out commissions for standalone Part D (PDP) drug plans.

But in good news for the nation’s biggest MA plan, United told investors today that it expects roughly 78% of its MA enrollees to be in plans rated 4 Stars or greater. This information came from Stars Plan Preview 2, which started today. It still will shed about 600,000 members next year to hit finance targets.

Humana told investors it expects ratings to improve but gave no details. Centene says it expects improvement as well. Elevance and CVS Aetna gave no guidance on quality bonuses.

Additional articles: https://www.modernhealthcare.com/insurance/mh-unitedhealth-hcsc-medicare-advantage-commissions/ and https://www.healthcaredive.com/news/unitedhealth-medicare-advantage-star-ratings-preview/759623/ and https://www.beckerspayer.com/payer/medicare-advantage/unitedhealthcare-expects-most-medicare-advantage-members-to-be-in-4-star-plans-in-2026/

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#medicareadvantage #stars #cms

https://www.fiercehealthcare.com/payers/unitedhealth-rises-positive-medicare-advantage-star-ratings-outlook

Democrats On Attack On Budget Bill Cuts

Democrats are seizing the opportunity to muddy Republicans on the budget reconciliation bill vote and the lack of enhanced subsidy extensions in the Exchanges. A report commissioned by Sens. Ron Wyden, D-OR, and Jeanne Shaheen, D-NH, was compiled by the Georgetown University Center on Health Insurance Reforms.

The report finds the following:

• The Congressional Budget Office (CBO) estimates 4.2 million people will lose coverage in the Exchanges if the enhanced subsidies expire. This is in addition to losses of 2.4 million due to the budget bill and 1.8 million from a recent Trump rule tightening Exchange enrollment and eligibility. This last item has had other estimates of as low as 900,000 impacted.
• Individuals who remain in Exchange plans will see their net premiums increase by 75% on average.
• Enrollment in Exchange plans could decrease by as much as 57%.
• Significant coverage losses and shifts in the Exchange risk pool will mean a median rate increase of 18% in 2026.

In other news, the American Hospital Association alleges that major pharmaceutical companies colluded to devise a plan to replace 340B drug program discounts with rebates. It sent a letter to the Justice Department and the Federal Trade Commission urging an investigation of several brand drug makers. This is a desperate act by the hospital lobby, which is fearful of losing one of several government giveaways.

Additionally, hospitals are pressing for action on and changes to several health policies, including overturning an $8 billion reduction to the Medicaid Disproportionate Share Hospital (DSH) Program in 2026 and more in future years.

Additional articles: https://www.fiercehealthcare.com/regulatory/leading-democrats-press-details-impacts-expiry-aca-subsidies and https://www.modernhealthcare.com/politics-regulation/mh-340b-program-rebate-model-aha/

(Some articles may require a subscription.)

#budgetreconciliation #healthcare #coverage #aca #exchanges #hospitals #340b #uninsured

https://www.fiercehealthcare.com/providers/ahead-congress-funding-deadline-hospitals-target-expiring-pay-adjustments-aca-credits

Mercer Survey Confirms Employer Healthcare Struggles

A new survey and study from consulting firm Mercer adds to the growing worry about the status of employer coverage. It says employers are likely to see healthcare costs increase significantly next year.

Mercer polled more than 1,700 employers and found that total health benefit costs per employee are expected to rise by an average of 6.5% in 2026 after cost management and 9% before such measures. This 9% gross trend is consistent with the 8% to 9% seen in other studies and surveys. These trends are the highest in a decade. And this will mean the fourth-straight year of increased spending growth following a decade of more moderate cost hikes.

Reasons for the major trends are the following:

•  Medical treatments and therapies have become more sophisticated and more costly.
• Provider markets are increasingly consolidated, which means higher reimbursements/costs.
• Inflation broadly across the economy.

Mercer says 56% of employers intend to take cost-cutting measures for 2026, up from 48% in 2025. Deductibles and other cost-sharing will be increased.

Mercer says these steps in 2026 indicate a reversal of a trend over the past several years where employers have tried to shelter employees from higher costs.

Employers also will seek to better manage costs of the priciest claims and reviewing health programs to ensure they are providing value. Further, about two-thirds of large firms said they plan to enhance access to behavioral health as a strategy to manage overall costs.

See my recent blog on this topic: https://www.healthcarelabyrinth.com/my-biggest-worry-erosion-of-coverage/

#employercoverage #healthcare

https://www.fiercehealthcare.com/payers/mercer-survey-employers-anticipate-highest-health-benefit-cost-increase-15-years-2026