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More On MA Retrenchment

More details on the Medicare Advantage (MA) landscape files and the depth of retrenchment for 2027. In total, the number of MA plans to be offered will only drop from 5,553 in 2026 to 5,532 in 2027. But that hides the impacts of adds and cuts. The number of impacted enrollees looks much bigger than anticipated.

A Modern Healthcare analysis finds that the number of individual MA with Part D prescription drug coverage (MA-PD) products will decline 8% in 2027. Further, it says that there will be 181 counties with no plans next year, up from 67 this year. And at least 3.8 million people will be forced to select new coverage after their insurers terminate a plan. Various analyses peg 2026 impacts at between 2.9 million and 4.6 million. I think the 2027 impact will be closer to 3M — still a shock for me.

While many are adding products in areas, reductions of offerings is big. HCSC has the biggest net reduction at 498, with Centene at 344, United at 140, and Aetna at 123.

Despite major investments over the past few years, Dual Eligible Special Needs Plans (D-SNPs) are being reduced overall, with Chronic Care SNPs (c-SNPs) still increasing.

Additional article: https://www.modernhealthcare.com/insurance/mh-medicare-advantage-plans-2027-cms/

#medicareadvantage #enrollment

https://www.healthcaredive.com/news/medicare-advantage-cuts-2027-cms-landscape/831563/

Medicare Advantage Will See Huge Changes Again in 2027

The Trump administration is putting the best spin possible on a continuing retrenchment in the Medicare Advantage (MA) industry. The Centers for Medicare & Medicaid Services (CMS) announced that weighted average MA premiums are projected to fall more than 16% from 2026 to 2027, with MA prescription drug (MA-PD) premiums set to decrease by 38% year-over-year. Additionally, CMS said average premium for standalone Part D prescription drug plans is projected to rise by less than $1 per month in 2027.

The industry certainly has a different narrative. While it is true that MA remains broadly available, there is little doubt that benefits are being further diminished and that more plan terminations are occurring. This is evident in the landscape file release.

A Becker’s Payer article gives an overview of the retrenchment still occurring. MA choice will go down in 29 of 51 states and the District of Columbia in 2027. Florida is losing the most plans overall, from 611 in 2026 to 560 in 2027. Ohio is dropping from 212 to 180, and Illinois is falling from 157 to 136.

Tennessee will see the most plans added, rising from 132 to 155, followed by Missouri (157 to 174), Arizona (133 to 148) and Alabama (98 to 113).

Most assessments say about 2.9 million people were impacted by plan closures in 2026, or about 10%. A new study by the Alliance of Community Health Plans and consulting firm HealthScape Advisors says that number was bigger in 2026, 4.6 million or 16% of enrollees.

Humana already said that its 2027 plan exits are expected to affect about 600,000 members. Earlier 2027 estimates suggested at least 1 million could face plan terminations, but impacts were not expected to be as high in 2027. The new HealthScape number for 2026 and preliminary data we now know could push the 2027 number well higher. We will know much more as the data is analyzed.

In addition, Modern Healthcare updates on some major Special Needs Plan (SNP) changes that are happening. Starting in 2027, CMS will limit new enrollments in Dual Eligible SNPs (D-SNPs) to people enrolled in Medicaid plans from the same carrier. The limitation only exists if the D-SNP holds a state Medicaid contract in an overlapping service area. By 2030, CMS will require all D-SNP beneficiaries to enroll in an aligned Medicare-Medicaid plan. The change will for the first time lead to some changes in MA plans’ approach to SNPs moving forward, including closing enrollment in certain states. Some plans are now moving to create Chronic Care or C-SNPs, which are not subject to the same regulations. But CMS is known to want to tighten requirements on these plans over time as well.

Another new development: CMS is allowing prospective enrollment caps to encourage plans to retain marginal business propositions. It appears just a small number of plans, a bit over a dozen, are taking advantage of the new policy.

Insurers are also battling with CMS over enrollment decline predictions. One was predicted last year but MA still grew by a nominal amount.

Additional articles: https://www.cms.gov/newsroom/press-releases/medicare-advantage-medicare-prescription-drug-programs-expected-remain-stable-2027 and https://www.fiercehealthcare.com/payers/cms-projects-medicare-advantage-premiums-decline-16-2027 and https://www.modernhealthcare.com/insurance/mh-medicare-advantage-d-snp-enrollment-2027/ and https://www.beckershospitalreview.com/finance/cms-projects-lower-medicare-advantage-premiums-flat-enrollment-for-2027/ and https://www.beckerspayer.com/payer/medicare-advantage/the-states-losing-the-most-medicare-advantage-plans-in-2027/ and https://www.beckerspayer.com/payer/medicare-advantage/a-real-checkerboard-the-medicare-advantage-threats-facing-older-adults-community-plans/

#medicareadvantage #enrollment

https://www.modernhealthcare.com/insurance/mh-2027-medicare-advantage-enrollment-cms

Trump Admin Strikes Deal With 42 States On Improving Medicaid Quality

The Trump administration has announced that 42 states will partners with the Centers for Medicare & Medicaid Services to rethink how quality is measured in Medicaid and the children’s health program (CHIP). CMS said the partnership will put health outcomes “at the center of how success is defined” and streamline hundreds of reporting requirements.

The initial state participants have about 56 million Medicaid and CHIP beneficiaries and account for roughly $701 billion in fiscal 2024 Medicaid spending. At the center will be streamlining quality measure inventories, adopting digital quality measurement with near-real-time data when possible, and aligning financial accountability with outcomes measures.

The program lines up incredibly well with efforts to boost lagging Medicaid outcome performance, interoperability, as well as migrate all government programs to a universal foundation of measures.

Additional articles: https://www.fiercehealthcare.com/regulatory/37-states-partner-cms-initiative-rethink-medicaid-quality-measures and https://www.cms.gov/newsroom/press-releases/cms-refocuses-medicaid-quality-health-outcomes-launches-innovative-partnership-37-states

#quality #medicaid #cms

https://www.beckershospitalreview.com/legal-regulatory-issues/cms-launches-medicaid-quality-pledge-with-37-states/

Will Vertical Integration Be A Focus?

An interesting Becker’s Payer article indicating vertical integration will become a strong focus. Recently, late-night TV host John Oliver tore into the inner workings of huge vertically integrated company UnitedHealth Group. The article notes that UnitedHealth is now the fourth-largest company in the world by revenue, taking in $447 billion last year, up 11.8% year over year. It reported ten significant subsidiaries down from a reported 2,700 a short time ago. Vertical integration is not unique to United.

While health plan execs have defended vertical integration it is increasingly being looked at by Congress and federal agencies. Sens. Elizabeth Warren, D-Mass., and Josh Hawley, R-Mo., introduced the Break Up Big Medicine Act, which would prevent companies from simultaneously owning a health insurer or pharmacy benefit manager and a provider or management services organization.

#verticalintegration #healthplans #unitedhealthcare

https://www.beckerspayer.com/payer/as-vertical-integration-scrutiny-grows-unitedhealth-takes-center-stage/

MedPAC Chair Defends MA Analysis

Dr. Amol Navathe, the new chair of congressional Medicare policy arm MedPAC, defended the work and Medicare Advantage over-reimbursement estimates of his organization. He doubled down on MedPAC’s view that MA is reimbursed 14% more than what is spent in traditional fee-for-service (FFS). Critics of MedPAC, including me, stand by our assessment that MedPAC is relying on old data that does not recognize risk adjustment reforms and updates. In addition, MedPAC has picked up some spurious academic analyses on so-called favorable selection and has essentially adopted them as fact. The chairman himself is an academic and his defense of this process is expected.

Republicans in Congress are challenging MedPAC’s way of thinking, considering a bill to force MedPAC to broaden its viewpoints, including definitively setting aside the favorable selection argument. As MedPAC always does, it says it will open the doors and encourage engagement, but its studies seem to be closed to alternative ways of thinking. When it is found to be errant, it seems to obfuscate that fact with more of the same research. Indeed, the Centers for Medicaid and Medicaid Services (CMS) seems convinced the 14% number is absolutely inflated. Numerous other reports seem to conclude that as well, arguing MedPAC simply does not understand the difference between managed care and a 60-year-old FFS system.

#medpac #medicare #medicareadvantage

https://www.healthcaredive.com/news/medpac-medicare-advantage-overpayment-analysis-defense-bma/831126

Trump Admin To Disenroll 760K From Exchange

The Centers for Medicare and Medicaid Services (CMS) canceled 315,000 health insurance Exchange enrollments covering more than 760,000 people. CMS says these enrollments were unlawful and that the rescissions are part of its anti-fraud campaign. The agency said the government will save $2.2 billion in premium subsidies. 

In addition, CMS said it will terminate more than 200 agents and brokers that have failed to comply with enrollment standards.

Additional articles: https://www.fiercehealthcare.com/regulatory/cms-cancel-aca-coverage-760k-crack-down-brokers-latest-anti-fraud-push and https://www.modernhealthcare.com/politics-regulation/mh-cms-aca-enrollment-fraud/ and https://www.modernhealthcare.com/politics-regulation/mh-aca-broker-enrollment-freeze/ and https://thehill.com/policy/healthcare/6104381-vance-oz-aca-obamacare-crackdown/

#exchanges #healthcare #coverage #enrollment

https://www.beckershospitalreview.com/finance/cms-cancels-aca-policies-for-760000-people-freezes-broker-registrations/

ICHRAs Slated To Grow Demonstrably

Federal officials have rebranded individual coverage health reimbursement arrangements (ICHRAs) as CHOICE arrangements. While the name change is recent, new news that ICHRAs are slated to grow demonstrably. Oscar Health CEO Mark Bertolini projected during the company’s investor day that the ICHRA market will reach 2.5 million members by 2029, a 400% increase. It stands now at about 500,000.

States are passing laws to encourage the provision of healthcare. Three states are offering tax credits to employers providing ICHRA funds to workers, while other states are considering different methods to drive adoption.

#ichras #healthcare #coverage

https://www.modernhealthcare.com/insurance/mh-ichra-choice-mehmet-oz-indiana-georgia/

More Signs of Medicare Advantage Retrenchment

A number of plans have already signaled more retrenchment in Medicare Advantage (MA) in 2027. More exits are now being announced. Molina Healthcare will no longer sell Medicare plans in Connecticut, Mississippi, and Nevada. Earlier it said it will get rid of all mainstream, non-Special Needs Plans (SNPs) in 2027. It will also drop SNPs in those three states.

In addition, Health Care Service Corp. (HCSC) plans to exit the Connecticut, New York and District of Columbia MA next year. HCSC will cut its Healthspring-branded MA footprint to 450 counties in 2027 from 580 this year. HCSC reported a $4.57 billion underwriting loss last year. Not too many years ago, HCSC purchased the MA line from Cigna. It may exit 11 additional markets.

Last, CMS will allow MA plans to expand their service areas midyear when acquiring a competitor. The change is out of concern that more health insurance companies will quit the program and disrupt enrollee coverage.

Additional article: https://www.modernhealthcare.com/insurance/mh-molina-medicare-advantage-connecticut-mississippi-nevada/ and https://www.modernhealthcare.com/insurance/mh-cms-medicare-advantage-acquisitions/

#medicareadvantage #enrollment

https://www.modernhealthcare.com/insurance/mh-hcsc-medicare-advantage-exits-connecticut-new-york-dc/

House GOP Wants MedPAC To Be More Favorable To MA

A new bill from Ways and Means Republicans that passed on a party line vote would require the Medicare Payment Advisory Commission (MedPAC) to study the topic of overpayments in Medicare Advantage (MA) more favorably for insurers. I support the bill as MedPAC has shown major bias against MA over the years, undertaking twisted analyses and citing dubious research studies to further the idea that MA is markedly over reimbursed.

#medicareadvantage #overpayments #riskadjustment

https://www.statnews.com/2026/09/16/medicare-advantage-overpayments-analysis-medpac-change-apples-to-apples-act/

PBM Law Could Impact Drug Entities In The Shadows

A new law with restrictions on and reforms to pharmacy benefit managers (PBMs) will have a major effect throughout the drug channel. The law requires greater transparency and will likely expose various transaction fees between PBMs and rebate aggregators, group purchasing organizations, and others related entities.

#pbms #transparency

https://www.modernhealthcare.com/insurance/mh-pbm-reform-drug-rebate-aggregators