Newsfeed

Lilly Cuts Off 340B Discounts

Eli Lilly and Company ended 340B discount pricing for drugs for providers that have not agreed to submit claims for validating whether purchases meet the program’s requirements or may be double-dipping on other discount programs. Earlier this month, Lilly began enforcing the policy by telling its wholesalers to pull 340B pricing eligibility for certain non-conformers. Lilly said these were large and wealthy health systems. Hospitals are apoplectic and earlier derailed a 340b pilot that would have converted the upfront discounts to a retrospective rebate. Their fear: other drug makers follow suit and the Trump administration does not object.

Additional articles: https://www.fiercehealthcare.com/providers/eli-lillys-ultimatum-hospitals-send-340b-claims-data-june-1-or-lose-discounts

(Some articles may require a subscription.)

#340b #drugpricing #drugmanufacturers

https://www.modernhealthcare.com/providers/mh-eli-lilly-340b-drug-discounts-hospitals/

— Marc S. Ryan

CMS Recalculates Some SY 2026 Ratings

CMS this evening announced it is recalculating some contracts’ SY 2026 Star Ratings based on the better of the current ratings or the measures included in the recent Clover decision. A judge struck up to 20 measures. CMS went out of its way to note that this does not set policy for SY 2027 ratings or beyond. I still expect an appeal or other intervention to bring back a fulsome Star program.

#stars #quality #cms #medicareadvantage #partd #pdp

MedPAC Largely Pans Hospitals’ Complaint On MA Penetration

Congressional Medicare policy advisor MedPAC panned hospitals’ views that increased penetration of Medicare Advantage (MA) is impacting providers’ financial stability. Empirical analyses conducted by MedPAC staff showed no evidence of a significant association between MA market penetration and all-payer margins of hospitals, skilled nursing facilities (SNFs), and home health agencies. This does not appear to be the case in rural markets, either.

But MedPAC did find some changes in revenues, costs and utilization trends and some of it was in hospitals’ favor. MA enrollees’ average length of stay in fiscal year 2024 was actually 11.2% longer than fee-for-service (FFS) beneficiaries. This was related to those who were destined to be discharged to a post-acute care facility. And overall greater MA penetration was tied to dips in total SNF facility days and small declines in revenues and costs at SNFs and home health.

#medicareadvantage #providers #hospitals

https://www.fiercehealthcare.com/payers/medpac-offers-look-enrollment-hiccups-medicare-beneficiaries

Exchange Carrier Exits

Healthcare policy group KFF issued several issue briefers recently on carrier losses in the Exchanges.

The average number of issuers offering plans in the Exchanges has declined from 9.6 issuers per state in 2025 to 9.0 issuers per state in 2026. In total, 18 states experienced a net decrease in the number of issuers offering plans. Three in 10 counties have fewer participating insurers than last year. In 165 counties, only one issuer is offering plans, up from 93 counties in 2025.

Six carriers have announced that they will exit the Exchanges in 2027, either in some or all states that they are currently offering plans: Cigna Health, CareSource, PacificSource, Scott and White, Providence Health, and Taro Health.

In other news, Centene will offer buyouts to employees as it navigates a significant membership decline in both Medicaid and the Exchanges. During Q1, Centene reported a 6% decline in year-over-year membership to 26.3 million, driven largely by Exchange losses.

Additional articles: https://www.fiercehealthcare.com/payers/centene-offering-staff-buyouts-navigates-murky-aca-waters and https://www.modernhealthcare.com/insurance/mh-centene-buyouts-medicaid-aca-membership/ and https://www.beckerspayer.com/workforce/centene-offers-employee-buyouts/ and https://www.kff.org/affordable-care-act/tracking-insurer-participation-changes-in-the-aca-marketplaces-in-2027/

(Some articles may require a subscription.)

#exchanges #insurers #coverage #healthcare

https://www.kff.org/affordable-care-act/how-has-insurer-participation-in-the-aca-marketplaces-changed-in-2026/

Trump Seeks To Make Medicare Drug Price Negotiations Permanent In Regulation

The Trump administration and the Centers for Medicare & Medicaid Services (CMS) have proposed to codify the Biden-era Medicare Drug Price Negotiation Program — a fantastic turn of events that few would have predicted a few years ago despite Trump’s sympathies for drug price reform. They say the move will create a more transparent and sustainable process for lowering drug costs for millions of Medicare beneficiaries. There are a number of small concessions to drug makers as well.

I have given President Trump great credit for making a huge impact on drug pricing, more than any other recent president. This is more evidence.

Additional articles: https://www.cms.gov/newsroom/press-releases/cms-proposed-rule-locks-lower-prices-fosters-innovation-medicare-drug-price-negotiation-program and https://www.cms.gov/files/document/mdpnp-nprm-fact-sheet.pdf

#drugpricing #cms #medicare #partd #medicareadvantage #pdp

https://www.fiercehealthcare.com/regulatory/cms-proposes-permanent-framework-medicare-drug-price-negotiations

Healthcare Cost Projected To Soar

PwC says health plans expect commercial healthcare costs to climb 9% in 2027. Payers say increased use of artificial intelligence tools by health systems, hospitals and medical practices are in part to blame. AI is documenting greater specificity and reimbursable severity without proportionate increases in care intensity. Further, there is the growing use of expensive drugs, proliferation of mental health issues, and higher reimbursement demands.

A survey by Mercer says U.S. companies plan to charge more for employee health plans next year.

Additional articles: https://www.fiercehealthcare.com/payers/healthcare-costs-poised-jump-9-2027-health-plans-blame-ai-adoption-drug-prices and https://www.modernhealthcare.com/insurance/mh-health-insurance-costs-mercer-survey/

(Some articles may require a subscription.)

#employercoverage #healthcare #costs

https://www.modernhealthcare.com/providers/mh-healthcare-costs-2027-pwc-report

Clover May Get Stars Reset

The Centers for Medicare and Medicaid Services (CMS) could reset Clover Health’s SY 2026 rating for its largest contract after it won a lawsuit challenging the validity of some 20 measures. The health plan announced that CMS has recalculated the rating and advised the plan to submit an alternaive 2027 bid.

If the recalculation is applied, all of Clover Health’s 156,000 Medicare Advantage members would now be enrolled in plans rated at least four of five stars, generating some $120M in bonus payments in 2027.

But the “recalculation” is code for “we were directed to do so by the court and we likely are appealing the ruling.” So a small positive step, but not definitive for Clover yet. In essence, we still have pending litigation.

After the recent Clover ruling, Humana advised the court in its lawsuit of the Clover decision. Now, the judge in the CareFirst lawsuit has also agreed to delay a ruling given the Clover case.

The possible resetting of Clover’s ratings opens up the possibility of further lawsuits if the ruling is not overturned or CMS adjusting many plans’ SY 2026 ratings. It leaves SY 2027 in flux as well.

Additional article: https://www.beckerspayer.com/payer/medicare-advantage/carefirst-pauses-medicare-advantage-star-ratings-lawsuit-in-wake-of-clover-win/

(Some articles may require a subscription.)

#cms #medicareadvantage #stars #quality

https://www.modernhealthcare.com/insurance/mh-cms-clover-medicare-advantage-star-ratings

CMS Takes Tough Stance On Price Transparency Violations

More than 500 hospitals received warnings from the federal government since April for non-compliance on the hospital price transparency regulation. Further notices could be sent soon. Hospitals receive an initial 90-day warning with instructions to correct any deficiencies. A subsequent 45-day deadline is sent requiring a more concrete plan to address deficiencies. If hospitals remain out of compliance, sanctions can run as high as $5,500 per day or over $2 million per year.

Additional article: https://www.modernhealthcare.com/providers/mh-cms-hospital-price-transparency-data/

(Some articles may require a subscription.)

#pricetransparency #hospitals #cms

https://www.fiercehealthcare.com/providers/hundreds-hospitals-warned-over-price-transparency-failings-ap-reports

Many Unaware Of Coming Work Rule

A Health Management Academy survey finds that about 55% of Medicaid enrollees say they are unaware of upcoming work requirements. Work requirements go into effect on January 1 under the One Big Beautiful Bill Act. Many enrollees don’t know they’ll need to report work, education or volunteer hours starting in less than six months in order to stay covered. Another 27% said they knew something about work requirements but were unsure of the details.

While the vast majority of Medicaid enrollees who can work are employed, many will lose eligibility due to lack of knowledge of requirements, paperwork burden, and administrative snafus by states.

#workrequirements #states #medicaid #obbba

https://www.healthcaredive.com/news/over-half-medicaid-enrollees-unaware-work-requirements-health-management-academy-survey/822228

Cities and County Sue Over Exchange Rule

A group of cities and a county are suing the Trump administration over the just-finalized Affordable Care Act (ACA) Exchange rule for 2027. The parties argue that elements of the regulation — such as multi-year catastrophic plans, higher out-of-pocket caps and non-network plans as qualified health plans — are unlawful. The lawsuits say they should not be implemented.

(Article may require a subscription.)

#exchanges #aca #obamacare

https://www.modernhealthcare.com/politics-regulation/mh-hhs-lawsuit-aca-exchange-rule-2027