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Parts of No Surprises QPA Rule Struck

A federal appeals court has ruled that the government’s methodology for calculating the qualifying payment amount (QPA) within the No Surprises Act’s arbitration process is partly unlawful. This could lead insurers to have to recalculate such future offers at higher rates. The court found that inclusion of so-called “ghost rates” in the calculation and excluding bonus and incentive payments did not meet the law.

The law heavily favors providers already. The move could mean higher benchmark payments in general over time. But it could also move the last best offers of plans up in the arbitration process. Would that sway some arbitrators to award to plans? So far, the awards are 85% in favor of plans and at payment amounts that are well higher than before the law went into effect. It is driving higher prices overall.

Additional articles: https://www.beckershospitalreview.com/legal-regulatory-issues/5th-circuit-strikes-down-parts-of-no-surprises-qpa-rule-rejects-air-ambulance-challenge/ and https://www.beckerspayer.com/policy-updates/the-never-ending-no-surprises-saga/

(Some articles may require a subscription.)

#nosurprisesact #providers #healthplans #transparency

https://www.modernhealthcare.com/legal/mh-no-surprises-act-payment-appeals-court

Trump Administration Defends Exchange Paring

The Trump administration went on the offensive today arguing that studies prove the reduction in Exchange enrollment in 2026 was the result of fraud control efforts enacted during the last few years. It said the sharp rise in premiums was not the cause. Policy experts dispute this and argue that tougher enrollment processes and enhanced premium subsidy expiration led to a surge in premiums and enrollment declines.

Enrollment in Exchange plans fell by nearly 3 million nationwide this year to about 19.2 million. The Trump administration says 2.9 million people were removed through fraud initiatives. More are expected to cancel coverage throughout the year due to premium affordability issues.

I have a blog running Thursday on this topic. Stay tuned. But a hint on where I stand – the truth is always somewhere in the middle.

#exchange #enrollment #coverage

https://www.fiercehealthcare.com/regulatory/kennedy-oz-contend-fraud-crackdown-not-skyrocketing-prices-led-millions-leave-obamacare

Many Plans Still Showing Losses

Despite a reasonable recovery among the national health players in Q2 2026, HealthScape Advisors, part of Chartis, says health plans remain under significant financial pressure. Its annual look at health plans’ financial performance finds that plans posting an operating loss increased over the past several years. In 2023, 54% of health plans reported an operating loss, and that grew to 70% in 2024. And in 2025, that rose again to 73%.

HealthScape says operating losses are concentrated among regional plans and Blues plans, with 72% of regional insurers and 83% of Blues reporting one in 2025. Fourteen percent of national payers reported an operating loss in 2023 and 2024, but the rate jumped to 43% in 2025.

Read my blog last week on the national players here: https://www.healthcarelabyrinth.com/are-insurers-turning-the-financial-corner-yes-but-there-is-more-work-to-be-done/

#healthplans #margins

https://www.fiercehealthcare.com/payers/number-health-plans-reporting-operating-losses-growing-report

340B Bill Would Hinder Administration’s Reforms

Another bill with bipartisan Senate support has been introduced to stop the administration from extending a rebate pilot it plans to launch that would convert 340B upfront discounts to retrospective rebates. 

The bill would establish an independent, third-party data clearinghouse to address Big Pharma’s concerns that discounts are being diverted and duplicated by qualifying hospitals and other participants. The entity would coordinate 340B transaction data between parties and oversee any issues.

#340b #drugpricing #branddrugmakers #hospitals

https://www.fiercehealthcare.com/regulatory/new-bipartisan-340b-reform-bill-curbs-hhs-rebate-pilot

Oscar, Clover Have Good Financial Results

Exchange-dominant Oscar Health reported strong Q2 results, with a profit of $362 million compared with a loss of $228.4 million a year ago. The company saw record profitability in 1H 2026, generating $1.1 billion in earnings from operations and $1 billion in net income.

Clover Health’s Medicare Advantage (MA) membership grew 48% year-over-year in Q2 to 157,309 members. The company posted $153 million in profit, up 54% from Q2 2025, and revenue of $743 million, up 56% from Q2 2025. It was also buoyed by its Star lawsuit win.

Additional article: https://www.fiercehealthcare.com/finance/oscar-health-boosts-2026-earnings-outlook-after-record-profitability-during-first-half-year

#healthplans #margin

https://www.fiercehealthcare.com/finance/clover-health-reaffirms-ai-commitments-discusses-star-rating-amid-strong-q2-performance

CVS Health Reports Good Q2 News But Signals Disappointing 2027 Guidance

CVS Health reported good financial performance in Q2, but signaled caution for 2027. This led to a decline in its stock price. CVS reported higher revenues across all segments but said its pharmacy benefits manager (PBM) was facing headwinds due to 340B and other market trends.

Aetna was the star for CVS as the insurer showed a stunning recovery from a few years ago. Like United and Cigna, it called out the deleterious impact of the out-of-control No Surprises Act arbitration process. Medicare Advantage’s (MA) recovery drove a great deal of earnings.

Net income for CVS rose 196% to almost $3 billion.  Income increased 7% year over year to $106.1 billion. 

In other news, Becker’s Payer ranks payers by Q2 2026 profit.

As well, UnitedHealthcare may end MA sales in 34 counties in 12 states next year. This would impact 20,000 enrollees, some of whom may not have any MA alternatives.

Additional articles: https://www.modernhealthcare.com/insurance/mh-cvs-earnings-aetna-caremark-membership/ and https://www.modernhealthcare.com/insurance/mh-cvs-earnings-guidance-medicare-advantage/ and https://www.beckerspayer.com/rankings-ratings/payers-ranked-by-q2-2026-profits/ and https://www.modernhealthcare.com/insurance/mh-unitedhealth-medicare-advantage/

(Some articles may require a subscription.)

#cvshealth #aetna #margins #healthplans

https://www.healthcaredive.com/news/cvs-triples-net-income-q2-2026-raises-outlook/827041/

Fireworks At Senate Committee Meeting On Medicaid

Explosive remarks at a Senate Finance Committee this week on Medicaid. Democrats attacked the recent One Big Beautiful Bill Act (OBBBA), especially the impact of work requirements, reductions in coverage, and impacts on providers and hospitals. The bill reduces Medicaid expenditures from its baseline by about $1 trillion.

Republican senators on the other hand focused on Medicaid’s potential fraud. Brian Blase, PhD, founder and president of the Paragon Health Institute, said his organization finds that improper enrollment of certain Medicaid beneficiaries cost the federal government about $33 billion in 2024.

#medicaid #obbba #coverage #healthcare #congress

https://www.medpagetoday.com/publichealthpolicy/medicaid/122489

The Big Debate Over Dropping Exchange Enrollment

The Trump administration recently went on the offensive, arguing a drop in Exchange enrollment should be credited to its ongoing efforts to crack down on improper and fraudulent enrollment. A recent administration report says 5.6 million people were fraudulently enrolled in Exchange plans in 2025, and that it removed 2.9 million through various initiatives.

But critics argue the drop in enrollment is tied to rising premium costs, including the expiration of enhanced premium subsidies passed and extended during the COVID years. They argue more will drop throughout 2026 due to affordability issues.

The truth is likely somewhere in the middle. For sure, rising premiums have led many to disenroll. But the Trump administration is likely also right. There is little question in my mind that zero premiums led many to be fraudulently enrolled.

#exchanges #enrollment

https://kffhealthnews.org/medicaid/aca-fraud-crackdown-skyrocketing-prices-enrollment-decline/

HRSA Finalizes 340B Rebate Pilot

The Health Resources and Services Administration (HRSA) finalized a revamped version of its contentious 340B Rebate Model Pilot Program after public comment. Earlier, a judge had struck the pilot due to regulatory deficiencies. The new pilot would move from upfront discounts to retrospective rebates for some drugs. Another Trump proposals would reduce Medicare drug reimbursement for 240B providers to ensue no double-dipping on discounts. The revised pilot is now set to begin on Jan. 1, 2027 and will run for at least a year.

In other news, a Health Affairs Forefront blog says there could be duplication of discounts between the Medicare drug price negotiation program and 340B as well.

Additional articles: https://www.modernhealthcare.com/politics-regulation/mh-340b-drugs-rebate-pilot-hrsa-safety-net/

(Some articles may require a subscription.)

#340b #drugpricing #hospitals #providers

https://www.fiercehealthcare.com/providers/revised-340b-rebate-model-pilot-program-moves-forward-despite-provider-pushback

Senate Dems Float RFI For Healthcare Reform

Senate Democrats released a white paper detailing their goals for reforming healthcare. Some of the document gives hope that Democrats may abandon their more radical “Medicare for All” persona in favor of reforming the current private delivery system. It is especially focused on affordability and lowering costs.

At the same time, there are the normal political attacks and positions, including a rehash of expired Exchange subsidy enhancements, Medicaid cuts in the One Big Beautiful Bill Act (OBBBA), and a proposal for a public health plan option to run side-by-side with private plans.

Democrats would take a hard line on health plans and corporate greed.

Additional article: https://www.beckerspayer.com/policy-updates/senate-democrats-eye-public-option-in-insurance-reform-push/

#healthcarereform #coverage #congress

https://www.axios.com/2026/07/30/senate-democrats-health-insurance-overhaul