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GOP May Run Another Reconciliation Bill

Republicans may run another budget reconciliation bill to advance a number of President Donald Trump’s stalled priorities, including funding for the war, a voting bill, and to fund the Department of Homeland Security. Within the bill likely will be more healthcare cuts to meet spending rule and deficit mandates. Not all of the initiatives would pass the Byrd rule, which limits what can be in such a bill.

Among the healthcare cuts that could be included are:

• Implementing aggressive site neutrality in Medicare.
• Funding cost-sharing reductions in the Exchanges (to save on premium tax credits).
• Further reining in Medicaid eligibility for some populations.
• Aspects of Trump’s healthcare plan, including expanding ICHRA reimbursement and small business healthcare tax credits, Exchange benefit package changes, replacing Exchange subsidies with Health Savings Account (HSA) contributions, and codifying TrumpRx.
• Requiring greater price transparency from health insurance companies and providers.

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#congress #trump #reconciliation #exchange #coverage

https://www.modernhealthcare.com/politics-regulation/mh-gop-budget-reconciliation-bill-medicaid-aca

Senate Deal On Private Coverage Insulin Costs

Sens. Jeanne Shaheen, D-NH, Susan Collins, R-ME, Raphael Warnock, D-GA, and John Kennedy, R-LA, reached a deal to limit out-of-pocket costs for people with diabetes by waiving any deductibles and limiting cost sharing to the lesser of $35 or 25 percent of the list price per month. This could lead to the passage of the legislation in the upper chamber.

The bill would also require pharmacy benefit managers (PBMs) to pass through 100% of insulin rebates and other compensation to insurers. A pilot program in 10 states would also be set up to identify uninsured people with diabetes and providing them with $35 monthly insulin.

#drugpricing #insulin #diabetes

https://thehill.com/policy/healthcare/5800233-insulin-cost-cap-legislation

CVS Health To Settle PBM Lawsuit With FTC

CVS Health’s Caremark has become the second of the Big 3 pharmacy benefit managers (PBMs) to reach a settlement with the Federal Trade Commission (FTC) over insulin pricing. A court document filed Monday indicates the parties have requested that the matter be withdrawn “for the purpose of considering a proposed consent agreement.”

No details on the settlement were made public, but the concessions likely mirror the far-reaching elements agreed to earlier by Cigna’s Express Scripts PBM. United’s OptumRx PBM will undoubtedly have to settle too.

Additional articles: https://www.fiercehealthcare.com/payers/cvs-caremark-ftc-reach-settlement-insulin-pricing-case and https://www.healthcaredive.com/news/cvs-caremark-ftc-proposed-settlement-insulin-lawsuit/815581/

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#ftc #cvshealth #pbms #insulin #drugpricing

https://www.modernhealthcare.com/politics-regulation/mh-cvs-health-ftc-insulin-rebate-lawsuit/

Two Major Medicare Advantage Developments

Two major Medicare Advantage (MA) developments today.

Modern Healthcare reports that MA plans are pushing the Centers for Medicare and Medicaid Services (CMS) to change the $40 per member per month total beneficiary cost threshold that has been in place since 2024. Plans say this is needed so as to allow scaling back benefits more to respond to rising costs and paltry rate hikes.

The 2027 proposed hike is roughly flat due to several changes in how risk adjustment will be applied. It could increase some (say to between 2% and 3%) but the final hike will not be near the cost growth in the program (that was as much as 9% coming into the year) or the over 5% hike last year.

Plans have been reducing geographic footprints, shuttering expensive Preferred Provider Organization (PPO) products, and reducing benefits the past few years. But benefit reductions are constrained by the $40 benefit cost threshold. And plans know they will need to pare benefits again in 2027.

Humana and Scan are two big plans that have seen enrollment jump tremendously and are among plans asking for the change. The cap on total beneficiary cost was introduced in 2012 and is meant to be a consumer protection but does not appear to be keeping up with the huge trend in the program. In February, CMS proposed maintaining the $40 per member per month total beneficiary cost threshold that has been in place since 2024. The agency intends to finalize it in April.

Meanwhile, President Trump’s Medicare director said CMS may consider default enrollment of new Medicare beneficiaries. The proposal could automatically enroll beneficiaries into MA or traditional Medicare accountable care organizations (ACOs). Individuals could then opt out to different coverage. Right now, people who don’t make a choice are covered by traditional Medicare.

Additional article: https://www.statnews.com/2026/03/20/medicare-advantage-default-enrollment-chris-klomp-project-2025/

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#medicareadvantage #coverage #cms #healthplans #medicare

https://www.modernhealthcare.com/insurance/mh-cms-medicare-advantage-benefits-humana-scan

Read My Lips — No New Faxes: CMS Finalizes Electronic Exchange Rule

The Centers for Medicare & Medicaid Services (CMS) finalized a new healthcare and electronic processes rule that is aimed at slashing wasteful spending and antiquated paperwork. The rule establishes national standards for the electronic exchange of clinical documentation used to support healthcare claims. CMS says the initiative will help end faxing and mailing in favor of electronic transactions. The agency hails the change as a way to reduce providers’ administrative burden. CMS says the rule will reduce costs, save time, ensure faster care delivery, and enhance security and efficiency.

CMS says the “Administrative Simplification; Adoption of Standards for Health Care Claims Attachments Transactions and Electronic Signatures Final Rule” is projected to save the healthcare industry $781 million annually. The standards adopted apply to any Health Insurance Portability and Accountability Act (HIPAA)-covered entities, including health plans, healthcare clearinghouses, and healthcare providers. Covered entities must comply by May 26, 2028.

Additional article: https://www.cms.gov/newsroom/press-releases/cms-rule-phases-out-fax-machines-snail-mail-save-taxpayers-781-98-million-year

#cms #healthplans #providers #interoperability #priorauthorization #claimsdenials

https://www.cms.gov/newsroom/fact-sheets/administrative-simplification-adoption-standards-health-care-claims-attachments-transactions

Senate Dems Unveil Healthcare Agenda If They Take Over

Twelve Democratic senators signed a letter detailing their plan for health insurance reforms they will pursue if they take back the Senate. They want to focus on affordability, reduce barriers to insurance, and hold insurance companies accountable. The Democrats said Republicans were responsible for recent healthcare cuts, including the expiration of enhanced subsidies in the Exchanges and Medicaid and Exchange cuts. They would undo the reductions.

Democratics want more affordable coverage, smoother enrollment — through “a one-stop shop” — and wider offerings for lower-income people. They would extend coverage to those in states that did not expand Medicaid and want a “Medicare-type” public option for all Americans. They also want to turn back recent changes on skimpier policies and standardize plans. In addition, they would focus on price transparency, prior authorization, and medical loss ratio gaming reforms.

Vertical integration reform of insurers, pharmacy benefits managers, and more would be a priority as well.

Additional articles: https://www.fiercehealthcare.com/regulatory/democratic-senators-detail-plans-take-big-insurance and https://www.modernhealthcare.com/politics-regulation/mh-democrats-trump-tax-law-aca-subsidies/

(Some articles may require a subscription.)

#healthcare #coverage #democrats #midterms

https://www.beckerspayer.com/policy-updates/senate-democrats-lay-out-health-insurance-reform-agenda-and-put-industry-on-notice/

— Marc S. Ryan

Praise For And Panning Of Trump Proposals

Insurers and hospitals are largely together in criticizing the Trump administration’s proposed rule to allow non-network benefit plans to become qualified health plans under the Affordable Care Act (ACA) and in the Exchanges. The groups say individuals won’t be able to grasp the differences between network and non-network plans and this would expose them to higher-than-expected out-of-pocket costs. Trump officials argue premiums have gone up so much over the years that alternatives must be tested.

At the same time, in an unlikely event, billionaire entrepreneur Mark Cuban praised the federal government’s TrumpRx drug platform, saying the initiative is saving Americans money. “Everyone wants me to rip on TrumpRx,” Cuban wrote on X. “Reality is, it’s saving patients money on IVF and a few other drugs. A lot of money. IMO, anything that saves patients money is a win.”

Cuban is right. While TrumpRx does not always save the most, the president deserves credit for a number of initiatives he has worked on to reduce drug pricing. He has done far more than any other president in recent years.

Additional article: https://www.fiercehealthcare.com/payers/payers-hospitals-pan-cms-plan-bring-non-network-plans-aca-exchanges

#exchanges #trump #regulations #coverage #trumprx #drugpricing

https://thehill.com/policy/healthcare/5790314-mark-cuban-praises-trump-rx

Moody’s Keeps Insurers On Negative Outlook

Credit agency Moody’s Ratings has affirmed the negative credit outlook for the health insurance industry. Moody’s says medical costs continue to rise and plans will have limited prospects for profitable growth. It expects plan redesigns, benefit cuts, and exits from low-performing markets to continue. Moody’s notes that cost inflation has impacted every business line and will continue through the coming months. It says reimbursement rates have generally lagged these inflation rates.

#healthplans #margins

https://www.fiercehealthcare.com/payers/moodys-insurers-2026-outlook-negative-cost-pressures-continue-batter-industry

CMS Quality Conference Opens

The Centers for Medicare and Medicaid Services (CMS) Quality Conference began today with some major addresses by CMS Administrator Dr. Mehmet Oz and other top officials. I will have a blog on the major addresses soon. In the meantime, some key points that were addressed:

At the HIMSS conference in Las Vegas last week, Oz went all in on the use of AI, agentic AI, and digital health. Opening the CMS conference, Oz raised some of the same themes, saying CMS is devoted to a tech-first transformation, interoperability, and patients engaging digitally. He said technology was a solution to controlling disease exacerbation, rural health access, and driving annual wellness visits.

Oz also noted the following:

• Bad quality care is our biggest problem.
• Digital expansion models have been approved, including ACCESS, ELEVATE, and TEMPO, but such tech models must show outcomes.
• Rural health can be transformed with technology.
• Reducing drug costs and expanding GLP-1s are a key goal.
• Fraud will remain center stage.
• Payment transformation is necessary.
• The Exchange benefits are being transformed.
• He called out prior authorization reform across all lines of business as an achievement.

In related news, announced grant applications for the ELEVATE Model in Medicare. The model will offer Medicare coverage to functional and lifestyle medicine providers. Interested participants seeking grants under the model must submit a Letter of Intent by April 10, with the final application deadline set for May 15. CMS is planning to select 30 participants for the model to receive a collective $100 million of funding. CMS said that these participants will be split into two cohorts, one for the 2026 model year and one for 2027.

Further, CMS has announced that all brand drug makers that manufacture the fifteen drugs selected for Medicare drug price negotiations in the third round have chosen to participate.

Additional article: https://www.cms.gov/newsroom/fact-sheets/cms-announces-manufacturer-participation-third-cycle-medicare-drug-price-negotiation

#cms #quality #primarycare #technology #maha #digitalhealth

https://www.fiercehealthcare.com/regulatory/cms-unveils-new-model-aimed-functional-lifestyle-medicine

CMS All In On AI and Digital Health

Centers for Medicare and Medicaid Services (CMS) Administrator Dr. Mehmet Oz championed the use of AI, agentic AI, and digital health at a recent healthcare tech conference. CMS is rapidly endorsing models to use such technology, and CMS is starting to use the technology too.

Oz argued that such tech could help reduce rural healthcare gaps and that digital health and remote patient monitoring also could reduce costs by focusing care further upstream before diseases become acute. Oz argued: “I can win the battle for health, not in the ER or in the ICU, but in your home, in your kitchen, your bedroom, in your living room, with remote patient monitoring and better tools to validate that.”

Seniors appear to be endorsing the technology too. A recent healthcare policy group KFF survey found that the vast majority of seniors are using digital health tools and are interested in making greater use of them. About eight in 10 Medicare beneficiaries ages 65 and older used a healthcare app or website in the last year. A sizeable majority said it made it easier to use the health system. Some lack of trust of AI must be overcome, however.

Additional article: https://www.fiercehealthcare.com/ai-and-machine-learning/himss26-dr-oz-cms-officials-push-agentic-ai-adoption

#ai #digitalhealth #cms #healthcare

https://www.healthcaredive.com/news/cms-artifical-intelligence-ai-fraud-mehmet-oz-himss/814650