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Congress Inches Toward Site Neutral Payments

Congress didn’t pass site neutral payments in Medicare but did make some incremental progress toward the reform in the FFY 2026 appropriations bill that was recently passed. This could lead to cuts to the tune of billions of dollars in hospital reimbursements in the future.

The bill requires health systems to obtain unique National Provider Identifiers, or NPIs, for their outpatient departments by 2028. This will have the effect of giving the government detailed information about outpatient care provided at hospital-owned facilities — and its cost — to support broader site-neutral policies.

The Trump administration did implement site neutral payments for drug administration via regulation this year. That follows some other modest reforms several years ago. Site neutrality pays the same rate to provider regardless of the site the service is performed at – physician office, ambulatory surgery center, off-campus hospital outpatient department, or on-campus hospital outpatient department.

(Article may require a subscription.)

#hospitals #siteneutral #medicare

https://www.modernhealthcare.com/politics-regulation/mh-congress-outpatient-pay-site-neutral-reform/

— Marc S. Ryan

SNPs Up; Major Plan Terminations In MA

Two new articles on the 2026 open enrollment season in Medicare Advantage (MA).

A Modern Healthcare analysis says membership in Special Needs Plans, or SNPs, is now 8.2 million as of Feb. 1, up 12.2% from a year before. While enrollment growth overall slowed from 2025 to 2026, SNP growth actually went up. SNP growth was 10.1% in 2025. About a quarter of all enrollees are now in SNPs.

A study in JAMA examined the major contraction in MA and rates of forced moves. It found that one in 10 MA enrollees were forced to disenroll from their current product choice heading into 2026 due to insurer exits or contractions. That is a ten-fold increase from historic averages and is up from 6.9% in 2025. Among the 28.6 million MA enrollees that were part of the study sample, 2.9 million were forced to find new coverage for 2026, with an estimated 25.8 million able to retain their current plan.

Smaller insurers accounted for 48.8% of forced disenrollments. Twelve states had more than 20% of their MA enrollees facing forced disenrollment.

The 2.9 million figure is similar to other studies, including one that estimated an impact to 2.6 million.

You can read my analysis on the 2026 enrollment season here: https://www.healthcarelabyrinth.com/2026-medicare-advantage-enrollment-season-good-news-bad-news/

Additional article: https://www.modernhealthcare.com/insurance/mh-medicare-special-needs-plan-enrollment-2026/

(Some articles may require a subscription.)

#medicareadvantage #enrollment

https://www.beckerspayer.com/payer/medicare-advantage/10-of-medicare-advantage-enrollees-forced-to-switch-plans-for-2026-study/?origin=PayerE&utm_source=PayerE&utm_medium=email&utm_content=newsletter&oly_enc_id=1115F9468978C5V

— Marc S. Ryan

More Bad News On Affordability Front

A new Commonwealth Fund report finds that middle-income workers and their families are spending an average of 10.1% of median income on their health premiums and deductibles. The 2024 data from the employer-sponsored insurance market show that premium contributions for family coverage ranged from an average of $5,584 in Oregon to $9,148 in California. In 19 states, the average premium and deductible contribution topped 10% of that state’s median income. Costs varied by region, industry, and employer size. Five states’ costs breached the affordability metric under the Affordable Care Act (ACA), which could trigger coverage in the Exchanges.

The researchers recommend employers adjust out-of-pocket requirements and premiums based on the income of employees. The report also notes one of my key reform recommendations – a shift in the broader trends around healthcare pricing and spending.

#healthcare #coverage #affordability

https://www.fiercehealthcare.com/payers/family-premiums-account-10-income-19-states-commonwealth-fund

UHG Still Made The Most

Despite major financial challenges, UnitedHealth Group still made the most of the major national health plan vertically integrated behemoths in 2025. UHG brought in just over $12 billion in earnings for 2025. That was followed by Cigna at about $6 billion, with Elevance Health at almost $5.7 billion. CVS Health was at about $1.8 billion and Humana at about $1.2 billion. Centene lost $6.7 billion. Most of the plans see 2026 as yet another transition year with improving results.

#healthplans #margins

https://www.fiercehealthcare.com/payers/unitedhealth-group-was-most-profitable-payer-difficult-2025-industry

GOP Worried On Affordability

Some Senate Republicans are worried that the GOP leadership is not doing enough on the affordability issue as the 2026 midterms approach. Right now, the House is almost assuredly going back to the Democrats, while the Senate is favored for the GOP but getting too close for comfort.

Sen. John Kennedy, R-LA, has been urging Republicans to pass a second reconciliation bill to pass additional healthcare measures. President Trump has dismissed the idea of yet another bill, but House Republicans want to pass a second one as well. Lawmakers could still do so over the president’s objections.

#healthcare #coverage #midterms

https://thehill.com/homenews/senate/5738150-republicans-affordability-midterms

2026 Medicare Advantage Enrollment Finally Published

After a long delay, the Centers for Medicare and Medicaid Services finally published results for January and February for Medicare Advantage (MA). While many predicted that the program would contract, I had said that enrollment would be flat or one of the lowest growths we had seen recently. Some analysts suggested that there would be a decline because of the mass exodus of large plans from certain markets and efforts by them to shed huge enrollment.

But despite the huge challenges in the program, MA showed some resiliency. Enrollment in February 2025 was 34.941 million. In December 2025, MA had 35.700 million members. In February, we saw 35.814 million. January numbers showed a contraction from December of about 400K. We know January 2025 numbers had some issues. That could also be the case for January 2026. But February 2025 to February 2026 numbers showed a growth of 873K or 2.5%. The open enrollment slump was not close to the 1M some had said it might be.

It appears that seniors and the disabled continued to see the value of MA compared with traditional Medicare and sought out the best plan they could, including with their existing insurer or smaller and regional players in place of big national plans.

UnitedHealthcare is down over 900K. Humana is up about 1.2M. Elevance Health is down over 300K, with CVS Aetna down over 100K.

#medicareadvantage #enrollment

https://www.cms.gov/data-research/statistics-trends-and-reports/medicare-advantagepart-d-contract-and-enrollment-data/monthly-enrollment-plan

Aledade Touts Primary Care and VBC Growth

Value-based enablement company Aledade added more than 700 primary care practices to its network for 2026 and sees strong momentum for value-based care (VBC) growth.

Aledade has more than 3,000 primary care organizations across the country with over 3 million patients in VBC programs. These include Medicare Shared Savings Program (MSSP), Medicare Advantage (MA), Medicaid, and commercial contracts.

Transition to VBC from transaction payments has been slow with a mixed record on savings and better outcomes. See my blog today on VBC: https://www.healthcarelabyrinth.com/the-2027-aca-exchange-rule-the-good-and-bad/ .

In other news, Humana President and CEO Jim Rechtin said the company is looking to expand its primary care footprint. He says a strategic acquisition should be announced soon. But as I noted earlier and Becker’s says in its article, the biggest national health plans are under heavy criticism about sweet-heart deals of plans and pharmacy benefits managers (PBMs) with sister company entities. A Health Affairs analysis found that plans using their own providers can inflate medical spending figures and limit their rebate responsibilities. United’s ambulatory surgery center (ASC) acquisitions led to steep price increases for competing insurers. The study’s authors want disclosure of internal payment arrangements.

Additional article: https://www.beckerspayer.com/m-and-a/humana-ceo-hints-at-upcoming-primary-care-deal/

#healthplans #verticalintegration #providers #vbc

https://www.fiercehealthcare.com/providers/aledade-grows-value-based-care-network-3000-primary-care-practices

Humana Turning Around But On A Bumpy Road

Humana reported Q4 2025 results today. While the Medicare Advantage (MA) insurer is making inroads, the road remains bumpy. During the fourth quarter, Humana’s net loss grew 14.9% to $796 million. Revenue rose 11.3% to $32.5 billion. For the full year, net income declined 1.6% to $1.2 billion and revenue increased 10.1% to $129.7 billion. Humana reported an medical loss ratio (MLR) of 93% in the fourth quarter and 90.2% in 2025.

Humana ended 2025 with 5.8 million MA members, a 6.3% decline since 2024. It expects enrollment to be 25% higher this year. This is in contrast to most of the other large national plans. Humana says earnings from individual MA plans will dip just below breakeven this year. Humana stock tumbled because investors fear benefits are too high for 2026, driving enrollment. This could impact margins in 2026, which investors see as a lack of operational controls necessary to meet expectations.

About 45% of Humana’s renewing MA members and 30% of its new enrollees chose plans that will not earn Star Ratings program quality bonuses. The cataclysmic drop in Star ratings has cost Humana $3.5 billion in 2026.

Humana CEO Jim Rechtin sounded conciliatory on the flat rates expected in 2027. He acknowledged the fiscal pressures on Medicare but that rates will be inadequate. He said Humana would adapt if the rate remained flat after lobbying.

Additional articles: https://www.modernhealthcare.com/insurance/mh-humana-medicare-advantage-enrollment-2026/ and https://www.beckerspayer.com/financial/humana-posts-796m-loss-in-q4/ and https://www.modernhealthcare.com/insurance/mh-humana-earnings-medicare-advantage/

(Some articles may require a subscription.)

#medicareadvantage #humana #margins

https://www.fiercehealthcare.com/payers/humana-posts-796m-loss-q4-elevated-medicare-advantage-costs-continue

Unlikely Pair Attacking Vertical Integration

An unlikely pair of senators, Elizabeth Warren, D-MA, and Josh Hawley, R-MO, have teamed up to pass the “Break Up Medicine Act.” The bill would seek to break up major vertically integrated healthcare behemoths due to the cozy relationships companies within the master entity have with each other. The bill proposes prohibiting parent companies from owning a medical provider or management services organization and a PBM or insurer. It also proposes prohibiting parent companies of prescription drug or medical device wholesalers from owning a medical provider or management services organization.

#healthplans #verticalintegration

https://thehill.com/policy/healthcare/5732189-break-up-big-medicine-act

Seismic Changes To ACA and Exchanges Proposed

Building on changes in the One Big Beautiful Bill Act (OBBBA) and other regulatory changes in 2025, the Trump administration’s 2027 Affordable Care Act (ACA) and Exchange rule aims to make additional seismic changes in healthcare.

Among the major changes include:

• Eliminating a Biden administration rule that limited insurers to two non-standard plan designs per metal level on the Exchanges. 
• Eliminate requirements that plans offer standardized options on the Exchanges, with the option to continue current standardized options.
• Changing the permissible cost-sharing parameters for Bronze plans and to update cost-sharing requirements for catastrophic plans, beginning in PY 2027. These proposals would improve consumers’ access to affordable healthcare coverage and provide consumers the flexibility to tailor their coverage to their needs. 
• Allowing insurers to offer catastrophic coverage in one-year terms or in longer terms of up to 10 years.
• Allowing multi-year catastrophic plans to be permitted to utilize value-based insurance designs to cover preventive services over and above those that currently must be covered under certain recommendations and guidelines (before an enrollee satisfies a deductible or hits an out-of-pocket maximum).
• Allowing more people over 30 to choose a catastrophic plan if they want to.
• Expanding affordable options by allowing lower deductibles but higher out-of-pocket maximums.
• Allowing certain innovative, non-network plans to obtain qualified health plan status if they can demonstrate a broad enough slate of provider options.
• Tightening citizenship limits and eligibility verification.
• Proposing stronger eligibility and income checks alongside stronger enforcement policies to protect against improper enrollments and unauthorized plan changes.
• Instituting new legal requirements around eligibility for tax credits and other assistance for immigrants as well as suggesting that states’ improper payments measurement programs evaluate how state-based Exchanges are handling premium tax credit payments.
• Implementing stronger standards for brokers and agents to deter fraud and misleading marketing.
• Outlining prohibited marketing practices, such as offering cash equivalents to prompt enrollment, falsely claiming no premiums and enrollment timelines and deadlines.
• Allowing federally facilitated Exchange states to carry out their own provider access reviews and granting state-based Exchanges more discretion with network adequacy.
• Shifting 2027 HHS risk adjustment models and harnessing improved HHS-RADV error estimation methodology.
• Easing the transition to a state-based Exchange.
• Permitting state-based Exchanges to use a “private sector-based approach” by relying on web brokers to manage consumer-facing websites.
• Preventing adult routine dental work to be considered an essential health benefit.
• Establishing stricter parameters around cost defrayal of state-mandated benefits.
• Maintaining the prohibition on the 150% federal poverty line special enrollment period.

Proponents argue the changes are needed to reduce costs and provide more affordable options. Critics argue the changes will simply erode the Exchanges financial position and increase risk.

Additional articles: https://www.fiercehealthcare.com/regulatory/cms-plans-roll-back-limits-non-standard-aca-plan-options and https://www.beckerspayer.com/payer/aca/cms-proposes-aca-implementation-rule/ and https://www.cms.gov/newsroom/press-releases/cms-proposes-regulations-lower-health-care-costs-expand-consumer-choice-protect-taxpayers and https://www.cms.gov/newsroom/fact-sheets/hhs-notice-benefit-payment-parameters-2027-proposed-rule

#exchanges #healthcare #coverage #trump #cms #regulations

https://www.modernhealthcare.com/politics-regulation/mh-aca-exchange-rule-2027-standardized-coverage