Exchange Saga
Top House Democrats on Thursday called on House Speaker Mike Johnson, R-LA, to hold an immediate vote under the discharge process on extending the enhanced Exchange premium subsidies so they do not expire at the end of the year. Johnson is unlikely to do this due to objections from conservative caucus members. The House adjourns tomorrow for rest of the calendar year.
A discharge petition for a bill to extend the subsidies received 218 signatures, including four moderate GOP lawmakers who snubbed the Speaker after he broke promise to run an amendment on the subsidy extension. These members are now working with moderates in the Senate to vote on a consensus bill in January.
#exchanges #coverage #healthcare
https://thehill.com/homenews/house/5654903-jeffries-democrats-johnson-obamacare-subsidies/?tbref=hp
More Charged For Fraud in MN
The Department of Justice (DOJ) charged more individuals as part of a huge Medicaid fraud scandal in Minnesota. In part the scandal focuses on the Somali immigrant community. The latest indictments involve people accused of defrauding the state’s Housing Stabilization Services (HSS) and Early Intensive Developmental and Behavioral Intervention (EIDBI) programs, which offer Medicaid-funded housing assistance to those with disabilities, mental illnesses and substance-use disorders and those under the age of 21 with autism.
The state has terminated the housing program over the fraud allegations.
#medicaid #fwa
https://thehill.com/homenews/state-watch/5655370-doj-charges-minnesota-fraud
2026 Part D Drug Savings
A new study from AARP finds that Medicare enrollees could save roughly half of what they usually pay for certain drugs next year. The study found that the out-of-pocket cost of 10 drugs included in the first round of Medicare drug price negotiation in 2024 (which go into effect in 2026) will decrease substantially in five states with high enrollment in the program — California, Florida, New York, Pennsylvania and Texas — once negotiated prices go into effect on Jan. 1, 2026. When announced, the net price reduction under the Medicare drug price negotiation process was said to be about 22%.
#partd #pdp #medicareadvantage #drugpricing #cms
https://thehill.com/policy/healthcare/5655103-lower-medicare-drug-costs
Medicare ACOs Overhauled Again
The Trump administration has revealed a major reform and extension of the Accountable Care Organization (ACO) program in traditional Medicare. The current ACO REACH model concludes at the end of 2026.
The Center for Medicare and Medicaid Innovation unveiled the Long-Term Enhanced ACO Design (LEAD) model. LEAD will be a decade-long voluntary program that begins Jan. 1, 2027 and concludes Dec. 31, 2036.
CMS said the model will include two risk-sharing options for participants. Under the global risk option, participants are eligible to receive back 100% of generated savings and will be liable for 100% of losses based on their performance benchmark. In the professional risk option, providers can receive 50% of generated savings and will be responsible for 50% of losses related to benchmarks. The current ACO REACH program had migrated to a risk model.
The model aims to be more inclusive of smaller, rural, and independent practices and wants more accurate risk adjustment and benchmarking, especially for high-needs populations. The model allows ACOs to incentivize beneficiaries to seek out care, such as Part B cost-sharing support and eventually a Part D premium buy-down. The initiative will support episode-based risk arrangements among ACOs, specialists and provider organizations to foster stronger relationships, along with an episode-based falls prevention program.
This is the third model announced recently. The others, ACCESS and ELEVATE, focus on the use of technology to impact patient disease state costs and quality.
In addition, CMS will launch a voluntary pilot in 2026 to gather service-level data on prior authorization determinations and appeals in Medicare Advantage. After the pilot, the agency expects to expand the data-collection efforts to all plans in 2027.
Last, healthcare policy group KFF has a good briefer on pharmacy benefits managers’ (PBMs) role, as well as the Trump administration’s and Congress’ efforts to bring reform.
Additional articles: https://www.fiercehealthcare.com/regulatory/cms-unveils-lead-its-new-10-year-accountable-care-model and https://www.beckerspayer.com/payer/cms-long-term-enhanced-aco-design-model-6-things-to-know/ and https://www.beckerspayer.com/payer/medicare-advantage/cms-to-pilot-medicare-advantage-service-level-data-collection/ and https://www.kff.org/other-health/what-to-know-about-pharmacy-benefit-managers-pbms-and-federal-efforts-at-regulation/
(Some articles may require a subscription.)
#medicare #acos #medicareadvantage #pbms #drugpricing
https://www.modernhealthcare.com/politics-regulation/mh-cms-aco-reach-lead-model-2027
— Marc S. Ryan
