CMS Reins In Part D PDP Premium Stabilization Program
The Centers for Medicare & Medicaid Services (CMS) released preliminary technical Medicare Part D bid information for contract year 2026. It released the national average monthly bid amount (NAMBA) and base beneficiary, which are used in bid preparation. CMS also announced it was again funding a special premium stabilization demonstration started in 2025 to keep premiums from rising dramatically.
The culprit for rising premiums is largely the passage of cost-sharing limits in Part D in the Democrats’ Inflation Reduction Act. The Democrats did not adequately fund the changes and therefore pushed many of the costs to plans, which then had to increase premiums and cost-sharing and make other reductions. The IRA changes have badly impacted the financial stability of the standalone Part D offerings (PDPs).
For 2026, the generosity of the demonstration will be less. In 2026, CMS is reducing the uniform base beneficiary premium reduction from $15 to $10, increasing the increase limit on a plan’s total Part D premium from $35 to $50, and eliminating the narrowed risk corridor thresholds. While PDP enrollees saw less offerings and higher costs in 2025, they will likely see more of this in 2026.
In other news, healthcare policy group KFF published a review of 2025 Medicare Advantage (MA) plans. A key finding: In 2025, more than three quarters (76%) of enrollees in individual MA plans with prescription drug coverage pay no premium other than the Medicare Part B premium.
Further, KFF also published a review of 2025 MA enrollment so far. More than half (54%) of eligible Medicare beneficiaries are enrolled in Medicare Advantage in 2025. In 2025, one in five (21%) Medicare Advantage enrollees is in a special needs plan (SNP), reflecting a steady increase in recent years. Slightly less than one in five (17% or about 5.7 million) Medicare Advantage enrollees are in a group plan offered to retirees by an employer or union.
Additional articles: https://www.kff.org/medicare/issue-brief/medicare-advantage-premiums-out-of-pocket-limits-supplemental-benefits-and-prior-authorization/ and https://www.kff.org/medicare/issue-brief/medicare-advantage-enrollment-update-and-key-trends/
#medicareadvantage #partd #pdp #specialneedsplans #snps
JAMA Health Forum Reports On Physician Exits In Medicare
JAMA Health Forum reports on a study that finds a growing number of physicians are leaving traditional Medicare. Primary care physicians and solo practitioners are leaving at faster rates than other physicians. The study looked at fee-for-service (FFS) Medicare claims from 2010 to 2024 and found that the annual physician exit rate from Medicare doubled over that period. It climbed from 1.8% in 2010 to 3.6% in 2023. Primary care physicians (PCPs) had the highest exit rate of any specialty group in 2023 at 4.41%.
#medicare #physicians
CMS Wants A National Provider Directory
Accuracy of provider directories have plagued health plans for years and sent some states to create their own directories. Now, the Centers for Medicare and Medicaid Services (CMS) wants to set up a national directory. CMS says its goal is a “dynamic, interoperable directory that connects the data CMS has with what the industry knows, so we all work from the same map.”
The directory would be a huge and expensive undertaking by the federal government with many pitfalls. Many doubt the feasibility.
In other news, healthcare policy group KFF’s new poll finds that a large majority of Americans see prior authorization as delaying or denying care, have not heard of the proposed voluntary reforms, and doubt they will bear fruit.
Additional article: https://www.modernhealthcare.com/politics-regulation/mh-cms-national-provider-directory-ghost-networks/
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#providers #healthplans
— Marc S. Ryan
