Clover May Get Stars Reset
The Centers for Medicare and Medicaid Services (CMS) could reset Clover Health’s SY 2026 rating for its largest contract after it won a lawsuit challenging the validity of some 20 measures. The health plan announced that CMS has recalculated the rating and advised the plan to submit an alternaive 2027 bid.
If the recalculation is applied, all of Clover Health’s 156,000 Medicare Advantage members would now be enrolled in plans rated at least four of five stars, generating some $120M in bonus payments in 2027.
But the “recalculation” is code for “we were directed to do so by the court and we likely are appealing the ruling.” So a small positive step, but not definitive for Clover yet. In essence, we still have pending litigation.
After the recent Clover ruling, Humana advised the court in its lawsuit of the Clover decision. Now, the judge in the CareFirst lawsuit has also agreed to delay a ruling given the Clover case.
The possible resetting of Clover’s ratings opens up the possibility of further lawsuits if the ruling is not overturned or CMS adjusting many plans’ SY 2026 ratings. It leaves SY 2027 in flux as well.
Additional article: https://www.beckerspayer.com/payer/medicare-advantage/carefirst-pauses-medicare-advantage-star-ratings-lawsuit-in-wake-of-clover-win/
(Some articles may require a subscription.)
#cms #medicareadvantage #stars #quality
https://www.modernhealthcare.com/insurance/mh-cms-clover-medicare-advantage-star-ratings
Exchange Enrollment Dropping
Newly released state enrollment data show Exchange enrollment dropping as more and more cannot afford higher premiums. Monthly enrollment data through April from Arkansas, Colorado, Maryland, Massachusetts, New Mexico and New York showed a significant number of people dropping coverage. Maryland is down 13% from January to April with Arkansas down 16% and Massachusetts down 14%.
Initial data from several state exchanges showed that plan cancellations are up 24 percent compared to March 2025.
#exchanges #coverage
https://thehill.com/policy/healthcare/5918956-obamacare-coverage-losses-states
Employers Not Keen on GLP-1s
A survey from Pharmaceutical Strategies Group (PSG) finds that 49% of payers who do not currently cover GLP-1s for obesity would not do so at any price. Forty-five percent cite cost as the main reason.
#glp1s #weightlossdrugs #drugpricing
Alignment Confident In Growth
Alignment Health CEO John Kao is confident about the company’s continued growth, saying strong revenue and membership gains in Q1 would continue in Q2.
#alignment #medicareadvantage
No Side Happy With NSA Rule
Neither providers nor plans are happy with the recent federal rule that seeks to reform the No Surprises Act (NSA) arbitration process. Insurers argue providers use aggressive tactics that allow them to secure inflated payments. Providers say insurers are not paying upon award and disagree with the payment benchmark.
(Article may require a subscription.)
#nosurprisesact #pricetransparency
https://www.modernhealthcare.com/politics-regulation/mh-no-surprises-act-idr-rule-enforcement
More Plans Drop Out of Exchanges In 2027
Six insurers have announced they will stop offering Exchange plans, either nationally or in specific states, in 2027. Cigna will exit 11 states. PacificSource will exit 3 states.
Six insurers have announced they will stop offering ACA marketplace plans, either nationally or in specific states, after the 2026 plan year.
#exchanges #coverage
https://www.beckerspayer.com/payer/aca/6-insurers-exiting-aca-markets
— Marc S. Ryan
