Exchange Enrollment Falls Dramatically
A number of analyses have predicted that Exchange enrollment nationally will fall in 2026 after dropping from 24.3M in 2025 to 23.1 in January 2026. The analyses said that enrollment would drop to as low as 17.5M as people would not be able to afford their premiums throughout the year. Sure enough, the predictions seem to have come true, and the news may be being buried.
Today, a Health and Human Services (HHS) website posted an analysis on fraudulent and phantom enrollments and deep in the release were latest enrollment figures. HHS says around 19.2 million people are enrolled in the Exchanges as of now, a drop of about 4M since January.
HHS says millions are inappropriately receiving subsidies, including individuals misstating their income to gain access to free plans and phantom enrollees (those who are unknowingly enrolled in free plans by unscrupulous brokers or are auto enrolled). HHS says improper, phantom and fraudulent enrollment peaked at 5.6 million people in 2025.
While it did not trace the enrollment losses exactly to efforts to reduce inappropriate enrollments, HHS says it has deployed new regulations and tools to root out fraud and inappropriate enrollments. Administration program integrity efforts stopped about 1.5 million enrollees from receiving subsidies they did not qualify for and ended or blocked another 1.4 million through February 2026. HHS says 2.6 million improper and phantom enrollments remain.
#exchanges #enrollment
Elevance Pays Back Overpayments
Elevance Health sent $342 million to the Centers for Medicare and Medicaid Services (CMS) in late May to settle Medicare Advantage (MA) overbilling allegations. This is tied to potential sanctions, including a freeze on enrollment, that CMS says it will impose if Elevance does not come into compliance with risk adjustment coding and remittances back for overpayments. This is one of the first examples of an MA plan being pressured by CMS to repay overpayments. Elevance says its total potential exposure could be as high as $935 million.
Additional articles: https://www.modernhealthcare.com/insurance/mh-elevance-health-cms-medicare-advantage-overpayments/ and https://www.beckerspayer.com/legal/elevance-pays-cms-342m-amid-medicare-advantage-sanctions-threat/
(Some articles may require a subscription.)
#riskadjustment #overpayments #medicareadvantage #elevancehealth
https://www.fiercehealthcare.com/payers/elevance-health-pays-342m-government-midst-billing-probe
At Hearing, Medicaid Directors Defend Program Integrity
At a fiery Capitol Hill hearing, state Medicaid directors defended their program integrity efforts, Democrats attacked the administration for singling out Democratic states for attention, and Republicans said fraud crackdowns are long overdue.
Democrats argue there is a political element at play with the withholding of aid to California and Minnesota. In addition, the Trump administration is suing New York over fraud.
#fwa #medicaid
— Marc S. Ryan
