Clover Wins Star Suit
In a stunning decision, a federal judge in Georgia ruled in favor of Clover Health in its lawsuit challenging its 2026 Medicare Advantage (MA) Star Ratings. What’s more the judge seemingly has thrown out 20 measures in the program. The judge ordered just Clover’s 2026 ratings, impacting 2028 payments, to be recalculated. But it is hard to see how this could not impact all contracts if the ruling is upheld.
Clover’s ratings dropped considerably in Star Year 2026, with 93% of its members enrolled in plans with ratings below four. This cost Clover $120 million in bonus revenue. Clover’s two-prong argument that the court agreed with was that the Centers for Medicare and Medicaid Services (CMS) did not have the authority to collect data and score some measures and did not adequately notice changes for others.
The Supreme Court recently threw out the so-called Chevron doctrine in the 2024 Loper decision. Chevron gave wide deference to executive agencies in rulemaking. I argued that Chevron usurped policymaking from Congress. The question now is did the judge take the Loper decision too far? CMS is asking for the decision to be reconsidered and will undoubtedly appeal.
The suit’s decision is here: https://litigationtracker.law.georgetown.edu/wp-content/uploads/2026/01/Clover-Insurance-Company-v.-Department-of-Health-and-Human-Services-et-al_2026.05.27_ORDER-ON-MOTION-FOR-SUMMARY-JUDGMENT.pdf
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#cms #stars #quality #medicareadvantage
https://www.modernhealthcare.com/insurance/mh-clover-health-medicare-advantage-star-ratings-lawsuit
New Federal Rule Reforms No Surprises Act
The Trump administration today issued a final rule to address issues with the No Surprises Act Independent Dispute Resolution (IDR) process. It says it is making it more efficient and transparent, while also saving money for millions of Americans. It further states that the final rule improves the process used to resolve out-of-network payment disputes between providers and payers, cutting administrative costs and improving how disputes are handled.
This rule, finalized by the Department of Health and Human Services, through CMS, the Department of Labor and the Department of the Treasury (the Departments), along with the Office of Personnel Management, directly addresses bottlenecks by helping to reduce the number of ineligible disputes entering the system at reduced fees. The rule also allows more flexibility for claims to be resolved together in one batched dispute, reducing costs, while simultaneously speeding up decisions by placing reasonable limits on the number of claims per batched dispute.
While the changes are welcome, they do not go far enough. The IDR process has heavily favored providers and meant awarded payments far above the pre-IDR process. This has had the effect of driving up payments and overall costs in many areas. In addition, in a gross abuse of the process, a small number of entities have filed and won most of the awards. Since launching in April 2022, more than 5 million disputes have been filed.
Based on court rulings, it will take amendments by Congress to truly change the unlevel playing field here.
Additional articles: https://www.fiercehealthcare.com/regulatory/cms-finalizes-changes-no-surprises-act-dispute-resolution-process and https://www.healthcaredive.com/news/final-surprise-billing-dispute-resolution-rule-hhs-labor-treasury-nsa/821337/ and https://www.hhs.gov/press-room/federal-rule-takes-aim-health-care-bureaucracy-reducing-dispute-fees-boosting-transparency.html and https://www.cms.gov/newsroom/fact-sheets/federal-independent-dispute-resolution-operations-final-rule
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#nosurprisesact #healthplans #providers
https://www.modernhealthcare.com/politics-regulation/mh-no-surprises-act-rule-finalized-hhs
Highmark Has Turnaround
Highmark Health recovered in Q1 2026 from losses last year. The Pittsburgh-based nonprofit company reported Q1 net income of $183 million and operating income of $216 million. Revenues grew 3.8% to $8.3 billion. Highmark Health lost $175 million in 2025.
Additional article: https://www.modernhealthcare.com/insurance/mh-highmark-health-earnings-insurance-medicare-medicaid/
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#healthplans #margins
https://www.beckerspayer.com/financial/highmark-posts-216m-operating-income-in-q1
CMS To Host Webinar On GLP-1 Bridge
After not getting enough interest from health plans on its proposed BALANCE program to bring access to GLP-1s for those with obesity, the Centers for Medicare & Medicaid Services (CMS) is pushing hard to ensure knowledge of and participation in the BRIDGE program. BRIDGE will fund access to the drugs through December 31, 2027 by the federal government. CMS is hosting a webinar for pharmacies on June 11 from 12:00-1:00 p.m. EDT.
I am a recent convert on GLP-1 access. With the lower costs negotiated by President Trump, the BALANCE and BRIDGE initiatives are good policy and could mean better outcomes and lower costs over time. The president and his advisers deserve a great deal of credit.
#glp1s #weightlossdrugs #cms #partd #medicare
— Marc S. Ryan
