CMS Could Auto-Enroll Seniors In MA or ACOs
STAT reports that the Centers for Medicare and Medicaid Services (CMS) is currently mulling a plan that would automatically enroll beneficiaries into either Medicare Advantage (MA) plans or traditional Medicare Accountable Care Organizations (ACOs). The House GOP has shown interest in the proposal as have a number of right-leaning think tanks. The move would be consistent with CMS’ desire to radically expand value-based care (VBC) penetration in Medicare.
#medicareadvantage #acos #vbc
https://www.medpagetoday.com/publichealthpolicy/medicare/121161
Wash Post Covers Medicaid Enrollment Drops
The Washington Post says Medicaid enrollment continues to drop. Medicaid enrollment has declined by about 3.4 million between January 2025 and January 2026. The newspaper says that application approval timing is taking longer and procedural related reasons for disenrollment were up. As well, applications are down. The immigration crackdown could be part of the reason. All of this is before the changes in the One Big Beautiful Bill Act (OBBBA) kick in.
(Article may require a subscription.)
#medicaid #enrollment
Clover, Oscar Report Good Financial News
Medicare Advantage insurer Clover Health’s membership climbed 51% year over year in Q1 and reached about 156K enrollees in MA. In addition, the company also posted $27.3 million in profit for the quarter. Revenues in Q1 were $749.2 million. Both were greater than the year before. Clover’s medical loss ratio (MLR) was a respectable 86.5%.
Meanwhile, Exchange plan Oscar Health is seeing some favorable results in the Exchange market. The company posted $4.6 billion in revenue in Q1. Its MLR was a very respectable 75.4%. Oscar brought in $679 million in profit for Q1.
Oscar remains excited by the ICHRA employee reimbursement model for smaller employers. It offers its own coverage, that of other plans, and supplemental benefits as ICHRA components to attract employers and give choice.
Additional article: https://www.fiercehealthcare.com/payers/clover-healths-ma-membership-grows-51-year-over-year
#clover #oscarhealth #exchanges #medicareadvantage #margins #ichra
https://www.fiercehealthcare.com/payers/oscar-healths-profit-hits-679m-membership-rises-q1
States Look To Regulate PA
In the face of lagging action at the federal level, states are increasingly targeting insurance companies over hot-button issues such as prior authorization and artificial intelligence in the absence of federal action.
States are debating or have enacted changes on the use of AI, limits on prior authorization (PA), delayed payment to providers, cost-sharing, mandates, and networks.
See my blog on PA this week: https://www.healthcarelabyrinth.com/prior-authorization-restrictions-continue-to-take-hold/ .
(Article may require a subscription.)
#priorauthorization #claimsdelays #ai #healthplans
Hospital-At-Home Shows Value
The ongoing hospital-at-home model appears to be providing value. A study published in JAMA Network Open says such approaches were linked to better clinical outcomes and could be an alternative to traditional inpatient care. Hospital at home was associated with decreased emergency department use within 30 days of discharge and lower in-hospital mortality. But patients at hospital-at-home programs saw no significant difference in hospital readmissions within 30 days.
#hospitalathome #medicare
Trump Drug Changes Reviewed
Kaiser Health News (KHN) has an interesting article discussing all the changes the Trump administration is making in drug prices. While the article is largely balanced, it calls out a number of places where drugs are not always cheaper and the relatively small number of people impacted overall.
Fair enough, but President Trump deserves great credit for making major progress, especially for the most-favored-nation (MFN) drug pricing models in Medicare Parts B and D. KHN also applauds the continuation of Medicare drug price negotiations. Many of these drugs with lower prices are not sold on TrumpRx.
#drugpricing #trumpx #mfn #medicare #partd
https://kffhealthnews.org/health-care-costs/trumprx-reality-check-drugs-not-always-cheaper/
— Marc S. Ryan
