Centene Files Stars 2027 Lawsuit
We had four 2026 Stars measure lawsuits — Clover, Elevance, Scan, and Alignment.
We now have three 2027 Stars measure lawsuits — Alignment, Healthfirst, and Centene. Centene has become the latest insurer to sue over its Medicare Advantage 2027 Star ratings. Centene has filed in the same Georgia southern district as Clover and Elevance did in SY 2026.
Centene argues that CMS violated the Administrative Procedure Act in determining its 2027 ratings. Centene says that CMS ran afoul of “core statutory safeguards” in deploying 17 measures. Because of that, Centene says its 4 Star and greater enrollment dropped from 18% to 9% and cost the company $448 million in quality bonus payments for payment year 2028. Centene’s lawsuit parallels the Clover one.
Most importantly, Centene makes this fabulous point: CMS tacitly admits its methodology is wrong because it applied a different calculation to Clover in both 2026 and 2027.
While arguments in all these cases are similar (they argue statutory and/or regulatory deficiencies), the number of measures challenged in the lawsuits differ. Each rightfully is arguing to throw out certain measures so as to get the highest ratings.
Clover argues that 20 SY 2026 measures had statutory or regulatory problems and won.
Elevance argues it deserved the Clover measure set for SY 2026 as well, so essentially the same 20 measures.
Alignment and Scan argue that SY 2026’s CMS recalculation measure set needed 10 more measures thrown out to be consistent with the Clover judge’s decision. (An argument can be made that these cases essentially agreed with the 20 Clover measure deficiencies.)
For SY 2027, Alignment essentially argues similarly as it did in SY 2026.
Healthfirst wants 5 measures thrown out.
And now Centene argues 17 are deficient.
I predict more lawsuits on SY 2027 to come and I certainly do not blame plans for defending their interests.
CMS and Congress have to repair all the deficiencies and end the lawsuit madness. They need to get together to lay out a program that makes policy sense and has all problems addressed. 35 million people rely on Medicare Advantage for their coverage. The program is already fluid enough due to rate and other variables. We do not need more Star noise.
I suspect CMS will load up the 2028 regulatory rule that will come out in draft form in November with fixes. But that will not be enough. Congress needs to weigh in, too.
Additional articles: https://thehill.com/policy/healthcare/6165587-unitedhealthcare-humana-medicare-advantage-cancellations-to-affect-1-million/ and https://www.modernhealthcare.com/insurance/mh-centene-medicare-advantage-star-ratings-lawsuit/
#cms #medicareadvantage #stars #quality
House Investigates Alleged PBM Retaliation
The House Committee on Oversight and Government Reform announced an investigation into pharmacy benefit managers (PBMs) Optum Rx, CVS Caremark and Express Scripts. The committee believes that independent pharmacies have potentially been targeted for punitive audits in retaliation for their public support of reform legislation. The committee is seeking documents and communications.
Additional articles: https://www.fiercehealthcare.com/payers/house-oversight-committee-chair-probes-pbms-independent-pharmacy-audits and https://www.beckerspayer.com/legal/optum-rx-cvs-caremark-express-scripts-investigated-over-whether-pharmacy-audits-were-retaliation/
#pbms #pharmacies #congress
https://www.modernhealthcare.com/insurance/mh-optum-rx-express-scripts-cvs-caremark-house-probe
Another Rule On Exchange Eligibility
The Trump administration has proposed yet another rule regarding Exchange eligibility after it obtained reforms in other rules and via the One Big Beautiful Bill Act. The Centers for Medicare and Medicaid Services issued the proposed rule to impose stricter eligibility checks on the Exchange.
Exchanges would need to verify information such as income, eligibility, addresses, family size and immigration status. The rule would force pre-enrollment verification checks for the 2028 open enrollment period onward. Beginning Aug. 1, 2027, current enrollees could begin to confirm their information annually to keep subsidies.
CMS says the rule would result in 332,500 fewer individuals on the Exchanges each year.
Additional articles: https://www.modernhealthcare.com/politics-regulation/mh-cms-proposed-rule-aca-subsidy-verification/
#exchanges #enrollment #fwa
— Marc S. Ryan
