Two More Stars Suits
CVS’ Aetna has become the sixth health plans to sue the Centers for Medicare and Medicaid Services (CMS) over SY 2026 and/or SY 2027 Star ratings.
Aetna filed suit Monday in Georgia’s Southern District Court, the same that had the Clover suit. Aetna says 28 measures were “unlawfully adopted” and should have been excluded. The measures were adopted without notice-and-comment rulemaking and 12 also relied on data sources outside CMS’ statutory authority. The suit for SY 2027 challenges the 28 measures across 43 contracts. It relies on a great deal of the Clover decision.
Aetna says the CMS actions will likely cost it $2 billion in 2028 quality bonus payments and rebate retention. Aetna asks the court to declare the inclusion of the 28 measures unlawful, order CMS to raise its scores, and award $2 billion in additional bonus payments.
Scan also sued Monday on SY 2027. Scan’s suit essentially parallels its SY 2026 suit. The complaint argues that CMS improperly calculated ratings for four contracts by using the same 10 measures whose detailed specifications were never formally promulgated through the notice-and-comment. Scan argues that CMS has continued to use those measures for 2027 despite that ruling and its own objections.
Scan claims that removing the disputed measures would raise two contracts from 3.5 to 4.0 Stars and two others from 4.0 to 4.5 Stars, generating more than $152 million in additional payments and rebates for 2028. Scan filed again in the District of Columbia federal district.
Additional articles: https://www.fiercehealthcare.com/payers/alignment-healthcare-sues-cms-over-its-2027-medicare-advantage-star-ratings and https://www.beckerspayer.com/payer/medicare-advantage/5-payers-suing-over-2027-medicare-advantage-star-ratings/
#stars #medicareadvantage #cms #quality
https://www.modernhealthcare.com/insurance/mh-aetna-medicare-advantage-star-ratings-lawsuit
Centene Reports Q3 Financials
Centene Corporation posted a $71 million loss in Q3 2026, which is far less than the $6.6 billion loss in Q3 2025 following a $6.7 billion non-cash goodwill impairment charge. Through three quarters, Centene is in the black with $2.6 billion in profit, compared to a $5.6 billion loss for the same period in 2025.
Revenues in Q3 were $50.6 billion, up from $49.7 billion a year ago. Centene has brought in $154.2 billion in revenue so far in 2026, up from $145.1 billion in the first three quarters of 2025.
The medical loss ratio in Q3 was 92.7%, on par with the prior-year quarter.
Centene is also highlighting positive signals in Medicaid, saying it is in active discussions with states about rates and impacts of federal cuts.
Centene expects to break even in Medicare Advantage in 2026, a year ahead of its previously stated 2027 target.
Additional articles: https://www.fiercehealthcare.com/payers/centene-posts-71m-loss-506b-revenue-q3 and https://www.modernhealthcare.com/insurance/mh-centene-q3-earnings-medicare-advantage/
#healthplans #margins #centene
https://www.healthcaredive.com/news/centene-progresses-profit-recovery-cuts-workforce-by-6k/872816
Dems Probe Exchange Terminations
Several prominent Democratic senators are probing health plans over the termination of 760,000 people from Exchange coverage in September. Letters were submitted to Cigna, UnitedHealthcare, AmeriHealth Caritas, Centene, Elevance Health, Florida Blue, Health Care Service Corporation, Imperial Insurance Companies, Oscar Health and Molina Healthcare.
Additional article: https://www.fiercehealthcare.com/payers/democratic-senators-probe-insurers-role-canceling-aca-coverage-760k
#exchanges #coverage
HCA Takes New Hit On Exchange, Medicaid Revenue
Hospital chain HCA reported a $950 million hit to pretax income this year, including $400 million in the third quarter. Executives said that the downturn stemmed from patients dropping coverage under Exchange plans and becoming uninsured.
Exchange volumes dropped a higher-than-expected 19% in the quarter. Exchange losses are expected to continue into 2027, though not at the same level. HCA is expecting $550 million to $650 million less in net benefits from Medicaid state supplemental payments in 2027 as well.
#hca #exchanges #hospitals #coverage
https://www.modernhealthcare.com/providers/mh-hca-healthcare-earnings-aca-exchange-coverage
KFF Sees 4M In MA and PDP With Terminations
Studies on Medicare enrollees impacted by terminations of their products can often be wildly different. Healthcare policy group KFF weighs in with its study impacting both Medicare Advantage (MA) and standalone Part D (PDP) plans.
KFF’s magic number is 4.3M, including 3.1 million in MA and 1.2 million PDP enrollees who will have their plan terminated at the end of 2026.
Four parent organizations are terminating plans that account for 50% of enrollees losing MA-PD plan coverage. Those organizations are Humana, Inc. (19% or 530,000 enrollees), UnitedHealth Group (13% or 367,000 enrollees), CVS Health Corporation (9% or 254,000 enrollees), and Aware Integrated, Inc., which sold Blue Cross branded plans in Minnesota (9% or 249,000 enrollees).
Another 1.4 million MA enrollees are in a plan that is consolidating with another plan offered by the same insurer. These enrollees will be moved automatically, including 500,000 general enrollment MA members and 900,000 in Special Needs Plans (SNPs). SNPs saw reductions for the first time in awhile due to a regulatory change. Starting in January 2027, plans that offer a Dual Eligible SNP (D-SNP) and an affiliated Medicaid managed care plan in the same county generally can only offer one D-SNP plan for full-benefit dual-eligible individuals.
Additional article: https://www.beckerspayer.com/payer/medicare-advantage/4-3-million-medicare-beneficiaries-to-lose-plans-going-into-2027/
#medicareadvantage #enrollment
— Marc S. Ryan
