Regional Plans Not Faring Well
Despite some studies suggesting regional plans are doing better than national payers during this financial downturn, HealthScape Advisors says regional nonprofit insurance companies are falling behind their larger competitors. It says that in 2024, 71% of regional nonprofit insurers ended the year with an operating loss. By comparison, 53% posted operating losses in 2023, and just 22% did in 2020.
In other news, Humana will not pay agents and brokers for enrolling new members in many of its wider-network Medicare Advantage (MA) products for 2026. There will be 288 plans across 46 states and the District of Columbia impacted, about 80% of which are Preferred Provider Organizations (PPOs).
Further, a bipartisan group of lawmakers has introduced legislation requiring MA plans to promptly pay out providers’ claims, with up to a $25,000 fine and interest accrual. Plans would have a 14-day deadline to pay electronically submitted, in-network claims and a 30-day requirement for paper or out-of-network claims. Penalties would hit if 95% of “clean claims” were not paid timely.
Last, more MA contraction is expected and this will fall again on the amount and types of supplemental benefits. This could even impact more traditional benefit add-ons, such as dental.
Additional article: https://www.modernhealthcare.com/insurance/mh-humana-medicare-advantage-commissions-2026/ and https://www.fiercehealthcare.com/regulatory/bipartisan-bill-introduced-require-medicare-advantage-plans-promptly-pay-claims and https://www.modernhealthcare.com/insurance/mh-medicare-advantage-supplemental-benefits-2026/
(Some articles may require a subscription.)
#medicareadvantage #healthplans #margins #marketing #claimsdenials #supplementalbenefits
https://www.modernhealthcare.com/insurance/mh-regional-nonprofit-insurance-healthscape-advisors/
PBMs Could Propose Reforms To Avoid More Aggressive Changes
Threatened with aggressive regulatory action from both Congress and regulators, pharmacy benefits managers (PBMs) are working on a proposal to voluntarily change some of their business practices. This is similar to what happened on health plan prior authorizations when Trump administration officials threatened action.
Among the proposals under discussion are ensuring patients don’t pay more than a pharmacy would charge to someone without insurance, greater use of lower-cost versions of expensive biologic drugs, and increased payments to rural and independent pharmacies.
Pharmacies are highly suspicious of voluntary reforms from PBMs.
Additional article: https://www.modernhealthcare.com/insurance/mh-pbm-voluntary-changes-cms-pcma/
(Some articles may require a subscription.)
#drugpricing #pbms
Various Healthcare News
Democrats are counting on winning during the midterms in part on healthcare issues. This mimics what occurred in 2018 after the GOP attempted to repeal the Affordable Care Act (ACA). This time, coverage reductions of about 15 million will result from the One Big Beautiful Bill Act (OBBBA). They also think a potential government shutdown could help and call attention to the healthcare cuts. Democrats so far have said they will only vote for a bill to keep government funded if healthcare reductions are rolled back and enhanced premium subsidies extended.
In other news, the Trump administration’s plan to dramatically overhaul the H-1B visa application process and charge $100,000 for new visas is making healthcare providers worry that access to critical international talent could be threatened.
Further, the Government Accountability Office (GAO) reports that fewer doctors are employed by independent physician practices as offices are acquired by hospitals, health systems, insurers, and private equity firms. About 47% of physicians worked for or were affiliated with hospital systems last year, compared with less than 30% in 2012. GAO says physician consolidation with health systems can lead to higher prices due to changes in practice patterns to more expensive hospital-owned settings.
As well, an interesting piece from healthcare policy group that lays out why Republicans could extend Exchange premium subsidy enhancements. Many enrollees getting the subsidies are from red states or match Republican profiles. They would see premiums surge. A companion briefer looks at occupations with large shares of workers who rely on the Exchanges and subsidies.
Additional articles: https://www.healthcaredive.com/news/h-1b-visa-program-changes-could-worsen-healthcare-labor-shortages/761034/ and https://www.healthcaredive.com/news/physician-practice-acquistions-healthcare-consolidation-rising-government-accountability-office-gao/760919/ and https://www.kff.org/quick-take/why-might-republicans-consider-extending-obamacare-tax-credits/ and https://www.kff.org/affordable-care-act/occupations-with-large-shares-of-workers-who-rely-on-individual-market-coverage/
#healthcare #healthplans #physicians #coverage #medicaid #exchanges #governmentshutdown #ffy2026
https://thehill.com/policy/healthcare/5520612-democrats-bet-the-house-on-health-care
Drug Tariff And Price News; Drug Tariffs Coming
The Trump administration launched investigations into imports of robotics, industrial machinery and medical devices, which sets the stage for potential tariffs on medical devices. A similar investigation was launched for drugs earlier. That cleared the way for President Donald Trump to announce Thursday that brand-name pharmaceutical products will be subject to a 100% tariff starting October 1 unless the drug maker is building a manufacturing plant in the United States. we will learn more about the tariff and its impacts tomorrow. A recent Health Affairs Forefront blog discusses the impacts to providers and consumers of drug tariffs as well as ways to boost domestic production.
A separate Health Affairs Forefront blog discussed President Trump’s most-favored-nation drug (MFN) pricing proposal as well as drug price-setting and disparities. On September 25, 2025, the proposed rule for the “Global Benchmark for Efficient Drug Pricing (GLOBE) Model” (RIN: 0938-AV66) was sent by the Department of Health and Human Services (HHS) to the White House’s Office of Management and Budget (OMB) for regulatory review. This appears to be implementing MFN. The rule also rescinds a Trump 45 MFN model for Part B medical drugs.
Additional articles: https://www.modernhealthcare.com/medical-devices/mh-trump-medical-device-tariffs/ and https://www.healthaffairs.org/content/forefront/tariffs-added-strain-us-health-care-system and https://www.cnn.com/2025/09/25/business/imported-pharmaceuticals-tariff-trump
#drugpricing #mfn #tariffs
Special Needs Plans Growing
Healthcare policy group KFF had an in-depth primer on the growth of Special Needs Plans (SNPs) in Medicare Advantage (MA). Coincidentally, I posted a major blog on SNPs earlier today here: https://www.healthcarelabyrinth.com/the-meteoric-growth-of-special-needs-plans-snps/ .
In another KFF briefer, the group looks at the budget reconciliation bill and coverage loss for immigrants legally in the United States. About 1.4 million lawfully present immigrants will become uninsured. That would reduce federal spending by about $131 billion and increase federal revenues by $4.8 billion as of 2034. Others lawfully present will lose coverage due to the anticipated expiration of enhanced premium subsidies in the Exchanges. And more than 530,000 Deferred Action for Childhood Arrivals (DACA) recipients will be ineligible for federally funded coverage options under a new administration rule.
Additional article: https://www.kff.org/immigrant-health/1-4-million-lawfully-present-immigrants-are-expected-to-lose-health-coverage-due-to-the-2025-tax-and-budget-law/
#specialneedsplans #snps #medicareadvantage
— Marc S. Ryan
