2026 Medicare Advantage Fallout
Despite the announcement of a stable Medicare Advantage (MA) environment in 2026 by the Centers for Medicare and Medicaid Services (CMS) last week, more predictions that 2026 could be a rocky road for both plans and enrollees. Modern Healthcare has a good article on the possible impacts. It says UnitedHealthcare, Humana, Aetna and Elevance Health have all canceled products. Many are announcing elimination of broker commissions for some products and trimmed benefits and networks. There also have been plan pullouts.
Deft Research says a record 9.8 million, or 28%, could switch plans, compared with 23% in 2025. This is not those forced to switch due to plan terminations. Some plans, though, are expanding. And investments will continue to be made in Special Needs Plans (SNPs). Humana says it will maintain supplemental benefit investments.
At the same time, at least 29 health systems are dropping MA plans in 2026. Among the most commonly cited reasons for terminations are excessive prior authorization denial rates and slow payments from insurers.
In other news, Humana’s refiled lawsuit on its SY 2025 Star ratings is back in front of a court. The case now centers on CMS’ decision on call center metrics. Humana wants a quick decision – before October 15 open enrollment.
Additional articles: https://www.beckershospitalreview.com/finance/20-health-systems-dropping-medicare-advantage-plans-2025/ and https://insurancenewsnet.com/innarticle/humana-suit-3-phone-disconnects-could-cost-insurer-billions-in-revenue
(Some articles may require a subscription.)
#medicareadvantage #star #cms #quality #enrollment #hosptials
https://www.modernhealthcare.com/insurance/mh-aetna-elevance-unitedhealth-medicare-advantage-2026/
Government Shutdown Inches Closer
A White House meeting among the president and top congressional leaders failed to bring a compromise on funding the government after September, making a government shutdown more probable. Democrats are demanding the GOP rescind budget reconciliation healthcare cuts and extend expiring Exchange premium subsidy enhancements. The GOP sees the demand as outrageous and points to bipartisan support of continuing resolutions in the past. Democrats say there is growing support among some Republicans to extend the Exchange subsidies but reined in somewhat (which may be unacceptable to Democrats). Democrats also say Trump is sympathetic to extension as well.
Various health programs expire on September 30, including hospital at home and telehealth. The administration has said Medicare, Medicaid, the Children’s Health Insurance Program, and the federal health insurance exchanges would continue operating for the immediate future.
Additional articles: https://www.fiercehealthcare.com/regulatory/telehealth-hospital-home-deadlines-approach-no-funding-deal-sight and https://thehill.com/homenews/senate/5527839-schumer-trump-gop-health-care-funding-bill/ and https://www.modernhealthcare.com/politics-regulation/mh-government-shutdown-cms-hhs-contingency-plans/
(Some articles may require a subscription.)
#governmentshutdown #crs #healthcare #coverage #ffy2026
Vertical Integration Gets Around Minimum MLR
A good Health Affairs Forefront blog showing more evidence that vertical integration helps these healthcare behemoths get around the minimum medical loss ratio (MLR) requirement under the Affordable Care Act. The blog points to a recent analysis of spending data from five states with healthcare cost growth targets. The analysis found an unexpected trend in 2023. Spending grew sharply in service categories that historically increased more slowly, especially payments made through financial arrangements between providers and health insurers that are not tied to individual claims. The payments rose by an average of 40.4 percent across the five states.
The authors see insurer-provider vertical integration as the potential culprit and blame it for weakening minimum MLR rules. Because there is no minimum MLR on providers, integrated companies shuttle payments from the insurer to the unregulated provider entity as medical expense (not admin or profit to the insurer) to get around the rule. The provider may also enter into inflated agreements with the insurer, above what are market prices to non-owned provider entities.
(Article may require a subscription.)
#minimummlr #medicalexpense #verticalintegration #insurers #providers #healthcare
— Marc S. Ryan
