1115waivers

House GOP Wants MedPAC To Be More Favorable To MA A new bill from Ways and Means Republicans that passed on a party line vote would require the Medicare Payment Advisory Commission (MedPAC) to study the topic of overpayments in Medicare Advantage (MA) more favorably for insurers. I support the bill as MedPAC has shown major bias against MA over the years, undertaking twisted analyses and citing dubious research studies to further the idea that MA is markedly over reimbursed. #medicareadvantage #overpayments #riskadjustment https://www.statnews.com/2026/09/16/medicare-advantage-overpayments-analysis-medpac-change-apples-to-apples-act/ CMS Gives In To Texas In a rather blatant political move, the Centers for Medicare and Medicaid Services has given in to Texas and extended a hospital and other provider funding plan. The state, which did not expand Medicaid, will have about $12 billion restored just as CMS is reining in provider taxes and similar payments. #texas #medicaid #hospitals https://www.beckershospitalreview.com/finance/cms-approves-12b-in-texas-medicaid-funding-after-monthslong-dispute/ Healthcare Agentic AI Boom Outpacing Governance

PBM Law Could Impact Drug Entities In The Shadows A new law with restrictions on and reforms to pharmacy benefit managers (PBMs) will have a major effect throughout the drug channel. The law requires greater transparency and will likely expose various transaction fees between PBMs and rebate aggregators, group purchasing organizations, and others related entities. #pbms #transparency https://www.modernhealthcare.com/insurance/mh-pbm-reform-drug-rebate-aggregators NCQA Releases Plan Ratings Healthcare quality organization NCQA released its annual Star rating for health plans. Eighteen plans scored a perfect 5 Stars for 2026, up from 11 in 2025. There are no for-profits among them. Of large plan entities, CVS Aetna had the best average rating across plans of 4.009. Additional article: https://www.beckerspayer.com/rankings-ratings/the-best-rated-health-plans-of-2026-ncqa/ #ncqa #quality #healthplans #stars https://www.healthcaredive.com/news/ncqa-plan-ratings-2026-nonprofits-outperform/830521 — Marc S. Ryan

ACCESS Program To Expand The new tech-based chronic disease management ACCESS program will expand the diseases and conditions eligible for enrollment. The Centers for Medicare and Medicaid Services (CMS) announced that new clinical tracks will be added next Spring, including heart failure and substance use disorders. CMS Administrator Dr. Mehmet Oz also said he eventually wants the model adopted in Medicare Advantage (MA) and Medicaid. Right now, it services traditional Medicare enrollees. The initiative has CMS contracting with technology organizations, which team up with Medicare physicians to use tech to track and improve outcomes for people with certain cardio-kidney-diabetes disease states, anxiety and depression, and musculoskeletal conditions. The new disease states include health failure, chronic obstructive pulmonary disease, substance abuse, and tobacco cessation. Additional article: https://www.modernhealthcare.com/health-tech/mh-cms-access-model-chronic-care-tracks/ #medicare #chronicdisease #caremanagement #access https://www.beckershospitalreview.com/finance/cms-expanding-access-model-4-things-to-know/ Younger Gens Do Not Trust Insurers A new survey finds that member trust in insurers is on the decline

Trump Rejects Amodei’s Call President Donald Trump rejected Anthropic CEO Dario Amodei’s call to slow the pace of advanced artificial intelligence development. Trump said that existing federal authority and presidential oversight are sufficient. “The only control or ‘guardrails’ that AI needs is a STRONG AND SMART (High IQ!) PRESIDENT,” President Trump wrote in a Truth Social post. Of course, neither is true and the nation does not have a true game plan to control the roll out of AI across industries. Amodei published an essay last week where he argued that AI capabilities are advancing faster than safety measures designed to govern them. He called for slowing development, implementing new safeguards, and allowing third-party evaluators to verify measures undertaken. Anthropic will implement the evaluator safeguard unilaterally. Check out my blog published today on AI and regulation: https://www.healthcarelabyrinth.com/ai-in-healthcare-innovate-but-with-guardrails/ #healthcare #ai #regulation https://www.beckershospitalreview.com/healthcare-information-technology/innovation/trump-rejects-anthropic-ceos-call-for-more-ai-guardrails/ Taiwan’s Single Payer System A good Health Affairs Forefront

Does PDP Program Need A Fallback Plan? I have made much of the politically motivated Democratic Inflation Reduction Act’s (IRA) provisions to reduce cost-sharing for seniors in Part D. It was a terrible piece of public policy that has led to a huge increase in costs and risk to plan sponsors. While Medicare Advantage (MA) has survived, it certainly led to benefit reductions. But in the standalone Part D (PDP) world (which largely serves the traditional Medicare beneficiaries), the IRA changes have led to benefit reductions, rising premiums, fewer choices and coverage, and a financially untenable system. A Health Affairs Forefront blog makes the case that a government-facilitated fallback plan may need to be introduced now before the financial situation gets worse. The author traces the failures to growing MA and its payment and benefit advantages, which means the PDP market gets smaller and riskier. The capping of cost-sharing and

MA Star Cut Points Rise Good Healthcare Dive article on the release of Plan Preview 2 information for Medicare Advantage Stars and the new cut points. As the article discusses, assessing what will happen to overall Star ratings is hard to do. Tougher cut points can or cannot be a sign that things will go up overall. My companion blog tends to think that some of the increases tie to true initiatives on performance improvement and others to MA plan exits. I think if things do go up overall, it will be modest. That blog is here: https://www.healthcarelabyrinth.com/two-star-blogs-in-one-what-will-cms-do-next-on-stars-and-despite-cut-point-moves-widespread-overall-ratings-hikes-unlikely/ #medicareadvantage #partd #stars #quality https://www.healthcaredive.com/news/medicare-advantage-stars-cutpoints-2027-cms/829963 Federal Exchange Enrollees To Receive Rebate The White House announced that it will issue $500 refunds to close to a million people enrolled in the federal Exchanges. The administration says the rebates are tied to overcharges collected in the Biden administration through user fees intended to fund

Impact Of OBBBA Cuts Two new analyses describe the looming impacts of the Medicaid and Exchange cuts in the One Big Beautiful Bill Act (OBBBA). Upcoming statutory limits on providers’ state-directed payments (SDPs) in Medicaid are expected to cost states tens of billions of dollars for state match and lower spending by double that or more. The analysis published in Health Affairs says 17 hard-hit states could see impacts of 10% to 25% of total annual Medicaid spending. The analysis outlined at least $51.8 billion in reductions across 36 states. A proposed rule would expand reductions beyond what is outlined in the OBBBA to all such SDPs. Federal policy changes and budget cuts are forcing states to scale back Medicaid benefits for immigrants. Because of looming cuts, California, Colorado, Illinois, Minnesota, New York, Washington and the District of Columbia have scaled back state-funded coverage for immigrants. The changes will also

States Turning To Managed Care For Medicaid Long-Term Care An excellent Modern Healthcare article on Medicaid long-term care. Twenty-four states contract with Medicaid managed care organizations to cover people who need long-term services and supports. This is a remarkable shift from decades ago when managed care covered largely only TANF welfare and related populations. States have turned to private delivery to save costs and reduce trends. However, some states are actually rolling back long-term managed care. Indiana and Nebraska recently ended insurer contracts amid provider concerns. #medicaid #longtermcare #managedcare https://www.modernhealthcare.com/insurance/mh-medicaid-managed-care-long-term-services State Initiatives To Reduce Healthcare Costs Growing Another interesting Modern Healthcare article on state efforts to reduce healthcare costs. Eight states have established cost growth targets. Enforcement ranges from hard penalties down to performance improvement plans and reporting. Some states are also looking to cap certain healthcare services and payer types. So far, there have been mixed reviews on state

Cuban Offers Ideas On Affordability Entrepreneur Mark Cuban, founder of Cost Plus Drugs, appeared before the Texas Legislature with affordability and reform ideas. They include: #healthcare #healthcarereform #cuban https://www.fiercehealthcare.com/regulatory/mark-cubans-recipe-affordable-healthcare-includes-these-5-policy-changes Cambia And Arkansas BCBS Affiliation Approved The Arkansas Insurance Department approved Arkansas Blue Cross and Blue Shield’s affiliation with Cambia Health Solutions, effective Oct. 1. The partnership will bring Cambia’s membership to nearly 6 million enrollees across six states. #bcbs #mergers https://www.modernhealthcare.com/insurance/mh-arkansas-blue-cross-cambia-health-approval — Marc S. Ryan

Hospitals Say Revenue Losses Will Mount With More Changes Hospital lobbies are turning up the heat on lawmakers given multiple funding reductions that threaten hospital finances. Impacts of the One Big Beautiful Bill Act will be $340 billion through 2034. But new rules proposed by the Trump administration would reform site neutral payments for imaging and enact reductions to drug reimbursement in Medicare for those with 340B status. That would mean another $681 billion loss over ten years. While I favor site neutral payments and some 340B reforms, it seems clear that all the reductions threaten to undermine providers. #hospitals #obbba #340b #siteneutral #medicaid #exchanges https://www.politico.com/news/2026/09/02/hospitals-say-coming-regulations-worse-than-medicaid-cuts-01060086 Centene To Exit Some Commercial Markets Centene subsidiary Health Net is pulling out of the commercial employer group market in California and Oregon. Additional article: https://www.modernhealthcare.com/insurance/mh-centene-california-oregon-commercial-group-plans/ #centene #employercoverage https://www.beckerspayer.com/payer/centenes-health-net-to-exit-commercial-group-market-in-california-oregon/ ICHRAs Now CHOICE The Centers for Medicare and Medicaid Services (CMS) has announced the rebranding