1115waivers

Final Budget Score In From CBO: 10 Million To Lose Coverage The One Big Beautiful Bill Act that President Donald Trump signed into law on Independence Day will add $3.4 trillion to the national debt from 2025 to 2034. This is from the final scoring of the bill from the Congressional Budget Office (CBO). The estimated deficit rise reflects $1.1 trillion in cuts to direct spending and a $4.5 trillion government revenue loss due to extended and new tax cuts. CBO also projects the number of uninsured individuals will increase by 10 million by 2034 due to the Medicaid and Exchange reductions in the bill. This is about 2 million less than previously estimated due to some provisions being ruled unallowable by the Senate parliamentarian. Adding the expected 4.2 million to lose coverage when the enhanced Exchnage subsidies expire December 31 as well the 900,000 to lose coverage due to

Humana Loses Stars Lawsuit Humana’s lawsuit on Star calculations was thrown out of court this week. The judge indicated that the plan did not exhaust internal appeals processes at the time of the filing and thus the suit did not have standing. The suit could be refiled, though. The Centers for Medicare and Medicaid Services (CMS) later rejected Humana’s appeal. Humana’s suit was far-reaching and pointed. It said CMS did not follow its own regulations in its methodology for calculating ratings and said the agency does not provide plans the necessary data to calculate aspects of Star ratings. As an example, Humana said it could not replicate 60% of CMS’ cut point calculations. Humana’s average Star score fell from 4.37 in 2024 to 3.63 for 2025. Despite the lawsuit outcome, Humana is not wrong in its premise that inadequate data and a lack of transparency pervades the Star process. While

Democratic States Challenge Exchange Rule Finalization Democratic states sued the Trump administration today over the finalization of the Exchange rule that will significantly tighten the enrollment season and dampen eligibility. Provisions in the budget reconciliation bill will further clampdown on enrollment. The states are arguing that the administration did not follow all regulatory rules before finalization and that the rule is arbitrary and capricious. They also argue that the changes will boost the uninsured rate and cost states a great deal of money. In related news, the administration supplied data on improper enrollments in government programs. Analyzing 2024 enrollment data, the administration found 1.2 million enrolled in Medicaid or the Children’s Health Insurance Program in multiple states, and 1.6 million enrolled in one of those programs and an Exchange plan. Data-sharing and procedural requirements in the budget bill seek to further address this issue. As well, the Centers for Medicare

Employers Could Transfer Costs to Employees While there has been some increased costs for employees the past few years, employers attempted to shelter much of the huge trend in employer healthcare costs from their employees. Given ongoing trends, that is likely about to change. Analysts at Mercer polled 711 employers and found that 51% said they are likely or very likely to shift costs to employees in 2026. That’s up from 45% in 2025. About 19% said they were very likely to shift costs and 33% said they were likely to do so in 2026. More than half of employers are likely or very likely to make plan design changes that will shift more cost sharing to employees in 2026. Additional article: https://www.fiercehealthcare.com/payers/mercer-survey-employers-may-make-return-healthcare-cost-shifting-strategies #employercoverage #healthcare #coverage https://www.beckerspayer.com/payer/employers-plan-to-shift-more-healthcare-costs-to-employees-2026-10-things-to-know Study Looks At Consequences Of Medicaid Cuts New research in JAMA Health Forum says Medicaid cuts in the budget reconciliation bill could have far-reaching

CMS Issues Additional Payment Reform Rules After publishing a far-reaching rule Monday, the Centers for Medicare and Medicaid Services (CMS) issued today a proposed reform rule as well as proposed rates for outpatient hospitals and ambulatory surgery centers. Outpatient rates for hospitals would increase by 2.4% in 2026. Ambulatory surgery centers also would increase by 2.4% in 2026. Most important, CMS proposes important reforms to reduce the costs in Medicare over time. Many of these were proposed earlier during Trump 45, but the Biden administration rescinded the proposals upon coming to office. The reforms include: — Phasing out the inpatient only list over a 3-year period and allowing the services to be performed in a hospital outpatient setting or ambulatory surgery center. — Reforming the ambulatory surgery center list by updating its general criteria and shifting five exclusion criteria into a new, nonbinding section to allow the expansion of services,

Medicare Physician 2026 Rate And Reforms The Centers for Medicare & Medicaid Services (CMS) released its 2026 physician fee schedule on Monday evening, announcing an increase of 3.62% over the 2025 rate. The budget reconciliation bill increased rates for that year by 2.5%. The added amount was due to other changes in the rate-setting system. Physicians in alternative payment models will see an increase of 3.83%. CMS also unveiled a series of rate and other reforms, including rewarding certain physicians for avoiding hospitalizations, coordinating better with primary care, and early intervention. CMS also proposed removing 10 quality measures that do not improve patient health outcomes and introduced five new ones, with an emphasis on preventive services and expanding Medicare diabetes prevention. Additional articles: https://www.fiercehealthcare.com/regulatory/cms-proposes-36-pay-bump-docs-takes-aim-chronic-conditions-physician-fee-schedule and https://www.beckershospitalreview.com/finance/cms-pitches-2026-physician-pay-plan-with-2-conversion-factors-8-things-to-know/ and https://www.beckershospitalreview.com/finance/cms-proposes-2026-medicare-rule-6-notes/ and https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2026-medicare-physician-fee-schedule-pfs-proposed-rule-cms-1832-p and https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2026-medicare-physician-fee-schedule-proposed-rule-cms-1832-p-medicare-shared and https://www.cms.gov/newsroom/press-releases/cms-proposes-physician-payment-rule-significantly-cut-spending-waste-enhance-quality-measures-and (Some articles may require a subscription.) #cms #medicare #regulations #providers #physicians #acos https://www.modernhealthcare.com/politics-regulation/mh-medicare-physician-pay-cms-2026 A Second Budget

Mergers and Acquisitions Down Due to the major healthcare reductions in the budget reconciliation bill, mergers and acquisitions between hospitals and health systems were down in Q2 2025 against recent years. Eight transactions were announced in the second quarter, the lowest in the quarter since at least 2017. Another report says that employers need to brace for continuing increases in healthcare costs. This is in part due to underlying utilization trends but also the probable price hikes providers will demand due to the losses in other lines of business under the reconciliation bill as well as the threat of tariffs. Hospital uncompensated care costs are expected to grow by $443 billion over ten years. Additional article: https://www.healthcaredive.com/news/hospital-health-system-ma-falls-q2-medicaid-cuts-2025/752685/ #employercoverage #manda #mergers #acquisitions https://www.beckerspayer.com/payer/why-2026-may-hit-employers-with-a-one-two-punch-on-healthcare-costs Record Data Breaches In 2024 A record-high number of organizations reported healthcare data breaches in 2024. This year will be challenging as well. The Department of Health and

PAYGO Politics President Donald Trump and Republicans said they would not cut Medicare, but the budget reconciliation could very well do that. Since the bill actually increases the deficit in future years, what is known as PAYGO sequestration kicks in to address the increase. Medicare is one program that can be cut under the law to a cap of 4%. On an earlier version of the bill, the Congressional Budget Office (CBO) said about $500 billion in cuts could be triggered beginning in 2026. PAYGO can be overruled but the Senate Democrats would have to join Republicans to overrule PAYGO by 60 votes. In this political world, will that happen this time as it has in the past? Will Democrats blame Republicans for passing the budget bill and not overrule or would that then put the blame on Democrats? See my blog this week for all the details of the

A Second Budget Bill Coming? Capitol Hill was abuzz today when the budget chairs of each house signaled that they both would like to see a second bill. While budget reconciliation rules allow for only one bill per year, the GOP had FFY 2025 and FFY 2026 budget years they could use for the process. And technically, after October 1, 2025, FFY 2027’s budget could also be acted on with a budget reconciliation bill. Budget Chairs Mike Crapo, R-ID, and Rep. Jodey Arrington, R-TX, each confirmed a desire for a second bill later this year but did not specify what might be included. Separately, Ron Johnson, R-WI, said that he has a commitment from the White House and Senate GOP leadership to get another chance to repeal part of the Affordable Care Act’s (ACA) expansion of Medicaid. Johnson’s proposal would end the 90 percent federal cost-share at the end of

Good News, Bad News On Drug Tariffs President Trump said Tuesday that he could levy up to 200 percent tariffs on pharmaceutical products imported into the U.S. soon. “If they have to bring the pharmaceuticals into the country, the drugs and other things into the country, they’re going to be tariffed at a very, very high rate, like 200 percent,” Trump said during a Cabinet meeting. That is the bad news. In good news, Trump said any tariffs would not take effect immediately. “We’re going to give people about a year, year and a half, to come in, and after that, they’re going to be tariffed,” Trump said. America imports the majority of its generic drugs from abroad and Trump wants this production onshored for national security reasons. Many brand drugs are also imported. Levies on drugs would increase already steep spending trends in healthcare. #tariffs #drugpricing https://thehill.com/homenews/administration/5390505-trump-200-percent-tariffs-pharma-imports Employer Coverage Changes Not