2024

Cities and County Sue Over Exchange Rule A group of cities and a county are suing the Trump administration over the just-finalized Affordable Care Act (ACA) Exchange rule for 2027. The parties argue that elements of the regulation — such as multi-year catastrophic plans, higher out-of-pocket caps and non-network plans as qualified health plans — are unlawful. The lawsuits say they should not be implemented. (Article may require a subscription.) #exchanges #aca #obamacare https://www.modernhealthcare.com/politics-regulation/mh-hhs-lawsuit-aca-exchange-rule-2027 KFF Covers 2026 MA Enrollment And Benefits Healthcare policy group KFF has a number of briefers on Medicare Advantage (MA) enrollment and benefits. Some key highlights across the three briefers: Additional articles:  https://www.kff.org/medicare/medicare-advantage-in-2026-enrollment-update-and-key-trends/ and https://www.kff.org/medicare/medicare-advantage-out-of-pocket-limits-variation-and-trends/ #medicareadvantage https://www.kff.org/medicare/medicare-advantage-in-2026-premiums-out-of-pocket-limits-supplemental-benefits-and-prior-authorization/ Clover MA Star Lawsuit Fallout A good Modern Healthcare article on the uncertainty created by a federal court ruling throwing out Clover Health’s 2026 Star Ratings. Cover challenged on the grounds that the Centers for Medicare and Medicaid Services

Why Not Mandatory GLP-1s In Medicare For Obesity? A Health Affairs Forefront Blog argues that GLP-1 coverage for obesity should be made mandatory. I have given great credit to the Trump administration for reducing drug prices, including with GLP-1s. But the proposed BALANCE reform model failed to attract enough health plans in the voluntary program. The government funding and risk mitigation just did not solve the fundamental risk problem, especially for standalone Part D (PDP) plans. Instead, Trump healthcare officials are proposing the BRIDGE program through 12/31/2027 to have the government cover the cost of such drugs for obesity. The authors argue that voluntary BALANCE failed to attract plans so other options exist: (Article may require a subscription.) #glp1s #weightlossdrugs #drugpricing #medicare #medicareadvantage #partd #pdp https://www.healthaffairs.org/content/forefront/after-balance-why-voluntary-coverage-obesity-drugs-failed-and-comes-next Commonwealth: One In Five Hit With Coverage Denials The Commonwealth Fund released its 2025 Affordability Survey, which found that one in five adults said

Paragon Says Over 6 Million Improper Exchange Enrollments The influential conservative Paragon Health Institute says a quarter of all Exchange enrollments were improper in 2026, adding fodder for those arguing healthcare has rampant fraud and improper enrollments. Paragon argues taxpayers will improperly subsidize the program by nearly $25 billion.  In other news, Colorado Democratic Gov. Jared Polis signed into law funding for healthcare insurance affordability. Colorado’s health insurance affordability enterprise already collects fees from health plans and hospitals to reduce premiums in the individual market. The new law would issue bonds to generate up to $100 million beginning in 2027. In addition, another $40 million will be earmarked from the marijuana tax cash fund. The law also establishes a premium reduction target of 18% for the reinsurance program. Further, according to JD Power, national average satisfaction scores for commercial plans are down one point from a year ago and down three points from 2024. More than half of

Republicans Run From Healthcare Cuts On Campaign Trail Republican lawmakers are running from the massive healthcare cuts that were enacted as they crisscross districts back home in anticipation of the midterms. About the only one championing some changes is Maine Sen. Susan Collins, who campaigns on a $50B rural health fund but actually voted against the One Big Beautiful Bill Act (OBBBA). At the same time, lawmakers seem all-in support for value-based care, even as some see a mixed record over the past several decades. They note healthcare spending continues to grow rapidly, and models seem to save little or nothing so far. Additional article: https://www.modernhealthcare.com/insurance/mh-insurers-value-based-care-unitedhealth-cvs/ (Some articles may require a subscription.) #obbba #medicaid #exchanges #coverage #healthcare #ruralhealthcare #vbc https://www.modernhealthcare.com/politics-regulation/mh-republicans-health-insurance-2026-election-midterms Lilly Threatens To Withhold 340B Discounts Brand drug maker Eli Lilly says it will cut off providers from discounts under the 340B drug discount program if participating providers fail to

Trump Administration Issues Work Requirements Regulation The Trump administration issued draft regulations today that implement work requirements in Medicaid under the One Big Beautiful Bill Act (OBBBA). Able-bodied and non-pregnant adults aged 19 to 64 will be subject to the requirements, with exemptions in place for the medically frail, disabled, and others who are unable to meet the mandates. Individuals can meet the requirement by working, completing community service, or participating in a work program for at least 80 hours per month. States must implement the requirements prior to 2027. The rule includes broader than expected definitions for “medically frail” people, who are exempt from the mandate. Individuals can also self-attest that they’re exempt once before states require documentation. Critics argue that most on Medicaid work and that the mandate will lead to eligibility loss due to paperwork and a lack of knowledge of the requirements. States will also spend

Uninsurance Rate Holds Flat in 2025 The Centers for Disease Control and Prevention (CDC) reports that the uninsurance rate remained flat in 2025. This was despite the continuing insurance losses in Medicaid and the Exchanges. Last year, 28 million or 8.3% of Americans were uninsured – just up 0.1% from 2024. More people are likely to lose coverage due to coming healthcare spending cuts. #uninsured #healthcare #coverage https://www.healthcaredive.com/news/uninsurance-rate-steady-2025-cdc/821488/ Elevance Health Gets Another Sanction Reprieve Elevance Health has gotten yet another reprieve from deep sanctions over its handling of risk adjustment in Medicare Advantage (MA). The Centers for Medicare & Medicaid Services (CMS) said the company has made progress in complying with regulations and must fulfill additional key steps by June 30 or face the sanctions. Additional article: https://www.fiercehealthcare.com/payers/cms-set-suspend-enrollment-elevance-healths-medicare-advantage-plans (Some articles may require a subscription.) #medicareadvantage #regulations #sanctions #radv #riskadjustment #elevancehealth https://www.modernhealthcare.com/insurance/mh-elevance-medicare-advantage-enrollment-cms United To End Many Children’s Auths; Mass Sues Over

Clover Wins Star Suit In a stunning decision, a federal judge in Georgia ruled in favor of Clover Health in its lawsuit challenging its 2026 Medicare Advantage (MA) Star Ratings. What’s more the judge seemingly has thrown out 20 measures in the program. The judge ordered just Clover’s 2026 ratings, impacting 2028 payments, to be recalculated. But it is hard to see how this could not impact all contracts if the ruling is upheld. Clover’s ratings dropped considerably in Star Year 2026, with 93% of its members enrolled in plans with ratings below four. This cost Clover $120 million in bonus revenue. Clover’s two-prong argument that the court agreed with was that the Centers for Medicare and Medicaid Services (CMS) did not have the authority to collect data and score some measures and did not adequately notice changes for others. The Supreme Court recently threw out the so-called Chevron doctrine

Non-Network Plans Could Thrive Non-network plans have been approved as qualified health plans on the Exchanges under a new rule and a number of prominent healthcare companies, including Sidecar Health, may offer such plans in the future. Non-network plans do not hold contracts or negotiate prices with hospitals and doctors, but outline for enrollees how much they will pay for specific services. Usually, such prices are based on average local prices. The Trump administration has argued that such plans encourage innovation and lower costs. Opponents argue that such plans will boost costs for other enrollees if such plans end up as benchmark plans in the Exchanges. Further, they say healthier people could be attracted to such plans and increase risk in more comprehensive ones. Last, they also say such plans could end up being expensive for many due to limited benefits. States do have the choice to approve the offering

KHN Covers Alternative Insurance As traditional insurance coverage premiums spike, many are turning to alternative insurance coverage. Kaiser Health News looks at the issue. These policies are not qualified health plans under the Affordable Care Act (ACA) and often have limits and gaps. This coverage is different from cheaper, qualified coverage on the Exchanges, such as catastrophic coverage as well as reforms made by a recent rule proposed by the Trump administration. One popular alternative as premiums spike are so-called sharing initiatives, many of the Christian-based. #healthcare #coverage https://kffhealthnews.org/health-industry/alternative-health-plans-growth-sharing-ministries-short-term-aca-premiums/ CVS Sues To Overturn TN Law on PBMs CVS has filed a lawsuit to challenge a Tennessee law that would bar pharmacy benefit managers (PBMs) from owning pharmacies in the state. This takes effect in 2027 and will prohibit people or companies from owning, managing or controlling pharmacies in the state at the same time as PBMs and health insurance issuers. Other

Feds To Use AI To Audit States The Department of Health and Human Services (HHS) will use artificial intelligence to review state audits of federal funding recipients, including Medicaid agencies. HHS told governors that its new Audit Enforcement and Risk Oversight initiative will review the previous five years’ worth of audits of state agencies. The agencies are required to conduct audits of state programs and grantees if expenditures of federal funds are over $1 million. (Article may require a subscription.) #fwa #trump #hhs https://www.modernhealthcare.com/politics-regulation/mh-hhs-ai-medicaid-audit-states-funding Point32Health Reports Q1 Profit Turnaround Point32Health reported an adjusted net income of $248 million in Q1 2926, a reversal from a $21 million adjusted net income in Q1 2025. Point32Health is the Harvard Pilgrim Health Care and Tufts Health Plan parent. #healthplans #margins https://www.beckerspayer.com/financial/point32health-posts-86m-operating-income-in-q1/ — Marc S. Ryan