2024

CMS Recalculates Some SY 2026 Ratings CMS this evening announced it is recalculating some contracts’ SY 2026 Star Ratings based on the better of the current ratings or the measures included in the recent Clover decision. A judge struck up to 20 measures. CMS went out of its way to note that this does not set policy for SY 2027 ratings or beyond. I still expect an appeal or other intervention to bring back a fulsome Star program. #stars #quality #cms #medicareadvantage #partd #pdp DOJ Sues NY Over Fraud The Department of Justice (DOJ) is suing the New York State Department of Health (DOH), the state’s Medicaid director, and a company operating a $10 billion home health program. The Justice Department accused home health agency Public Partnerships, LLC (PPL) of making false or misleading statements about its ability to take over and run the state’s Consumer Directed Personal Assistance Program (CDPAP). DOJ also says DOH awarded PPL the contract after conducting

MedPAC Largely Pans Hospitals’ Complaint On MA Penetration Congressional Medicare policy advisor MedPAC panned hospitals’ views that increased penetration of Medicare Advantage (MA) is impacting providers’ financial stability. Empirical analyses conducted by MedPAC staff showed no evidence of a significant association between MA market penetration and all-payer margins of hospitals, skilled nursing facilities (SNFs), and home health agencies. This does not appear to be the case in rural markets, either. But MedPAC did find some changes in revenues, costs and utilization trends and some of it was in hospitals’ favor. MA enrollees’ average length of stay in fiscal year 2024 was actually 11.2% longer than fee-for-service (FFS) beneficiaries. This was related to those who were destined to be discharged to a post-acute care facility. And overall greater MA penetration was tied to dips in total SNF facility days and small declines in revenues and costs at SNFs and home health.

Exchange Carrier Exits Healthcare policy group KFF issued several issue briefers recently on carrier losses in the Exchanges. The average number of issuers offering plans in the Exchanges has declined from 9.6 issuers per state in 2025 to 9.0 issuers per state in 2026. In total, 18 states experienced a net decrease in the number of issuers offering plans. Three in 10 counties have fewer participating insurers than last year. In 165 counties, only one issuer is offering plans, up from 93 counties in 2025. Six carriers have announced that they will exit the Exchanges in 2027, either in some or all states that they are currently offering plans: Cigna Health, CareSource, PacificSource, Scott and White, Providence Health, and Taro Health. In other news, Centene will offer buyouts to employees as it navigates a significant membership decline in both Medicaid and the Exchanges. During Q1, Centene reported a 6% decline

Trump Seeks To Make Medicare Drug Price Negotiations Permanent In Regulation The Trump administration and the Centers for Medicare & Medicaid Services (CMS) have proposed to codify the Biden-era Medicare Drug Price Negotiation Program — a fantastic turn of events that few would have predicted a few years ago despite Trump’s sympathies for drug price reform. They say the move will create a more transparent and sustainable process for lowering drug costs for millions of Medicare beneficiaries. There are a number of small concessions to drug makers as well. I have given President Trump great credit for making a huge impact on drug pricing, more than any other recent president. This is more evidence. Additional articles: https://www.cms.gov/newsroom/press-releases/cms-proposed-rule-locks-lower-prices-fosters-innovation-medicare-drug-price-negotiation-program and https://www.cms.gov/files/document/mdpnp-nprm-fact-sheet.pdf #drugpricing #cms #medicare #partd #medicareadvantage #pdp https://www.fiercehealthcare.com/regulatory/cms-proposes-permanent-framework-medicare-drug-price-negotiations Democrats Search For The Next Obamacare Democrats are seeking to find their next Obamacare to win votes in the midterms. Lawmakers and policymakers are

Healthcare Cost Projected To Soar PwC says health plans expect commercial healthcare costs to climb 9% in 2027. Payers say increased use of artificial intelligence tools by health systems, hospitals and medical practices are in part to blame. AI is documenting greater specificity and reimbursable severity without proportionate increases in care intensity. Further, there is the growing use of expensive drugs, proliferation of mental health issues, and higher reimbursement demands. A survey by Mercer says U.S. companies plan to charge more for employee health plans next year. Additional articles: https://www.fiercehealthcare.com/payers/healthcare-costs-poised-jump-9-2027-health-plans-blame-ai-adoption-drug-prices and https://www.modernhealthcare.com/insurance/mh-health-insurance-costs-mercer-survey/ (Some articles may require a subscription.) #employercoverage #healthcare #costs https://www.modernhealthcare.com/providers/mh-healthcare-costs-2027-pwc-report Hospitals Don’t Like Rate Hike Or Joint Model Hospital groups want the Centers for Medicare and Medicaid Services’ (CMS) proposed annual pay rate increase of 2.4% for inpatient care to be increased. Further, it wants the agency to reconsider a mandatory bundled-payment joint replacement model. #hospitals #margins #medicare

Clover May Get Stars Reset The Centers for Medicare and Medicaid Services (CMS) could reset Clover Health’s SY 2026 rating for its largest contract after it won a lawsuit challenging the validity of some 20 measures. The health plan announced that CMS has recalculated the rating and advised the plan to submit an alternaive 2027 bid. If the recalculation is applied, all of Clover Health’s 156,000 Medicare Advantage members would now be enrolled in plans rated at least four of five stars, generating some $120M in bonus payments in 2027. But the “recalculation” is code for “we were directed to do so by the court and we likely are appealing the ruling.” So a small positive step, but not definitive for Clover yet. In essence, we still have pending litigation. After the recent Clover ruling, Humana advised the court in its lawsuit of the Clover decision. Now, the judge in

CMS Takes Tough Stance On Price Transparency Violations More than 500 hospitals received warnings from the federal government since April for non-compliance on the hospital price transparency regulation. Further notices could be sent soon. Hospitals receive an initial 90-day warning with instructions to correct any deficiencies. A subsequent 45-day deadline is sent requiring a more concrete plan to address deficiencies. If hospitals remain out of compliance, sanctions can run as high as $5,500 per day or over $2 million per year. Additional article: https://www.modernhealthcare.com/providers/mh-cms-hospital-price-transparency-data/ (Some articles may require a subscription.) #pricetransparency #hospitals #cms https://www.fiercehealthcare.com/providers/hundreds-hospitals-warned-over-price-transparency-failings-ap-reports Employers To Shake Up PBM Contracts A Pharmaceutical Strategies Group survey concludes health plans are thinking about shaking up how they manage pharmacy benefits due to surging costs. Among strategies include different drug pricing arrangements, rejecting single pharmacy benefit models, and embracing third-party vendors. Some are unbundling traditional pharmacy benefits manager services, looking for the best deal

Many Unaware Of Coming Work Rule A Health Management Academy survey finds that about 55% of Medicaid enrollees say they are unaware of upcoming work requirements. Work requirements go into effect on January 1 under the One Big Beautiful Bill Act. Many enrollees don’t know they’ll need to report work, education or volunteer hours starting in less than six months in order to stay covered. Another 27% said they knew something about work requirements but were unsure of the details. While the vast majority of Medicaid enrollees who can work are employed, many will lose eligibility due to lack of knowledge of requirements, paperwork burden, and administrative snafus by states. #workrequirements #states #medicaid #obbba https://www.healthcaredive.com/news/over-half-medicaid-enrollees-unaware-work-requirements-health-management-academy-survey/822228 TrumpRx Adds Drugs President Trump announced that over 100 prescription medications would be added to his administration’s direct-to-consumer drug platform, TrumpRx. #trumprx #drugpricing https://thehill.com/policy/healthcare/5913129-donald-trump-trumprx-expansion-160-drugs — Marc S. Ryan

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