2024

The Big Debate Over Dropping Exchange Enrollment The Trump administration recently went on the offensive, arguing a drop in Exchange enrollment should be credited to its ongoing efforts to crack down on improper and fraudulent enrollment. A recent administration report says 5.6 million people were fraudulently enrolled in Exchange plans in 2025, and that it removed 2.9 million through various initiatives. But critics argue the drop in enrollment is tied to rising premium costs, including the expiration of enhanced premium subsidies passed and extended during the COVID years. They argue more will drop throughout 2026 due to affordability issues. The truth is likely somewhere in the middle. For sure, rising premiums have led many to disenroll. But the Trump administration is likely also right. There is little question in my mind that zero premiums led many to be fraudulently enrolled. #exchanges #enrollment https://kffhealthnews.org/medicaid/aca-fraud-crackdown-skyrocketing-prices-enrollment-decline/ 2027 Exchange Premium Increases Healthcare policy group

HRSA Finalizes 340B Rebate Pilot The Health Resources and Services Administration (HRSA) finalized a revamped version of its contentious 340B Rebate Model Pilot Program after public comment. Earlier, a judge had struck the pilot due to regulatory deficiencies. The new pilot would move from upfront discounts to retrospective rebates for some drugs. Another Trump proposals would reduce Medicare drug reimbursement for 240B providers to ensue no double-dipping on discounts. The revised pilot is now set to begin on Jan. 1, 2027 and will run for at least a year. In other news, a Health Affairs Forefront blog says there could be duplication of discounts between the Medicare drug price negotiation program and 340B as well. Additional articles: https://www.modernhealthcare.com/politics-regulation/mh-340b-drugs-rebate-pilot-hrsa-safety-net/ (Some articles may require a subscription.) #340b #drugpricing #hospitals #providers https://www.fiercehealthcare.com/providers/revised-340b-rebate-model-pilot-program-moves-forward-despite-provider-pushback United Reports Cost Surge For Fully Insured UnitedHealth Group’s Center for Health Care Research reports that total medical costs for fully

Senate Dems Float RFI For Healthcare Reform Senate Democrats released a white paper detailing their goals for reforming healthcare. Some of the document gives hope that Democrats may abandon their more radical “Medicare for All” persona in favor of reforming the current private delivery system. It is especially focused on affordability and lowering costs. At the same time, there are the normal political attacks and positions, including a rehash of expired Exchange subsidy enhancements, Medicaid cuts in the One Big Beautiful Bill Act (OBBBA), and a proposal for a public health plan option to run side-by-side with private plans. Democrats would take a hard line on health plans and corporate greed. Additional article: https://www.beckerspayer.com/policy-updates/senate-democrats-eye-public-option-in-insurance-reform-push/ #healthcarereform #coverage #congress https://www.axios.com/2026/07/30/senate-democrats-health-insurance-overhaul Cigna Reports Q2 Financials Cigna reported good financial news for Q2 2026, driven by major growth in employer sponsored coverage and at its Evernorth services entity (with the exception of pharmacy benefits

Humana Will Exit More Counties In 2027 At a Q2 earnings call, Humana executives said it is planning additional Medicare Advantage (MA) market exits for 2027 to continue its road to financial recovery. Humana has been the biggest enroller in 2026 (expected 25% growth) and that could be part of the contraction plans. The county exits will impact about 600,000 but Humana expects to make up a good deal of that in more profitable counties. Humana’s medical loss ratio (MLR) was a high 91.1% in the quarter and the membership growth caused that. Humana downgraded its earnings guidance in part due to smaller quality bonuses, another struggle. Humana says it is on track to reach its goal of achieving top quartile Stars in the 2028 Star year. The company reported $694 million in profit for the quarter, up from $545 million in Q2 2025. Profits through the first half of

ACHP Urges “Better Of” Approach for Star Year 2027 In a letter sent to the Centers for Medicare and Medicaid Services (CMS), the Alliance of Community Health Plans (ACHP) requested that CMS continue its hold harmless methodology for 2027 Medicare Advantage (MA) Star Ratings. The non-profit plan trade group asked that CMS calculate the “better of” the 2025 measurement year original ratings and a version that removes measures affected by Clover Health’s litigation. The letter appears purposefully ambiguous on what the second scenario would be – CMS’ view used in SY 2026 or other possibilities that could result from lawsuits. Overall, the proposal makes sense. Additional article: https://achp.org/wp-content/uploads/ACHP-re-Clover-Litigation_Request-to-Apply-the-2026-Hold-Harmless-Methodology-to-the-2027-Medicare-Advantage-Star-Ratings_July-27-2026.pdf #medicareadvantage #stars #quality #cms https://www.beckerspayer.com/payer/medicare-advantage/achp-urges-cms-to-use-higher-of-2-ma-star-ratings-scores-in-2027-amid-clover-lawsuit/ Centene Reports Q2 Results, Raises Guidance Centene reported $1.1 billion in profit for Q2 2026 compared with a loss a year ago. First half 2026 profits were $2.6 billion, compared with 1H 2025’s $1.05 billion. Revenues in Q2

MA’s Value Underscored In New Study A new ATI Advisory analysis conducted on behalf of the Better Medicare Alliance finds that Medicare Advantage (MA) enrollees spend less on average than those in traditional Medicare fee-for-service (FFS) and yet have similar satisfaction rates. Looking at files from 2021 to 2023, ATI found that MA enrollees spent $2,824, or 36%, less out-of-pocket on average in 2023 compared to those in FFS. That difference has increased over time, with savings 16% higher in 2023 than in 2022. Just 12% of MA enrollees said they faced a significant cost burden, or spent more than 20% of their income on healthcare, compared to 24% of those in FFS. MA too cares for more lower income people – 54% in MA are at or below 200% of the federal poverty level vs. 30% in FFS. More than three-quarters of MA members have three or more chronic

Warning Signs For Hospitals On Exchange Enrollment Falloff For-profit hospital chains HCA and Tenet reported earnings for Q2 2026 and within the disclosures are tough news on Exchange revenue that could impact all hospitals. HCA reported that its overall loss due to Exchange enrollment declines will go from an estimated $1 billion to a new projection of $1.2 billion in 2026. HCA says volume declines of 15% are in line with original guidance estimates, but its assumption that 80% to 85% of the patients who lose Exchange coverage would become uninsured has been off. The number is closer to 100%. HCA’s admission decline for Exchange enrollees has been between 25% and 28% for the first half of the year. The Exchange issues alone have caused a $400 million impact on adjusted EBITDA in Q2. Similarly, Tenet Healthcare saw a 17% year-over-year decrease in Exchange-related revenue in Q2 and a 13.5%

Stars Redo Boosts 47 Contracts’ Ratings Centers for Medicare and Medicaid Services’ (CMS) data show that 47 contracts received recalculated 2026 Medicare Advantage that are higher than the original calculation. Thirty-six of those contracts secured at least four out of five stars to qualify for a quality bonus of 5%. Aetna and United Healthcare are two big plans that collected more revenue from the rescoring. The CMS Recalculation has driven several lawsuits. Elevance Health argues some of its contracts should be calculated based on what Clover Health was (CMS’ recalculation differed for other plans). Scan and Alignment Healthcare argue that they should be rated on an even more steamlined set of measures because CMS ignored part of the Clover ruling. (Article may require a subscription.) #cms #stars #quality #medicareadvantage https://www.modernhealthcare.com/insurance/mh-aetna-unitedhealthcare-medicare-advantage-star-ratings Congress Moves Healthcare Changes House and Senate committees approved a series of bills that would strengthen transparency requirements for providers

CMS Appeals Clover Decision Two major things in the past few days: The Centers for Medicare and Medicaid Services (CMS) updated the Medicare Plan Finder website and landscape files with the “better of” recalculated measures vs. original. This tells us exactly how many contracts got increases and impacts. Previous estimates suggested about 10% got an increase, with others the same or held harmless. CMS has appealed the Clover decision. We don’t have details yet but I will update as more is known. This was totally expected. We will see if they have appealed on both the statutory and regulatory deficiencies or just regulatory. Additional articles: https://www.fiercehealthcare.com/regulatory/cms-appeals-court-decision-behind-2026-ma-star-ratings-recalculations and https://www.healthcaredive.com/news/cms-appeals-clover-health-medicare-advantage-stars-lawsuit-cms/826003/ and https://www.beckerspayer.com/legal/cms-appeals-clovers-medicare-advantage-star-ratings-win/ (Some articles may require a subscription.) #cms #medicadvantage #stars #quality https://www.modernhealthcare.com/insurance/mh-cms-appeal-clover-medicare-advantage-ratings/ Commercial Insulin Cost-Sharing Cap Advances A bipartisan bill to cap the cost of insulin at $35 for people with private health insurance advanced through a key Senate committee Wednesday. Its

CMS Proposes Additional Medicaid Provider Tax Rule Based on the passage of the One Big Beautiful Bill Act (OBBBA), the Centers for Medicare and Medicaid Services (CMS) proposed another rule to implement certain Medicaid provider tax changes. The taxes, which help fund state matches for Medicaid spending, are used in almost all states. Under the OBBBA, beginning Oct. 1, all states are prohibited from imposing new provider taxes or increasing ones in effect on or after July 4, 2025. State “hold harmless” allowances are replaced by provider- and state-specific thresholds based on taxes that were effective July 4, 2025. The proposed rule would implement the legislation reducing the indirect hold harmless threshold by 0.5 percentage points every year from 2028 to 2032, when the thresholds reach 3.5% — the allowable levy. (Article may require a subscription) #medicaid #providertaxes https://www.modernhealthcare.com/politics-regulation/mh-cms-medicaid-provider-tax-restrictions/ HHS Defers $1 Billion In Funding To CA, MN The Department