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Aetna Delays And Changes Downcoding Policy After major pushback from lawmakers and providers, Aetna is easing a controversial “downcoding” policy for inpatient Medicare Advantage (MA) claims. The insurer said the policy’s start date has been delayed to Jan. 1, 2026 and that its severity review would now apply to urgent or emergent inpatient hospital stays that include at least one midnight but fewer than five. As part of the reimbursement approach, Aetna will approve these inpatient stays without a medical necessity review and cover the claim at a rate that aligns with observation services. Stays of five or more midnights will not be subject to a severity review in the updated policy. Additional articles: https://www.fiercehealthcare.com/payers/american-hospital-association-urges-aetna-rescind-new-inpatient-policy-payment and https://www.modernhealthcare.com/insurance/mh-aetna-medicare-advantage-downcoding-policy/ (Some articles may require a subscription.) #aetna #hospitals #claimsdenials #priorauthorization https://www.beckerspayer.com/payer/aetna-delays-new-inpatient-reimbursement-policy/ Exchange Subsidy Saga President Donald Trump’s Domestic Policy Council and senior health officials have been meeting privately on how to address the expiration

Healthcare Costs Continuing to Surge WTW’s 2026 Global Medical Trends Report indicates that healthcare increases remain “significantly higher” than the 7.6% seen in 2024. Further, healthcare cost increases are projected to rise 9.6% in the U.S. in 2026, only a little less than the 9.7% experienced this year. Globally, the average cost of health benefits is predicted to rise 10.3%, up from 10% in 2025 and 9.5% in 2024. Employers add that they believe elevated costs will continue for more than three years, driven by medical costs, regional pressure on pharmacy and outpatient services, and global structural factors. About three-quarters said new medical technologies as the top reason for medical inflation, followed by the decline of public health systems (52%) and advancements in pharmaceuticals (49%). Cancer tops the list of cost drivers globally. #healthcare #costs https://www.healthcaredive.com/news/us-healthcare-cost-increases-expected-to-fall-in-2026/805340 KFF Finds Medicaid Costs Will Rise A healthcare policy group KFF report finds that,

Government to Reopen – Finally! The House passed the Senate bill to reopen government this evening on a vote of 222 to 209. Six Democrats joined the vast majority of Republicans to pass the bill. Two Republicans voted with Democrats. The bill extends some expiring healthcare programs and delays cutbacks. But it did not include an extension of enhanced Exchange premium subsidies. The Senate leader has promised a vote in mid-December, while the House speaker has yet to make a commitment. Despite the Democrats’ focus on the subsidy extension, little has been proposed on healthcare reform by either party outside of President Trump’s efforts on drug pricing. Republicans are rumored to be compiling a reform plan that could be pared with some subsidy extension, but in the past the changes meant millions losing coverage. In other news, hidden in the government funding bill was a provision that overrides budget sequestration

With Government Shutdown Ending, GOP Struggles With Obamacare With the government funding bill almost assuredly to pass the House Wednesday, the GOP will next have to turn to what to do with the expiring enhanced Exchange subsidies and perhaps some healthcare reform in general. Senate Majority Leader John Thune, R-SD, promised a vote on the subsidies by mid-December, but House Speaker Mike Johnson, R-LA, refuses to make any commitment on a vote. Moderate GOPers in the Senate and about several dozen moderates in swing districts in the House GOP caucus want a vote and some sort of extension. Various potential compromises are being discussed including an income cap, minimum premiums, and an extension vs. permanency. The GOP may also want to pass healthcare reform changes but have yet to truly put up a plan. Conservatives, such as Rep. Majorie Taylor Greene, R-GA, have been pressuring the Speaker to pass yet

Trump Wants Healthcare Subsidies To Go To Individuals But Has No Detailed Plans Over the weekend, President Donald Trump declared that his solution for the Exchange subsidy stalemate and high costs in healthcare generally is to have subsidies go directly to individuals to purchase healthcare. But Treasury Secretary Scott Bessent said Monday that there is really no formal plan. Apparently, it was just musings from the president, along with a frontal assault on what he called “money sucking insurance companies.” The president’s social media post stated: “I am recommending to Senate Republicans that the Hundreds of Billions of Dollars currently being sent to money sucking Insurance Companies in order to save the bad Healthcare provided by ObamaCare, BE SENT DIRECTLY TO THE PEOPLE SO THAT THEY CAN PURCHASE THEIR OWN, MUCH BETTER, HEALTHCARE, and have money left over. In other words, take from the BIG, BAD Insurance Companies, give it

Government Funding Deal In Flux, But GOP To Push Democrats To Acquiesce This Weekend While bipartisan talks continue, today saw the two parties argue over a government funding bill and the parties appear further apart in the Senate. Senate Minority Leader Chuck Schumer, D-NY, proposed a bill that would fund some parts of government for the year and others partially, enact some additional funding being negotiated between the parties, and provide a one-year extension of enhanced Exchange premium studies. Republicans rejected the Democratic proposal. Instead, the Republicans will challenge Democrats to reject a bill based on the same bipartisan negotiations to fund some parts of government for the year and extend other funding to January. There would be no deal on subsidies. Senate Majority Leader John Thune, R-SD, has committed to a vote on subsidies later, but House Speaker Mike Johnson, R-LA, has refused to do so, and Democrats believe

Trump Announced GLP-1 Deals With Brand Drug Makers The Trump administration announced two major drug-related reforms today. The Centers for Medicare & Medicaid Services (CMS) announced a new model that aims to bring most-favored nation (MFN) pricing to the Medicaid space. Second, President Trump personally announced lower prices for self-pay and Medicare customers for GLP-1 and some other drugs. CMS says it will launch the GENErating cost Reductions fOr U.S. Medicaid (GENEROUS) model. State Medicaid programs will be able to purchase certain drugs at prices that align with what is paid in other countries beginning in 2026. Through the model, CMS will negotiate with participating pharmaceutical companies to bring down prices. In addition, Medicare will cover GLP-1 semaglutide and tirzepatide at much lower prices and this appears true for chronic conditions, these conditions with underlying obesity, and apparently obesity alone. “Until now, neither of these two popular drugs have been

Humana Reports Q3 Financial News Medicare Advantage (MA)-dominant Humana reported Q3 financial news today. Humana, the second biggest MA player, slashed its earnings guidance as enrollment ticks above initial expectations during open enrollment. It now projects to have about 425,000 fewer Medicare MA enrollees next year, not 500,000 fewer as previously anticipated. Investors worry that these additional members, driven by generous benefits, will increase medical expense more than projected. Humana says it is confident in projections despite higher enrollment numbers but says it can throttle back enrollment with several levers if needed. Operating expenses surged to $32.25 billion, up 11.75% year over year. Humana is spending more (hundreds of millions more) to better operations and increase Star ratings. Its Star Year 2026 rating actually dropped from a very low 25% of enrollment in 4 Star or greater plans to an even lower 20%. Third-quarter net income declined 59.6% to $194

Is UnitedHealthcare Gaming Medical Expense Regulation? A new study published in Health Affairs finds that UnitedHealthcare pays its owned providers at sister company Optum 17% more than those it does not own. And if United controls 25% or more of a market, that percentage increases to 61%. Researchers said the results suggest the company may be sidestepping government rules regarding calculation of medical expenses against premiums. If those rules are violated, rebates need to be sent to the government, employers, or individuals depending on the type of coverage. In effect, higher payments to owned providers would boost the so-called medical loss ratio (MLR) and more likely hit or exceed the required spending (usually 80% or 85%). United says the study is wrong. And the study clearly has some limitations. It looked at just 14 CPT medical codes and about 385,000 transactions. But these were frequently performed and high-cost procedures in

Government Shutdown End In Sight? After bipartisan weekend talks, Senate Majority Leader John Thune, R-SD, said Monday that he is “optimistic” lawmakers can strike a deal to reopen the government by the end of the week. He added that a stopgap spending bill could fund government through January or later to allow time to mark up and pass appropriations bills. The House will have to re-pass the temporary funding bill as it expires on November 21. Insiders say that Democrats could give in on their position to include Exchange subsidy extensions if a bill is pre-negotiated, likely with the president, or if GOP leaders announce a commitment to hold an up or down vote on an extension. Meanwhile, Rep. Marjorie Taylor Greene, R-GA, says Republicans deserve much of the blame for rising premiums, saying Republicans should have reformed the Affordable Care Act (ACA) sooner. “The Democrats passed Obamacare, but yet