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Note: This blog is published in partnership with Lilac Software. Learn more about Lilac’s Stars solutions at the link at the end of the blog. Seismic changes in Star ratings means MA plans need strategic planning and investments. Medicare Advantage (MA) plans continue to worry about the impacts of the proposed Stars regulatory changes and what they will mean to Star ratings and benefits in the future. This is occurring as the industry as a whole continues to struggle financially and has had to retrench from a geography, product, and benefit perspective. The major investment that has occurred has been in Special Needs Plans (SNPs) the past two years, but some of the regulatory changes do not bode well for Stars for plans that will have SNP lives or a high concentration of dual eligibles. Refresher on proposed changes Major measure realignment: Beginning primarily in Measure Year (MY) 2027 or

NOTE: This blog is published in partnership with Lilac Software. See more about Lilac’s offerings at the end of this blog. MA plans celebrate the sunset of the SNP-CM measure, but little really changes Many Medicare Advantage (MA) Special Needs Plans (SNPs) breathed a sigh of relief when the SNP Care Management measure was proposed to be sunset as of Star Year 2029/Measure Year 2027. Just one more year of the measure. The measure tracked the timely conduct of initial and annual reassessment Health Risk Assessments (HRAs). But I say — wait one moment! Even if the Star measure goes, SNP program audits and regulation remain and the HRA is the foundation of how plans ensure quality in their SNP care management program as well as program audit and regulatory compliance. Back on September 25 and 29 I published detailed blogs on the tremendous SNP enrollment growth as well as

Progress on drug price reform is remarkable True to an earlier announcement, the Trump administration has taken the first steps toward more expansive coverage of GLP-1 weight-loss drugs in Medicare and Medicaid. When he came into office, President Trump made the decision not to finalize a proposed rule by the Biden administration that would have expanded coverage for obesity alone in Medicare and Medicaid. At the time, it was the right call. Given GLP-1 prices, expansion could have significantly impacted the finances of the government programs. What has changed? But a great deal has changed since that decision. Trump issued several executive orders to begin to reform drug pricing, including all aspects of the drug channel and introducing most-favored-nation (MFN) pricing. After threatening tariffs on brand drugs manufactured abroad, he has struck more than a dozen deals with brand drug makers that lower costs in Medicaid and introduce lower prices

The GOP cannot escape the real affordability crisis in healthcare Affordability will be the election theme for the 2026 midterms. This will apply across Americans’ lives. While real wages have indeed mostly kept up with prices of late, there is a serious concern among Americans that getting ahead is out of reach for many, especially younger generations. Affordability very much brought Donald Trump and the GOP to dominate Washington after the 2024 elecions and the same issue could very well be their undoing in 2026 elections. Affordability issue most pronounced in healthcare The affordability issue is most pronounced in healthcare. We have seen huge price and inflation trends in healthcare since coming out of the COVID pandemic and there is little sign that the aggressive trends will subside anytime soon. In the biggest world of healthcare, employer coverage, trends have been 6% to 9% the past few years. Family coverage

Even a master seer would have problems predicting what may occur in healthcare in 2026. In my last blog, I gave you my 2025 Healthcare Year In Review. After that, as I always do each year, I play Nostradamus to prognosticate about what will happen in the next 12 months in the world of healthcare. Despite my Irish last name, I do have French blood (well, 50% French Canadien, so I count it). But I don’t claim to be an oracle or seer like our 16th century physician, apothecary, and astrologer friend. I do take a page from Nostradamus, though, in that my healthcare predictions for 2026 (not really prophecies) will be sometimes deliberately vague (they include a lot of less thans, abouts, probabilities, mays, coulds, shoulds, perhaps, likelys and possibles) so as to amass a reasonable record for those tracking and putting together my forecasting report card for the history books. It

A busy year in healthcare with insurer woes, a new president, and a decidedly different healthcare policy approach. As is my tradition at year’s end, I reflect back on all that occurred in healthcare in the year. It was a big year in healthcare and the new administration portends another massive one next year. I will have my 2026 healthcare predictions blog later this week. So, here are the major healthcare happenings from 2025. You can go to various blogs at the blog tab of this website to learn more. Presidential transition The year began with a presidential transition, with Joe Biden exiting the White House and Donald Trump returning after four years in the political wilderness. Trump has taken a decidedly different approach to healthcare coverage, but at the same time has shocked some with efforts to reduce drug pricing and coercing definitive concessions from Big Pharma. Trump convinced

An incredible analysis from Wakely Consulting, one of the foremost actuarial firms in the Medicare world. Wakey finds that annual wellness visits (AWVs) can demonstrably help control costs among Medicare beneficiaries. As the firm notes, AWVs are meant to identify disease states and conditions as well as create a care plan to act as a long-term preventive action plan. Wakely looked at a sample of traditional fee-for-service (FFS) Medicare program claims from 2018 – 2023. Beneficiaries who met the criteria for the institutional, end-stage renal disease (ESRD), or new enrollee risk score models were excluded. As well, only Medicare beneficiaries in the community with full calendar year data were included. The final sample comprised 733,532 beneficiaries with data for each year. Wakley also took into consideration social determinant and disease state impacts. Wakely broke out the sample into the following: Wakley found that AWVs are considerably underutilized. About 45% of

Given the holidays, we are going to be brief this week. Just a few ruminations from me today about recent healthcare events. We will do a quick blog on Friday regarding a great analysis by Wakely Consulting regarding the importance of wellness visits and prevention in Medicare. Next week, we will have my 2025 Healthcare Year in Review on Monday (12/29) and my Healthcare Predictions for the 2026 Year Ahead on that Friday (1/2). Here is wishing everyone a Merry Christmas, Happy Hanukkah (today is the last day), and Happy New Year. The courage of the moderates I have to give great credit to four GOP House moderates who have signed on to a Democratic discharge petition to force a vote in the House on extending the enhanced Exchange premium subsidies. They did so only after House Seaker Mike Johnson, R-LA, broke his promise to allow an amendment vote on

A quick blog to tell you about enrollment growth in Medicare Advantage (MA) in December 2025. The results show some interesting trends as we go into 2026. Many have predicted that MA enrollment could contract in 2026. I have said on a number of occasions that I doubted we would see that and instead see enrollment that is relatively flat or extremely small in terms of growth. I surmised that while most national plans want to see their enrollment contract by millions, I suspect regional plans will take on the challenge of enrolling robustly despite some financial risks. While it is too early to tell what will happen, we can read some tea leaves in the December data. What do the latest statistics show? Growth from January 2024 to February 2025 was 4.39% or 1.468 million. (I used February 2025 because of issues with the January 2025 statistics.) Enrollment in

Each year during open enrollment I get calls from family, friends, and even referrals from outsiders to help solve some of their perplexing insurance woes. I have tried to limit my so-called portfolio of free clients, but the caseload continues to be robust given the crushing affordability crisis. Here are a few of the cases I supported this year. At the end, I wil sum up and give you a feel for what changes need to be made to ensure all Americans gain affordable healthcare. 30-year-old graduate student with no employer sponsored coverage – good outcome individually but shows the huge inequity of the coverage gap as well as rising unaffordability This person was on an Exchange Platinum plan in 2025 because of previous complex surgery and required follow-ups. As a student, the person was unsubsidized in the Exchanges for years because Florida did not expand Medicaid. No Exchange subsidies