audits

CMS’ approach is right and should move quickly to return the program to its SY 2029 vision This is my fourth Clover-related blog this month, but the ruling was so watershed — and the potential impacts so far-reaching — that I had to tackle the topic again. I, too, wanted to signal to the Centers for Medicare and Medicaid Services (CMS) why it is so important to hold plans harmless now as well as push to salvage its 2029 vision for a more targeted Stars program. For those who are just getting up to speed or need to on the issue, here is a brief synopsis of the events of the last month or so on this important Medicare Advantage (MA) Star Year (SY) 2026 Ratings issue. What did the judge say and what did CMS do for SY 2026? At first, many of us reported that the judge pulled

The Centers for Medicare and Medicaid Services (CMS) announced late Wednesday it is recalculating some Medicare Advantage (MA) contracts’ SY 2026 Star Ratings based on the “better of” the current 2026 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. CMS said it recalculated using just HEDIS, CAHPS, and HOS measures. No Part D measures were included and the following were removed for Part C: SNP-CM, Complaints, Leave, the two Appeals measures, and Call Center. Based on the HPMS memo, in my view CMS does not appear to have followed the ruling exactly. I am waiting to see some plans’ recalculations to be sure. This could be related to measures that were clearly not covered by the statutes and those that were

This blog is a quick follow-up on the recent federal court decision in favor of Clover Health. The judge ruled that the Centers for Medicare and Medicaid Services (CMS) could not include 20 current measures in the Star Rating program as they either are not allowed via statute or the agency failed to notice their inclusion or changes properly. The judge ordered Clover’s 2026 Star ratings to be recalculated. The agency moved swiftly and in an investor release Clover announced that CMS has recalculated its SY 2026 rating for its largest contract and advised the plan to submit an alternative 2027 bid. SY 2026 Star ratings impact 2027 calendar year payments. If and when 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 there is

NOTE: With the midterms coming and a bit of a lull in healthcare news, over the past few weeks I have been re-publishing my 2024 election year series on healthcare reform (with a few updates). It remains as relevant for midterms 2026 as it was two years ago. This blog is one in a four-part series that digs into my modest proposal for healthcare reform. See the introductory blog here to review my proposal more broadly: https://www.healthcarelabyrinth.com/a-modest-election-year-proposal-for-healthcare-reform-2/ . Here is the first detailed part on price reform: https://www.healthcarelabyrinth.com/digging-into-my-modest-election-year-proposal-for-healthcare-reform-details-part-1-the-importance-of-price-reform/ . Here is the second detailed part on pivoting to primary care and care management: https://www.healthcarelabyrinth.com/digging-into-my-modest-election-year-proposal-for-healthcare-reform-part-2-pivoting-to-primary-care-and-care-management-from-our-obsession-with-utilization-management/ . Much of my proposal is taken from my book, The Healthcare Labyrinth, available at this site and through leading bookseller websites. It is available in print, ebook, and audiobook forms. Driving to affordable universal access “… Let me add that the health and vitality of our people are at least

The House still looks very likely Democrat, with the Senate still in limbo As the midterms approach, I always give you a fresh look at what could happen in terms of control of Congress. My last look was roughly a quarter ago on March 12. I likely will do so again sometime just after the summer ends as we really get into campaign season. Since I am a political junkie, I might give you a monthly update (and even more frequently at the end) until November 3 hits. As I have said, healthcare will be a big part of how votes are cast in November. Affordability overall is a top issue this election year and healthcare affordability dominates this issue in many ways. The GOP at a disadvantage You can go back to my March 12 blog here ( https://www.healthcarelabyrinth.com/a-look-at-the-status-of-congressional-midterm-elections/ ) but wanted to quickly refresh on the uphill battle

NOTE: With the midterms coming and a bit of a lull in healthcare news, over the next few weeks I will be re-publishing my 2024 election year series on healthcare reform (with a few updates). It remains as relevant for midterms 2026 as it was two years ago. This blog is one in a four-part series that digs into my modest proposal for healthcare reform. See the introductory blog here to review my proposal more broadly: https://www.healthcarelabyrinth.com/a-modest-election-year-proposal-for-healthcare-reform-2/ . Here is the first detailed part on price reform: https://www.healthcarelabyrinth.com/digging-into-my-modest-election-year-proposal-for-healthcare-reform-details-part-1-the-importance-of-price-reform/ . Much of my proposal is taken from my book, The Healthcare Labyrinth, available at this site and through leading bookseller websites. It is available in print, ebook, and audiobook forms. Pivoting to care management from our obsession with utilization management In my introductory blog, I stressed that the cornerstones of reform are three key tenets – driving affordable universal access, reforming price, and pivoting

Although Stars is not going anywhere, the combination of SY 2029 regulatory changes and the lawsuit mean more challenging times for Medicare Advantage plans. NOTE: This blog is published in collaboration with Lilac Software, Inc. For more information on Lilac’s Stars Analytics Platform, see the end of this blog. In a stunning decision, a federal judge in Georgia ruled in favor of Clover Health in its lawsuit challenging its 2026 Star Ratings. What’s more the judge seemingly has thrown out 20 measures in the program. The judge ordered just Cover’s 2026 ratings, impacting 2027 payments, to be recalculated. But it is hard to see how this could not impact all contracts if the ruling is upheld. Indeed, the Clover decision makes the 2024 Tukey cases and impacts look minor. I do not believe Stars is going anywhere. It is too important to value-based care overall. But the decision does throw

NOTE: With the midterms coming and a bit of a lull in healthcare news, over the next few weeks I will be re-publishing my 2024 election year series on healthcare reform (with a few updates). It remains as relevant for midterms 2026 as it was two years ago. This blog is one in a four-part series that digs into my modest proposal for healthcare reform. See the introductory blog here to review my proposal more broadly: https://www.healthcarelabyrinth.com/a-modest-election-year-proposal-for-healthcare-reform-2/ . Much of my proposal is taken from my book, The Healthcare Labyrinth, available at this site and through leading bookseller websites. It is available in print, ebook, and audiobook forms. The importance of price reform In my “A Modest Election-Year Proposal For Healthcare Reform” blog, I stressed that the cornerstones of reform are three key tenets – driving affordable universal access, reforming price, and pivoting to primary care and care management from our

NOTE: With the midterms coming and a bit of a lull in healthcare news, over the next few weeks I will be re-publishing my 2024 election year series on healthcare reform (with a few updates). It remains as relevant for midterms 2026 as it was two years ago. In a recent blog, I told you that Democrats are heavily favored to win the House and that the Senate has become amazingly competitive. In part, this is because the GOP has failed to tackle affordability and the cost of healthcare is top of mind for many voters. More and more have seen their employer coverage costs skyrocket even as coverage became skimpier. Over 24M Exchange enrollees saw surges in premiums due to COVID subsidy enhancements expiring. Millions are expected to lose coverage in 2026. As most American grapple with healthcare affordability, there is little doubt in my mind that the time

May enrollment bounces back In a February 16 blog, I detailed the growth in Medicare Advantage (MA) from February 2025 to February 2026 after a delay from the Centers for Medicare and Medicaid Services (CMS) in posting the annual data. As I noted, the January enrollment statistics in both years seemed off, so many analysts are comparing February to February each year. On March 30, I updated my blog site with results for March 2026. On April 20, I updated my blog site with results for April 2026. Now, we have May results. For those who may have missed the earlier blogs, I am refreshing on some of the annual and early 2026 results. The annual statistics show some of the financial struggles the industry continues to have. Growth is way down compared with prior years in the 2020s due to major geographic contractions as well as plan benefit reductions