audits

Just after the Centers for Medicare and Medicaid Services (CMS) issued Star Year (SY) 2027 results, we got some new lawsuits attacking the agency’s calculations, in part related to the favorable treatment obtained again by Clover Health. So, it was time for a comprehensive update on SY 2026 and SY 2027 litigation. I have tried to keep the updates short and cogent, but Stars is not that at all right now. Where we stand on litigation We have seven total plans suing CMS for SY 2026 and/or SY 2027. A total of 9 lawsuits, not counting CMS’ appeal of Clover. We had four 2026 Stars measure lawsuits — Clover, Elevance, Scan, and Alignment. We now have five 2027 Stars measure lawsuits — Alignment, Healthfirst, Centene, Scan, and Aetna. Alignment and Centene filed in the same Georgia southern district as Clover did. Healthfirst filed in a New York district court. SY

CMS is proposing reforms to address longstanding problems with Medicare Advantage and pharmacy benefit managers The Consolidated Appropriations Act of 2026 included several provisions that could meaningfully improve transparency and accountability in Medicare Advantage (MA) and Medicare Part D. The Centers for Medicare and Medicaid Services (CMS) has now proposed regulations to implement them. I support these changes. They address problems that have persisted for far too long, and they reinforce a principle I have argued repeatedly: healthcare organizations should be accountable for the value they deliver to members. MA must get Its networks right I have long supported MA. It offers millions of seniors coordinated care, additional benefits, and quality alternatives to traditional Medicare. But supporting MA does not mean ignoring its shortcomings. Provider directories and network accuracy have been problems for decades. Members choose plans based on whether their physicians, hospitals, and other providers participate. When that information

While few are talking about it, America’s debt crisis is perhaps the most important issue out there now and for future generations. The United States has crossed $40 trillion in gross federal debt, bond investors around the world are demanding the highest yields in a quarter century, and the political class is behaving as if nothing is wrong. Too harsh? Read on and you will see why this is perhaps the most important issue facing voters this election cycle. I believe a fiscal reckoning is on the horizon. The warning signs are clear from a series of bond events we have just witnessed. A budget director’s vantage point. As a former state budget director and management secretary, I have spent a career reading budgets the way a physician reads a medical chart: looking past the headline number to the underlying vital signs. A state, unlike Washington, D.C, cannot print money,

Will MA have yet another rate headache with the GUARD and GLOBE models? I have been a major proponent of President Donald Trump’s GUARD and GLOBE drug pricing models for Medicare Part D. More than any president, Trump has really made great traction on drug pricing. Of course, critics poke holes in the myriad of reforms. I have some questions too, such as why brand drug makers agreeing to other drug price deals with Trump should be exempt from these MFN programs. But on balance, the movement is important to finally get our arms around the ongoing surge in drug prices. Yes, I admit the Biden administration took steps with the Medicare drug price negotiations. But it is ironic that a Republican administration now has done more than any administration to pursue real reform. Today’s blog, though, covers a concern Medicare Advantage (MA) plans should have about how GUARD and

Plans’ Star ratings stabilized a bit but challenges remain Thursday night saw the release of Star Year (SY) 2027 quality performance results for the Medicare Advantage industry, and the news was again not good. For all practical purposes, we are in the fifth year now of poor results coming out of the COVID pandemic and a peak in SY 2022. We did have some notable gainers, who recovered from years of Star doldrums. But other big players saw considerable declines. All things said, the industry was basically flat. The results add to the challenges plans have with declining risk adjustment revenue and rates that are not keeping up with utilization trends. A high-level barometer look I like to look at three figures the minute results are released. They tend to encapsulate the whole picture. The data throughout this blog compares SY 2027 results to the recalculated “better of” ratings announced

Coming out of summer, Democrats look well placed to possibly take both chambers As the midterms approach, I always give you a fresh look at what could happen in terms of control of Congress. Back on August 31 I did my last forecast. A great deal has changed. I told you that summer election polling is notoriously unreliable. There is a lack of engagement during the summer months by voters. Such polls also usually hit registered voters instead of likely voters. And, history would show that summer polls appear to be biased toward Democrats, consistently overestimating support for the party. Polls begin to become more accurate post Labor Day as polling switches to likely voter concentration and voters become more engaged. The problem for Republicans, though, is that the latest polls appear to be saying the same thing they did prior to Labor Day. There is some evidence that GOP

The CMS headline is stability. The details say another tough year for members and plans. The Centers for Medicare and Medicaid Services (CMS) wants you to see Medicare Advantage (MA) in 2027 as a story of lower premiums and steady choice. In its Sept. 28 release, CMS projected that the weighted average monthly MA premium would fall from $14.37 to $12, a 16.5% drop, and that the average Part D premium inside MA drug plans would fall 38%, from $11.32 to $7. The industry tells a different story. Once you open the landscape and crosswalk files, I think the industry has it right. Stability on top, churn underneath The total number of MA plans barely moves, from 5,553 in 2026 to 5,532 in 2027. But that net number hides a lot of adds and cuts. The average beneficiary will have 28 MA-PD options, down from 32. MA-PD products will fall

Smaller businesses could drop traditional coverage My September 7 blog on being priced out of healthcare ( https://www.healthcarelabyrinth.com/we-are-being-priced-out-of-healthcare-and-it-is-not-just-an-exchange-problem/ ) made the case that the affordability crisis went far beyond the Exchange subsidy debate. The bigger crisis we have is with employer coverage, where most Americans get their insurance. We also have a growing underinsured crisis as huge annual spending trends hit employers. Employers can only absorb so much. Eventually, the math catches up with everyone. Two recent developments make me even more concerned that we are approaching a genuine crisis. The first involves something most Americans have probably never heard of: the No Surprises Act’s federal arbitration process. The second is much easier to understand. Small and midsize employers are increasingly saying they may simply stop offering traditional health insurance. Those two developments may seem unrelated. They aren’t. They are two different manifestations of the same problem: Healthcare costs are

CMS and 37 states are taking a hard look at Medicaid quality measurement. The opportunity is much bigger than simply eliminating paperwork. For years, Medicaid has had a quality problem. There has been no shortage of quality measures, reports, audits, core sets, HEDIS measures and external quality reviews. The problem is that all of that measurement has not necessarily translated into better health outcomes. Now, the Centers for Medicare and Medicaid Services (CMS) is trying to change that. On September 25, CMS announced its Investing in Health Outcomes initiative, with 37 states signing a voluntary Medicaid Quality Pledge. Those states represent approximately 56 million Medicaid and CHIP beneficiaries and about $701 billion in Medicaid spending during fiscal year 2024. The focus is long overdue. A CMS analysis of Medicaid managed care programs across 42 states found approximately 450 quality reporting requirements representing about 260 unique quality measures. Many focus on

September enrollment shows a dramatic slowing going into open enrollment, with SNPs a majority of the increase 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. Each month since then, I have updated with monthly growth numbers. Now, we have September results. For those who may have missed earlier blogs, I am refreshing on some of the annual results. The annual statistics show some of the financial struggles the industry continues to have. Annual growth is way down compared with prior years in the 2020s due to major geographic contractions as well as plan benefit reductions by major MA players the