#bcbsa

Hospitals Penalized For Readmissions The Centers for Medicare and Medicaid Services (CMS) announced that 2,334 hospitals, about 80% of those evaluated, are being penalized under the Hospital Readmissions Reduction Program in fiscal 2027. CMS said 244 hospitals, or 8.4%, received penalties of 1% or more. Ten hospitals will face the maximum 3% penalty, with 34 facing penalties of 2% or more. Most hospitals — 71.8% — will see penalties below 1%. The share of hospitals receiving no penalty will drop to 19.8% (578 hospitals) from 21.8% (641) in 2026. The Fiscal 2027 round of penalties used both Medicare Advantage and fee-for-service data, but penalties continue to apply only to traditional Medicare payments. The performance period included discharges from July 1, 2023, to June 30, 2025. #hospitals #quality #readmissions https://www.beckershospitalreview.com/finance/cms-penalizes-2334-hospitals-for-high-readmissions-6-things-to-know/ Health Plan Enrollment Declines Health insurers’ membership declined 2.8% year-over-year to about 312.5 million people in 1H 2026. Losses in the

Insurers Backing Away From Medicaid Given the looming budget cuts to hit Medicaid over the next decade, there are signs that some health plans are backing out of certain Medicaid managed care contracts. Insurers such as Centene and Elevance Health have walked away from Medicaid managed care contracts as costs rise. This has led to other plans picking up the slack in affected states. Providers complain that successors may not have enough providers in their network. Plans have said there are some good signs coming from certain states who are increasing rates to deal with financial problems in managed care. Louisiana increased rates. It appears that Arkansas and D.C. may have done so as well. #medicaid #managedcare #obbba https://www.modernhealthcare.com/insurance/mh-centene-elevance-medicaid-states-providers/ Optum and Express Scripts Grow Pharmacy benefits managers (PBMs) Optum Rx and Express Scripts each hold 23% of the PBM market, up from 21% and 17%, respectively. CVS Caremark fell from

Stricter Price Transparency The Trump administration finalized its proposed rule that would make the data files mandated under price transparency regulations more usable. The Centers for Medicare & Medicaid Services said the regulation will improve the standardization, accuracy, and accessibility of the data plans and hospitals submit. It also would hold healthcare entities accountable for submitting incomplete or inaccurate data. In addition, Federal Trade Commission (FTC) Chairman Andrew Ferguson said his agency will crack down on hospitals that are not providing complete and accurate price data, whether or not they are compliant with CMS’ transparency requirements. The FTC noticed 24 large hospitals and health systems for potential violations of consumer protection laws. In part, the regulation removes the submission of junk data tied to  infrequently applied rates or ghost networks. The administration did not finalize certain proposals that would have made price disclosures even more robust. Additional articles: https://www.fiercehealthcare.com/regulatory/cms-finalizes-updates-price-transparency-regulations-aim-improve-usability and

PDP Premium Increases And Hidden Hurt Healthcare policy group KFF examined the standalone Part D (PDP) market. Of course, the Trump administration says the end of the suspect premium stabilization program will not mean major impacts to beneficiaries, but hidden hurt can be seen in the details. KFF finds that PDP availability and premiums for 2027 show a mixed picture. There are modest premium increases for many Part D enrollees for their current plan, but steeper increases are in store for others. There also is a reduction in the number of PDP options for the fourth year in a row. KFF’s key takeaways include: In related news, Devoted Health has garnered major financing for expansions of their Medicare advantage business. Additional article: https://www.beckerspayer.com/payer/medicare-advantage/devoted-health-closes-1-2b-financing-deal-amid-expansion-push/ #partd #pdp #kff #medicare https://www.kff.org/medicare/many-medicare-part-d-stand-alone-drug-plan-enrollees-will-see-modest-premium-increases-for-2027-but-others-could-pay-much-more-if-they-dont-switch-plans/ 340B Pilot Proceeds After an initial failure and a second published rule, the Health Resources and Services Administration is ready to launch

More MA Retrenchment News Articles and analyses continue on the recent release of the landscape files and now with the go live of 2027 benefits on the Medicare Plan Finder. These new assessments continue to speak to the commotion under the seeming stability. Of large plans, only one, Molina, is fully exiting Medicare Advantage (MA) mainstream coverage. It will continue to offer Special Needs Plans (SNPs). Second-place Humana has the largest county footprint (2,694) followed by leader UnitedHealthcare (2,655). But all of the major plans are paring considerably in certain counties, while growing in others. For the most part, most big plans have modestly smaller overall offerings, with Centene being an outlier. Analyses now seem to say that the largest number of people ever will face terminations of their existing plans. Numbers vary, but the impact loosk to be 3 million or more. MA plans argue they are preserving core

GLOBE Model Finalized The Centers for Medicare and Medicaid Services (CMS) finalized GLOBE, a mandatory five-year model linking Medicare Part B drug prices to cost benchmarks in 19 developed countries. The program starts in January and lasts for five years. The model targets drugs in oncology, rheumatology, immunology, ophthalmology and endocrinology. The parallel Part D program is not yet finalized. The models build on various initiatives undertaken by the Trump administration. Two problems here: GLOBE will reduce fee-for-service costs and effectively reduce Medicare Advantage payments without giving plans any lower costs. This could further reduce benefits in the program over time. As well, the final rule exempts from the model drug manufacturers in the parallel GENEROUS model for Medicaid. Drug makers struck price deals in Medicaid with the president. While I support Trump’s overall efforts, I think that is a mistake. Additional articles: https://www.modernhealthcare.com/politics-regulation/mh-cms-globe-medicare-part-b-drug-model/ and https://www.beckershospitalreview.com/pharmacy/cms-finalizes-new-drug-pricing-model-7-notes/ #drugpricing #partb #partd #medicare

More On MA Retrenchment More details on the Medicare Advantage (MA) landscape files and the depth of retrenchment for 2027. In total, the number of MA plans to be offered will only drop from 5,553 in 2026 to 5,532 in 2027. But that hides the impacts of adds and cuts. The number of impacted enrollees looks much bigger than anticipated. A Modern Healthcare analysis finds that the number of individual MA with Part D prescription drug coverage (MA-PD) products will decline 8% in 2027. Further, it says that there will be 181 counties with no plans next year, up from 67 this year. And at least 3.8 million people will be forced to select new coverage after their insurers terminate a plan. Various analyses peg 2026 impacts at between 2.9 million and 4.6 million. I think the 2027 impact will be closer to 3M — still a shock for me.

Medicare Advantage Will See Huge Changes Again in 2027 The Trump administration is putting the best spin possible on a continuing retrenchment in the Medicare Advantage (MA) industry. The Centers for Medicare & Medicaid Services (CMS) announced that weighted average MA premiums are projected to fall more than 16% from 2026 to 2027, with MA prescription drug (MA-PD) premiums set to decrease by 38% year-over-year. Additionally, CMS said average premium for standalone Part D prescription drug plans is projected to rise by less than $1 per month in 2027. The industry certainly has a different narrative. While it is true that MA remains broadly available, there is little doubt that benefits are being further diminished and that more plan terminations are occurring. This is evident in the landscape file release. A Becker’s Payer article gives an overview of the retrenchment still occurring. MA choice will go down in 29 of

Trump Admin Strikes Deal With 42 States On Improving Medicaid Quality The Trump administration has announced that 42 states will partners with the Centers for Medicare & Medicaid Services to rethink how quality is measured in Medicaid and the children’s health program (CHIP). CMS said the partnership will put health outcomes “at the center of how success is defined” and streamline hundreds of reporting requirements. The initial state participants have about 56 million Medicaid and CHIP beneficiaries and account for roughly $701 billion in fiscal 2024 Medicaid spending. At the center will be streamlining quality measure inventories, adopting digital quality measurement with near-real-time data when possible, and aligning financial accountability with outcomes measures. The program lines up incredibly well with efforts to boost lagging Medicaid outcome performance, interoperability, as well as migrate all government programs to a universal foundation of measures. Additional articles: https://www.fiercehealthcare.com/regulatory/37-states-partner-cms-initiative-rethink-medicaid-quality-measures and https://www.cms.gov/newsroom/press-releases/cms-refocuses-medicaid-quality-health-outcomes-launches-innovative-partnership-37-states #quality #medicaid #cms https://www.beckershospitalreview.com/legal-regulatory-issues/cms-launches-medicaid-quality-pledge-with-37-states/

Will Vertical Integration Be A Focus? An interesting Becker’s Payer article indicating vertical integration will become a strong focus. Recently, late-night TV host John Oliver tore into the inner workings of huge vertically integrated company UnitedHealth Group. The article notes that UnitedHealth is now the fourth-largest company in the world by revenue, taking in $447 billion last year, up 11.8% year over year. It reported ten significant subsidiaries down from a reported 2,700 a short time ago. Vertical integration is not unique to United. While health plan execs have defended vertical integration it is increasingly being looked at by Congress and federal agencies. Sens. Elizabeth Warren, D-Mass., and Josh Hawley, R-Mo., introduced the Break Up Big Medicine Act, which would prevent companies from simultaneously owning a health insurer or pharmacy benefit manager and a provider or management services organization. #verticalintegration #healthplans #unitedhealthcare https://www.beckerspayer.com/payer/as-vertical-integration-scrutiny-grows-unitedhealth-takes-center-stage/ Oz Says AI Will Cost More In