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Two Major Medicare Advantage Developments Two major Medicare Advantage (MA) developments today. Modern Healthcare reports that MA plans are pushing the Centers for Medicare and Medicaid Services (CMS) to change the $40 per member per month total beneficiary cost threshold that has been in place since 2024. Plans say this is needed so as to allow scaling back benefits more to respond to rising costs and paltry rate hikes. The 2027 proposed hike is roughly flat due to several changes in how risk adjustment will be applied. It could increase some (say to between 2% and 3%) but the final hike will not be near the cost growth in the program (that was as much as 9% coming into the year) or the over 5% hike last year. Plans have been reducing geographic footprints, shuttering expensive Preferred Provider Organization (PPO) products, and reducing benefits the past few years. But benefit

Read My Lips — No New Faxes: CMS Finalizes Electronic Exchange Rule The Centers for Medicare & Medicaid Services (CMS) finalized a new healthcare and electronic processes rule that is aimed at slashing wasteful spending and antiquated paperwork. The rule establishes national standards for the electronic exchange of clinical documentation used to support healthcare claims. CMS says the initiative will help end faxing and mailing in favor of electronic transactions. The agency hails the change as a way to reduce providers’ administrative burden. CMS says the rule will reduce costs, save time, ensure faster care delivery, and enhance security and efficiency. CMS says the “Administrative Simplification; Adoption of Standards for Health Care Claims Attachments Transactions and Electronic Signatures Final Rule” is projected to save the healthcare industry $781 million annually. The standards adopted apply to any Health Insurance Portability and Accountability Act (HIPAA)-covered entities, including health plans, healthcare clearinghouses, and

Senate Dems Unveil Healthcare Agenda If They Take Over Twelve Democratic senators signed a letter detailing their plan for health insurance reforms they will pursue if they take back the Senate. They want to focus on affordability, reduce barriers to insurance, and hold insurance companies accountable. The Democrats said Republicans were responsible for recent healthcare cuts, including the expiration of enhanced subsidies in the Exchanges and Medicaid and Exchange cuts. They would undo the reductions. Democratics want more affordable coverage, smoother enrollment — through “a one-stop shop” — and wider offerings for lower-income people. They would extend coverage to those in states that did not expand Medicaid and want a “Medicare-type” public option for all Americans. They also want to turn back recent changes on skimpier policies and standardize plans. In addition, they would focus on price transparency, prior authorization, and medical loss ratio gaming reforms. Vertical integration reform of

Praise For And Panning Of Trump Proposals Insurers and hospitals are largely together in criticizing the Trump administration’s proposed rule to allow non-network benefit plans to become qualified health plans under the Affordable Care Act (ACA) and in the Exchanges. The groups say individuals won’t be able to grasp the differences between network and non-network plans and this would expose them to higher-than-expected out-of-pocket costs. Trump officials argue premiums have gone up so much over the years that alternatives must be tested. At the same time, in an unlikely event, billionaire entrepreneur Mark Cuban praised the federal government’s TrumpRx drug platform, saying the initiative is saving Americans money. “Everyone wants me to rip on TrumpRx,” Cuban wrote on X. “Reality is, it’s saving patients money on IVF and a few other drugs. A lot of money. IMO, anything that saves patients money is a win.” Cuban is right. While TrumpRx

Moody’s Keeps Insurers On Negative Outlook Credit agency Moody’s Ratings has affirmed the negative credit outlook for the health insurance industry. Moody’s says medical costs continue to rise and plans will have limited prospects for profitable growth. It expects plan redesigns, benefit cuts, and exits from low-performing markets to continue. Moody’s notes that cost inflation has impacted every business line and will continue through the coming months. It says reimbursement rates have generally lagged these inflation rates. #healthplans #margins https://www.fiercehealthcare.com/payers/moodys-insurers-2026-outlook-negative-cost-pressures-continue-batter-industry Healthcare Entities Struggle With Interoperability Mandate The Workgroup for Electronic Data Interchange (WEDI) says a share of payers and providers have yet to start working toward the application programming interface (API) requirements for the interoperability and prior authorization final rule. WEDI advises the Department of Health and Human Services (HHS) on health information technology. Payers and providers must complete API requirements by Jan. 1, 2027.  As of February, 10% of

CMS Quality Conference Opens The Centers for Medicare and Medicaid Services (CMS) Quality Conference began today with some major addresses by CMS Administrator Dr. Mehmet Oz and other top officials. I will have a blog on the major addresses soon. In the meantime, some key points that were addressed: At the HIMSS conference in Las Vegas last week, Oz went all in on the use of AI, agentic AI, and digital health. Opening the CMS conference, Oz raised some of the same themes, saying CMS is devoted to a tech-first transformation, interoperability, and patients engaging digitally. He said technology was a solution to controlling disease exacerbation, rural health access, and driving annual wellness visits. Oz also noted the following: In related news, announced grant applications for the ELEVATE Model in Medicare. The model will offer Medicare coverage to functional and lifestyle medicine providers. Interested participants seeking grants under the model

CMS All In On AI and Digital Health Centers for Medicare and Medicaid Services (CMS) Administrator Dr. Mehmet Oz championed the use of AI, agentic AI, and digital health at a recent healthcare tech conference. CMS is rapidly endorsing models to use such technology, and CMS is starting to use the technology too. Oz argued that such tech could help reduce rural healthcare gaps and that digital health and remote patient monitoring also could reduce costs by focusing care further upstream before diseases become acute. Oz argued: “I can win the battle for health, not in the ER or in the ICU, but in your home, in your kitchen, your bedroom, in your living room, with remote patient monitoring and better tools to validate that.” Seniors appear to be endorsing the technology too. A recent healthcare policy group KFF survey found that the vast majority of seniors are using digital

New Poll Finds Unaffordability Having Consequences As we enter the midterms, healthcare affordability remains a significant challenge. A new poll finds that one in three Americans had to cut back on daily living expenses to afford care. A new West Health/Gallup survey says about a third of those surveyed cut back on at least one daily expense to afford healthcare last year. That is the equivalent of about 82 million Americans. For those that did not have insurance, about 62% said they made a cutback. For those with income of $24,000 or less, the tradeoff rate was about 55%. About 48% of those earning between $24,000 and $48,000 in annual household income said the same. In other news, a Modern Healthcare analysis finds that healthcare revenue rose faster than all other services categories in 2025. Increased prices and growing demand from an aging population drove much of this. Revenue tied

Aetna Settles MA Risk Adjustment Case Aetna will pay $117.7 million to resolve False Claims Act allegations that it overbilled the Medicare program. The agreement settles claims related to past risk adjustment submissions in Medicare Advantage (MA). The Department of Justice said some diagnostic codes were not fully supported but were still submitted to secure higher payouts. Aetna also failed to withdraw some inaccurate diagnoses. Additional articles: https://www.modernhealthcare.com/insurance/mh-aetna-medicare-advantage-upcoding-claims/ and https://www.beckerspayer.com/payer/medicare-advantage/aetna-to-pay-118m-to-resolve-medicare-advantage-upcoding-allegations/ (Some articles may require a subscription.) #medicareadvantage #riskadjustment #overpayments #fwa https://www.fiercehealthcare.com/payers/aetna-pay-1177m-settle-medicare-advantage-false-claims-case-doj CMS Goes Hollywood On Fraud The Centers for Medicare and Medicaid Services (CMS) has gone Hollywood with glitzy ads bringing attention to fraud, waste, and abuse (FWA). The Trump administration has had some success. The Department of Justice reported a record $6.8 billion in settlements and judgments under the False Claims Act in the fiscal year that ended Sept. 30, 2025. #fwa #cms https://www.medpagetoday.com/special-reports/exclusives/120256 Researchers Track MA Diversity A

Oz Says Exchanges Have Major Fraud Problem Centers for Medicare and Medicaid Services (CMS) Administrator Dr. Mehmet Oz claimed in his strongest terms yet that he believes major fraud exists in the Exchange enrollment process. He says millions could be inappropriately enrolled. Conservatives say the enhanced Exchange subsidies that have now expired led to millions being enrolled due to zero or near-zero premiums. A number of brokers have been accused of fraudulently enrolling Americans. In January, enrollment in the Exchanges dropped about 1 million, which is far less than estimates. Conservative groups, including the Paragon Institute, have argued that so-called “shadow enrollees” remain in the program. Oz did say he expects enrollment to drop throughout the year to around 19 million. In part this is because of affordability issues due to premium hikes and people being unwilling to pay any premium. #exchanges #coverage #fwa https://thehill.com/policy/healthcare/5776734-oz-claims-aca-fraud-millions JEC Piles On Regarding MA