biosimilars

Large MA And Part D Rule Issued For 2026

2026 Medicare Advantage and Part D rule has major changes to the programs The Biden administration issued its draft 2026 Medicare Advantage (MA) and Part D rule last week. A draft is available, but the Federal Register indicates the rule was pulled back for additional clarifications and would be reposted on December 10. Due to its late posting, the rule will not be finalized before the Trump administration takes office and therefore could simply be revamped rather than be rescinded. In some ways, the rule does not have some of the mega changes that some expected in the areas of Star, risk adjustment, and more. This could be due to some sensitivity to the current financial woes of the MA industry. But there is plenty for the industry to object to. I have read the 700-plus page draft rule and reviewed the Centers for Medicare and Medicaid Services (CMS) Fact

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Constitutional Checks And Balances Working

The Gaetz withdrawal shows the Constitution is being taken seriously Another quick deviation from healthcare in the interest of democracy this Thanksgiving weekend. On November 18, my blog covered the issue of recess appointments. I said that the Senate has to fulfill its constitutional functions and resist the concept of recess appointments as recommended by President-elect Donald Trump. Days after taking office, President-elect Trump urged the Senate to allow him to make such recess appointments to get his cabinet and other key officials in place quickly. I argued that this would amount to an abrogation of the Senate’s duty to vet and approve key officials. Yes, recess appointments are mentioned in the Constitution, but the provision was included for good reason in bygone days when Congress was not in session year-round. It helped ensure government could function properly by giving the president some latitude to appoint officials when Congress was

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Healthcare Coverage Under Trump 47

Medicare Advantage (MA) could benefit under Trump, Kennedy, Oz With the nominations of Robert F. Kennedy Jr. as Health and Human Services Secretary and Mehmet Oz as Administrator of the Centers for Medicare and Medicaid Services (CMS), a slightly clearer picture has emerged as to what we can expect for healthcare policy and coverage. Admittedly, there is a lot still in question. Kennedy likely focuses on his core concerns If he does get confirmed, Kennedy is likely to focus on his passions of reforming the health regulatory agencies and bringing greater transparency to drug and food regulation.  In addition, he wants to impact chronic disease in a big way. Kennedy is a known vaccine skeptic. Under him will serve Dr. Marty Makary as Commissioner of the Food and Drug Administration (FDA) and Dr. Dave Weldon, Director of the Centers for Disease Control and Prevention (CDC). Both Makary and Weldon are

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Growth From October To November In Medicare Advantage

Medicare Advantage (MA) growth continues as we enter 2025 enrollment season I decided to continue my Medicare Advantage (MA) monthly enrollment blogs because of continuing month-over-month increases. The growth is tied to remaining strong benefit packages for 2024. Increases in MA enrollment still occur outside of the enrollment season given the aging of America and the ability of some populations, such as dual eligibles, to continue to make changes throughout the year. We are now in the enrollment season for 2025 and I wonder if we will see the normally robust month-over-month growth. So far, it seems to be there. New enrollees see huge value in enrolling in MA over the traditional fee-for-service (FFS) program. This value difference likely will continue to drive some growth in 2025 even with reductions in benefits, increased premiums and cost-sharing, and less choice in some geographies. The reductions are being caused by the return of

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Recess Appointments Are A Bad Idea Unless There Are Extreme Circumstances

The Senate should resist being pressured and fulfill its constitutional duties. The Republic will survive a speedy but thorough vetting process for nominees. While this blog’s topic would impact healthcare, I admit I am straying a bit from my normal musings here on the website. I usually try to keep politics largely out of my blogging. I describe myself as a moderate Republican, who holds healthcare views that span both of today’s parties. I tend to favor reasonably expansive healthcare coverage with government support, lining me up with Democrats. I think it is a wise and compassionate position. Affordable universal access will save healthcare dollars and is key to healthcare reform, which also includes price reform and a pivot to care management. At the same time, I remain a fiscal conservative who thinks that our national debt and deficits will lead to a lower standard of living and less opportunity

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The GOP Should Safeguard The ACA

The Affordable Care Act saves and is a prudent investment for America In my blog on Monday ( https://www.healthcarelabyrinth.com/what-will-happen-in-healthcare-with-gop-firmly-in-control/ ), I told you about the fact that a GOP Washington could mean a big change for healthcare policy. On one hand, I predicted that seismic changes may not occur for a number of reasons – 2026 election politics, Donald Trump’s desire to leave a legacy, and tight margins in each chamber of Congress. On the other hand, I said budget measures would be passed to extend tax cuts and that would have impact on healthcare and coverage. If seismic changes to healthcare occurred, the biggest worry would be what could happen to the Affordable Care Act (ACA). As I said Monday, Trump and his VP partner, JD Vance, sought to downplay talk of ACA repeal. But they did weigh in on possible changes during the campaign. GOP Speaker Mike Johnson

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What Will Happen In Healthcare With GOP Firmly In Control?

With the GOP likely in control of everything in D.C., what happens may come down to how aggressive Trump and Republican lawmakers want to be. While the weeks before the election certainly favored the election of Republican Donald Trump as president, the election outcome was in fact stunning. For the first time since George W. Bush in 2004, a Republican won the popular vote — by slightly less than 4 million votes and a majority of all voters. Leading up to the election, the electoral college looked like there were seven states that could swing either way – Nevada, Arizona, Georgia, North Carolina, Pennsylvania, Michigan, and Wisconsin. In the end, Trump beat Democrat Kamala Harris 312 to 226 in the electoral college, sweeping all seven of the battleground states. While many often saw Trump as hurting down-ticket candidates, he clearly had major political coattails this election. The GOP was always

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Medicare Advantage Penetration Saves Medicare Dollars

Medicare Advantage’s additional value is driving savings in the traditional program I wrote about this Elevance Health study as part of my Healthcare Labyrinth Newsfeed but I was so excited about it I wanted to add to it in a blog. Capitol Hill is being dominated with headlines about gross overpayments to Medicare Advantage (MA). Estimates from various opponents, including congressional policy arm MedPAC and academics, put overpayments in the $80 billion range, with some now over $100 billion a year. As you know I dismiss these as fanciful. While some level of overpayment exists and needs to be reformed, some of the calculated overpayments are deliberate policy decisions by Congress and the fact that MA plans simply code better under the rules (even taking away the outliers and potential fraud). MA more efficient But often missed is that MA is far more efficient than the traditional and antiquated fee-for-service

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Election Tomorrow Close And Will Decide Some Of The Nation’s Healthcare Agenda

Seismic healthcare changes unlikely regardless of election winners I love this time of year. I am a political junky through and through! The presidential and congressional elections are tomorrow in what is one of the closest races of modern times. While Trump appeared to be surging in the last week or so there is some evidence that the race again is tightening. The unknowns are: (1) how much has Harris’ closing message impacted undecided voters and (2) has historic undercounting of GOP support in the polls in many swing states continued or been solved. Here is where things stand right now. President Right now, odds show Trump ahead in most betting markets but Harris has closed the gap a little. The Real Clear Politics (RCP) betting averages is at about 58% for Trump, down from about 60% a few days ago. The popular vote is back to a tie in

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The Healthcare Labyrinth Blog’s Halloween Edition: More Gory News On HRAs and Manual Chart Reviews In Medicare Advantage

Latest investigative report will increase focus on Medicare Advantage risk adjustment In a May 9th blog here ( https://www.healthcarelabyrinth.com/will-cms-rein-in-risk-adjustment-submissions/ ), I made the case that a reasonable reform to tackle Medicare Advantage (MA) overpayments may be to bar MA health plans from getting credit from diagnoses reported only via health risk assessments (HRAs) and other manual chart reviews.  After all, enrollees should be treated by a physician for any disease states or conditions and providers should know their patients well enough to report all diagnoses over time on encounter or claim submissions. At the time, there was a growing body of evidence about the impact of HRAs and manual chart reviews on MA plan payments — specifically, that many plans were reporting diagnoses only from HRAs and manual chart reviews and not on subsequent encounters from doctors. The Department of Health and Human Services’ Office of Inspector General (HHS OIG)

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