budgetreconciliation

Another Model Deadline Extended The Centers for Medicare & Medicaid Services (CMS) is extending the application deadline for drug manufacturers to apply to the GENErating cost Reductions fOr U.S. Medicaid (GENEROUS) Model. The deadline was extended by the agency to June 11 from April 30. CMS says the reason was due to overwhelming interest from prescription drug manufacturers. However, it cites that more time will help small to mid-sized firms to join. Participation agreement deadlines will be extended from June 30 to July 17. CMS is also extending the deadline for states to apply to the GENEROUS model from July 31 to September 10 and to finalize participation agreements from August 31 to September 30. The program intends to have the federal government negotiate with drug makers to obtain a most-favored-nation (MFN) price. MFN drug pricing is also being set up in Medicare under the GLOBE and GUARD models. Read my

Site Neutral Stunner On Capitol Hill Health system CEOs faced a grilling on a range of hospital issues today on Capitol Hill, but in a stunning turn of events the executives said that they are willing to discuss reasonable changes to their long-standing opposition to site neural payments in Medicare. Under site neutral, the same services at all locations are paid the same rate, which would drop hospital payments dramatically. What emerged was some consensus on moves to site neutral that would recognize hospital differences in some cases and changes that might be phased in so as not to undermine finances at health systems. Lawmakers, mostly on the GOP side, otherwise accused health systems of driving high costs and reducing competition. Democrats focused on the cuts in the One Big Beautiful Bill (OBBBA). The Trump administration finalized another small step on site neutrality, but Capitol Hill has always been stymied

Health Plan CEO Comp Drops Slightly Health insurance CEO pay dipped slightly in 2025 as companies struggled financially. CEO comp dropped at Centene, Cigna and Molina Healthcare and rose at UnitedHealth Group, Elevance Health, Aetna parent company CVS Health, Humana, Alignment Health and Oscar Health. The average compensation package for the nine CEOs was $16.7 million in 2025, down less than 2% from 2024. (Article may require a subscription.) #compensation #healthplans https://www.modernhealthcare.com/insurance/mh-insurance-ceo-compensation-2025-unitedhealth-humana Employer Relief On GLP-1s Could Come Employers and health systems have struggled with rising costs of GLP-1s in their employee health plans, but relief could be on the way with the introduction of cheaper pill versions and drug price reductions negotiated by President Trump. #glp1s #weightlossdrugs #employercoverage   https://www.beckerspayer.com/payer/employers-glp-1-coverage-dilemma-grows Humana and Cost Plus Drug Team Up Humana’s CenterWell Pharmacy and Mark Cuban’s Cost Plus Drugs have partnered on creating new end-to-end employer prescription solutions. CenterWell Pharmacy becomes an

Health Plans Continue Prior Authorization Reforms Two insurance lobbies, AHIP and the Blue Cross Blue Shield Association, said that leading health plans continue to make significant progress to adopt a standardized approach for providers submitting electronic prior authorization (PA) requests for the majority of medical services. About 88% of Aetna’s prior authorizations already adhere to the standards, with UnitedHealthcare and Cigna saying their standards will apply to more than 70% of their PA volume by the end of the year. Key reforms include reducing the number of services subject to prior authorization as well. In addition, lawmakers proposed bipartisan legislation aimed at strengthening Medicare Advantage (MA) plan oversight to ensure seniors receive timely and high-quality care. The bill aims to address barriers to coverage and treatment, including: Additional articles: https://www.fiercehealthcare.com/payers/unitedhealthcare-aetna-tout-progress-standardize-prior-authorization-part-industry-wide and https://www.modernhealthcare.com/insurance/mh-cigna-humana-prior-authorization-standardized-requirements/ (Some articles may require a subscription.) #healthplans #priorauthorization #providers https://www.fiercehealthcare.com/regulatory/lawmakers-introduce-bipartisan-legislation-improve-access-quality-care-medicare Med Supp Premiums Surging Complaints that Medicare Supplement or Medigap

Paragon Urges Hospital Payment Reform The influential Paragon Institute, which influenced the One Big Beautiful Bill Act (OBBBA) and no extension of Exchange enhanced subsidies, has issued a new report challenging hospitals’ views on their finances and advocating payment reform. About one third of over $5 trillion each year is spent on hospital care and Paragon notes that hospitals are a key factor in driving premiums given major cost hikes annually. It notes that since 2000 hospital prices have risen three times faster than inflation and double wage growth. It says government policies inflate and distort hospital prices as well as encourage consolidations and physician acquisition. It argues hospitals can make money at Medicare rates and hospitals have had strong positive margins. It calls attention to the success of some hospitals with large government program patient loads. Paragon proposes a number of reforms below. Hospital groups took issue with the

Elevance Beats The Street Elevance Health beat Wall Street expectations for Q1 2026 and raised its full-year guidance. It has instituted a performance improvement and turnaround program and is managing medical costs. The company reported $1.8 billion in Q1, down 19.2% from $2.2 billion in the prior-year quarter. Revenue in the quarter was $50.2 billion, up 2.6% from Q1 2025. Elevance had a $1.76 billion profit in Q1, down 19.4% year over year. It continues to have struggles in Medicare Advantage (MA) and Medicaid. On MA, it faces a potential exposure over risk adjustment of up to $1.5 billion. On Exchanges, it reports that more and more are choosing cheaper Bronze plans due to premium hikes and enhanced subsidy expiration. Elevance also says it will invest $1 billion in digital and AI capabilities. Additional articles: https://www.modernhealthcare.com/insurance/mh-elevance-health-earnings-stock-price/ and https://www.beckerspayer.com/virtual-care/inside-elevances-1b-ai-investment/ and https://www.beckerspayer.com/financial/elevance-reports-1-76b-profit-in-q1/ and https://www.fiercehealthcare.com/payers/elevance-health-raises-2026-outlook-it-posts-18b-q1-profit (Some articles may require a subscription.) #elevancehealth #healthplans

GLP-1 BALANCE Model On Hold The Trump administration’s effort to bring GLP-1 drugs for the obese to Medicare, BALANCE, is on hold. The Centers for Medicare and Medicaid Services (CMS) planned to negotiate lower GLP-1 prices for Medicaid and Medicare Part D coverage and have health plans and pharmacy benefits managers (PBMs) agree to offer the drugs in the programs. But too few applicants applied to participate, likely due to costs and risk. Critical mass in Part D, covering 80% of Part D enrollment, was not met. The Medicaid portion of the pilot will still move forward. In Medicare, to gather necessary data, CMS now plans on funding coverage via the temporary BRIDGE pilot through the end of 2027 before proceeding again with BALANCE. At the same time, UnitedHealthcare said it was hoping to participate in both the BRIDGE program in 2026 and in BALANCE. Additional articles: https://www.beckershospitalreview.com/glp-1s/cms-pauses-weight-loss-balance-model-indefinitely-for-medicare/ and https://www.beckerspayer.com/payer/medicare-advantage/unitedhealthcare-eyes-cms-balance-glp-1-model/

United To End Most PAs On Rural Hospitals Responding to the rural health crisis and its own bad PR, UnitedHealthcare says it will exempt rural hospitals from most prior authorizations. This will apply across all lines of business. United will also accelerate payments by up to 50% for about 1,500 rural hospitals and all critical access hospitals across the country. Additional article: https://www.beckerspayer.com/payer/unitedhealthcare-pares-back-prior-authorizations-speeds-up-payments-for-rural-providers/ #unitedhealthcare #priorauthoriztaion #ruralhealthcare https://www.fiercehealthcare.com/payers/unitedhealthcare-unveils-pilot-accelerate-payments-rural-hospitals United Financial Storms Subsiding? United Health Group reports today on its latest financial results and recovery. It is expected to be good news overall. United is making progress. An interesting article, though, outlining the Medicare Advantage (MA) rate challenges and how both United and investors were slow to see the impact on the insurer as well as its services unit, Optum. The article details some of the huge financial misses by United’s former leaders even with clear signals back three years ago. Investors,

PCP Stability In Doubt Elation Health finds that over 80% of primary care physicians (PCPs) are concerned about financial stability over the next several years. The company surveyed 280 PCPs from Jan. 31 to Feb. Fifty-two percent of respondents were fully independent and 48% have some affiliation.  About 64% cite government and commercial payer reimbursement as their top concern. Staffing costs, workforce challenges, technology and IT costs and rising operational costs are also challenges. Despite all this, 93% of respondents report remaining committed to primary care. Only 2% report planning to leave the practice.  #providers #physicians #margins https://www.fiercehealthcare.com/providers/over-80-pcps-concerned-about-financial-stability-over-next-several-years-elation-health Employer Affordability Challenges Purchaser Business Group on Health finds that more and more employers are considering switching insurance or pharmacy benefits managers (PBMs) as a result of rising costs. About 37% of members have issued request for proposals (RFP) for medical benefits, meaning they’re shopping between insurance providers. About 23% are conducting

Trump Getting Serious On Affordability There was a clear sign today that the Trump administration is worried about the impact of the lack of healthcare affordability. The Trump administration created a top-level healthcare position that will be a de facto affordability czar. Health and Human Services Secretary Robert F. Kennedy, Jr. has named Casey Mulligan as chief economist and chief regulatory officer of the agency. He’ll advise Kennedy and other agency leaders on affordability issues. Mulligan was on the Council of Economic Advisers during the first Trump administration and was most recently the U.S. Small Business Administration’s chief counsel for advocacy. Meanwhile, healthcare policy group KFF issued a briefer on Americans’ views of healthcare. Just under half of U.S. adults say it is difficult to afford healthcare costs, and about three in ten say they or a family member in their household had problems paying for healthcare in the past