cms

The other side of the story The headlines are ripping Medicare Advantage (MA) apart due to supposed huge overpayments compared with traditional Medicare fee-for-service (FFS). Critic MedPAC and aligned academics and researchers have argued MA abuses risk adjustment coding and somehow has favorable selection. We know that any risk adjustment abuse was largely that of larger players and that the new v28 risk adjustment payment model has reduced most overscoring incentives. As well, the Centers for Medicare and Medicaid Services (CMS) has just barred scoring of unlinked medical charts (those that do not have accompanying encounters) with one exception. But MedPAC and others will continue to cite major overpayments because of faulty or misleading analysis regarding favorable selection in the program. I have made the case over the years that many studies show that MA attracts a more diverse and lower income population. Within this population are individuals who are

April enrollment tails off 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. On March 30, I updated my blog site with results for March 2026. Now, we have April results. For those who may have missed the earlier blogs, I am refreshing on some of the annual and February results. The annual statistics show some of the financial struggles the industry continues to have. 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 past few years. As the chart below shows, February

NOTE: Co-published in partnership with Lilac Software. See more on Lilac at the end of the blog. 2027 Final Announcement makes no changes on Stars from the Advance Notice While the Medicare Advantage (MA) industry is facing major upheaval through Star Year 2029 due to the finalization of the MA and Part D 2027 rule, the coming year’s Final Announcement of rates and policies is very status quo from a Stars perspective. I have gone back to compare the Advance Notice and Final Announcement and here remains the all-important updates for Star Year 2027 and technical changes or proposals for future years. Go to my February 2, 2026 blog here for more details: https://www.healthcarelabyrinth.com/stars-changes-in-2027-advance-notice/ Deadline Calendar/Reminders for Star Year (SY) 2027 and SY 2028 For Measure Years (MY) 2025/SY 2027: For MY/2026/SY 2028: Note that these data review deadlines are before PDE and Appeals (at least for Reopens) have final

CMS moves a little on rate hike for plans given troubled finances and beneficiary impacts The Centers for Medicare and Medicaid Services (CMS) has released its Final Announcement for calendar year (CY) 2027 rates and policies for Medicare Advantage (MA) and Part D. I wrote about the Advance Notice back on January 29. I will not repeat much of the technical explanations again here, but please go back to that blog for in-depth explanations of various rate-setting terms. Proposed rates tend to increase each year between the Advance Notice and Final Announcement as more data is updated from the fee-for-service (FFS) program. The plan benchmarks are based on both FFS and MA costs. Based on past history, I had predicted that rates would end up between 2% and 3% as the Effective Growth Rate (EGR) would increase markedly between the advance and final notices. In the end, the EGR actually

CMS plows ahead on RADV without underlying rule On March 20, the Centers for Medicare and Medicaid Services (CMS) announced that it will proceed with Payment Year 2020 Risk Adjustment Data Validation (RADV) audits. In May 2025, CMS Administrator Dr. Mehmet Oz promised to audit every contract every year to reduce overpayments in the Medicare Advantage (MA) program. But that promise took a bit of a hit when a federal judge in September 2025 sided with Humana and struck the RADV rule finalized by the Biden administration in 2023. The judge nullified the entire rule, not just portions of it. The decision was not unexpected. The Biden administration included so many far-fetched and indefensible provisions. The court in the RADV case found that CMS did not follow the procedural requirements of the Administrative Procedure Act (APA). There were inadequate notice requirements. CMS did not justify its decisions via the comment

NOTE: This blog is co-published in collaboration with Lilac Software, now part of MediSolv. To learn more about Lilac’s Stars data analytics and agentic AI solutions, visit https://lilacsoftware.com Star Rating changes will lead to major volatility and revenue loss for many MA plans The Centers for Medicare and Medicaid Services (CMS) finalized the 2027 Medicare Advantage (MA) and Part D rule. While much of the rule did not have earth-shattering changes, it is safe to say that the major Star ratings reforms will have far-reaching impacts on MA plans for years to come. Star changes Let’s first inventory the Star changes. The proposed rule changes were all adopted with just one exception. CMS says these changes refocus the program on clinical care, outcomes, and patient experience where meaningful performance differences exist across contracts and reduce administrative burden by removing measures that provide little meaningful distinction between plans.  The changes break

More confirmation of America’s excessive spending on healthcare A short blog today to update you on healthcare spending around the developed world based on a new Peterson-KFF Health System Tracker chart collection recently published. I have covered this topic of spending and quality in the past many times. What did Peterson-KFF find last time on costs? In the earlier analysis, Peterson-KFF found the following: What did Peterson-KFF find last time on quality? Peterson-KFF finds that the U.S. performs worse in long-term health outcomes measures (e.g., life expectancy), certain treatment outcomes (e.g., maternal mortality and congestive heart failure admissions), some patient safety measures, and health system capacity. On the other hand, the U.S. performs similarly to or better than peer nations in other measures of treatment outcomes (e.g., mortality rates within 30 days of hospital admission) and some patient safety measures (e.g., post-operative complications). In essence, if you have good access

February to March enrollment grows after dismal enrollment season In a February 16 blog, I detailed the growth in Medicare Advantage (MA) from February 2025 to February 2025 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. To summarize, the annual statistics show some of the financial struggles the industry continues to have. 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 past few years. As the chart below shows, February 2025 to February 2026 enrollment growth was just 2.5% — way down from annual growth from January 2020. Now we have statistics for March 2026. MA enrollment continues to grow due

Since the feds won’t act, states seeking to limit healthcare costs I have made the case that healthcare reform is largely frozen at the national level — with neither party really willing to tackle the root causes of healthcare’s costs. Republicans line up to skinny down benefits, while Democrats advocate for greater and greater subsidies. While I support universal access and tackling the affordability crisis with experimentation, price reform (teamed with primary care and prevention and affordable universal access), is the core of true reform. Under Trump 45, the administration sought to make some meaningful incremental reforms, only to have them reversed by the Biden administration. Trump 47 has come back with some of the same reforms: In the end, these are indeed modest reforms and Congress appears reluctant to truly jump into the fundamental issue of price. That is why states have begun doing their best to tackle prices

Oz’s CMS looks very different Two major healthcare conferences recently occurred – the HIMSS conference in Las Vegas followed by the Centers for Medicare and Medicaid Services (CMS) Quality Conference the next week. CMS Administrator Dr. Mehmet Oz spoke at both conferences and Oz and other top sister agency officials discussed the Trump administration’s vision for healthcare. Suffice it to say that the Trump CMS is vastly different in tone and philosophy than Biden’s CMS. Furthermore, while themes and approaches were similar between Trump 45 and 47, you can say that Trump 47 is on steroids when it comes to grand visions and efforts to implement change. It is both the personality and drive of Oz as well as President Trump now understanding government and what it takes to implement change. If Trump 45 was incremental and conservative in approach, Trump 47 is far more aggressive and swift. At the