dreamers

Clover May Get Stars Reset The Centers for Medicare and Medicaid Services (CMS) could reset Clover Health’s SY 2026 rating for its largest contract after it won a lawsuit challenging the validity of some 20 measures. The health plan announced that CMS has recalculated the rating and advised the plan to submit an alternaive 2027 bid. If the recalculation is applied, all of Clover Health’s 156,000 Medicare Advantage members would now be enrolled in plans rated at least four of five stars, generating some $120M in bonus payments in 2027. But the “recalculation” is code for “we were directed to do so by the court and we likely are appealing the ruling.” So a small positive step, but not definitive for Clover yet. In essence, we still have pending litigation. After the recent Clover ruling, Humana advised the court in its lawsuit of the Clover decision. Now, the judge in

CMS Takes Tough Stance On Price Transparency Violations More than 500 hospitals received warnings from the federal government since April for non-compliance on the hospital price transparency regulation. Further notices could be sent soon. Hospitals receive an initial 90-day warning with instructions to correct any deficiencies. A subsequent 45-day deadline is sent requiring a more concrete plan to address deficiencies. If hospitals remain out of compliance, sanctions can run as high as $5,500 per day or over $2 million per year. Additional article: https://www.modernhealthcare.com/providers/mh-cms-hospital-price-transparency-data/ (Some articles may require a subscription.) #pricetransparency #hospitals #cms https://www.fiercehealthcare.com/providers/hundreds-hospitals-warned-over-price-transparency-failings-ap-reports Employers To Shake Up PBM Contracts A Pharmaceutical Strategies Group survey concludes health plans are thinking about shaking up how they manage pharmacy benefits due to surging costs. Among strategies include different drug pricing arrangements, rejecting single pharmacy benefit models, and embracing third-party vendors. Some are unbundling traditional pharmacy benefits manager services, looking for the best deal

Many Unaware Of Coming Work Rule A Health Management Academy survey finds that about 55% of Medicaid enrollees say they are unaware of upcoming work requirements. Work requirements go into effect on January 1 under the One Big Beautiful Bill Act. Many enrollees don’t know they’ll need to report work, education or volunteer hours starting in less than six months in order to stay covered. Another 27% said they knew something about work requirements but were unsure of the details. While the vast majority of Medicaid enrollees who can work are employed, many will lose eligibility due to lack of knowledge of requirements, paperwork burden, and administrative snafus by states. #workrequirements #states #medicaid #obbba https://www.healthcaredive.com/news/over-half-medicaid-enrollees-unaware-work-requirements-health-management-academy-survey/822228 TrumpRx Adds Drugs President Trump announced that over 100 prescription medications would be added to his administration’s direct-to-consumer drug platform, TrumpRx. #trumprx #drugpricing https://thehill.com/policy/healthcare/5913129-donald-trump-trumprx-expansion-160-drugs — Marc S. Ryan

Cities and County Sue Over Exchange Rule A group of cities and a county are suing the Trump administration over the just-finalized Affordable Care Act (ACA) Exchange rule for 2027. The parties argue that elements of the regulation — such as multi-year catastrophic plans, higher out-of-pocket caps and non-network plans as qualified health plans — are unlawful. The lawsuits say they should not be implemented. (Article may require a subscription.) #exchanges #aca #obamacare https://www.modernhealthcare.com/politics-regulation/mh-hhs-lawsuit-aca-exchange-rule-2027 KFF Covers 2026 MA Enrollment And Benefits Healthcare policy group KFF has a number of briefers on Medicare Advantage (MA) enrollment and benefits. Some key highlights across the three briefers: Additional articles:  https://www.kff.org/medicare/medicare-advantage-in-2026-enrollment-update-and-key-trends/ and https://www.kff.org/medicare/medicare-advantage-out-of-pocket-limits-variation-and-trends/ #medicareadvantage https://www.kff.org/medicare/medicare-advantage-in-2026-premiums-out-of-pocket-limits-supplemental-benefits-and-prior-authorization/ Clover MA Star Lawsuit Fallout A good Modern Healthcare article on the uncertainty created by a federal court ruling throwing out Clover Health’s 2026 Star Ratings. Cover challenged on the grounds that the Centers for Medicare and Medicaid Services

Why Not Mandatory GLP-1s In Medicare For Obesity? A Health Affairs Forefront Blog argues that GLP-1 coverage for obesity should be made mandatory. I have given great credit to the Trump administration for reducing drug prices, including with GLP-1s. But the proposed BALANCE reform model failed to attract enough health plans in the voluntary program. The government funding and risk mitigation just did not solve the fundamental risk problem, especially for standalone Part D (PDP) plans. Instead, Trump healthcare officials are proposing the BRIDGE program through 12/31/2027 to have the government cover the cost of such drugs for obesity. The authors argue that voluntary BALANCE failed to attract plans so other options exist: (Article may require a subscription.) #glp1s #weightlossdrugs #drugpricing #medicare #medicareadvantage #partd #pdp https://www.healthaffairs.org/content/forefront/after-balance-why-voluntary-coverage-obesity-drugs-failed-and-comes-next Commonwealth: One In Five Hit With Coverage Denials The Commonwealth Fund released its 2025 Affordability Survey, which found that one in five adults said

Paragon Says Over 6 Million Improper Exchange Enrollments The influential conservative Paragon Health Institute says a quarter of all Exchange enrollments were improper in 2026, adding fodder for those arguing healthcare has rampant fraud and improper enrollments. Paragon argues taxpayers will improperly subsidize the program by nearly $25 billion.  In other news, Colorado Democratic Gov. Jared Polis signed into law funding for healthcare insurance affordability. Colorado’s health insurance affordability enterprise already collects fees from health plans and hospitals to reduce premiums in the individual market. The new law would issue bonds to generate up to $100 million beginning in 2027. In addition, another $40 million will be earmarked from the marijuana tax cash fund. The law also establishes a premium reduction target of 18% for the reinsurance program. Further, according to JD Power, national average satisfaction scores for commercial plans are down one point from a year ago and down three points from 2024. More than half of

Republicans Run From Healthcare Cuts On Campaign Trail Republican lawmakers are running from the massive healthcare cuts that were enacted as they crisscross districts back home in anticipation of the midterms. About the only one championing some changes is Maine Sen. Susan Collins, who campaigns on a $50B rural health fund but actually voted against the One Big Beautiful Bill Act (OBBBA). At the same time, lawmakers seem all-in support for value-based care, even as some see a mixed record over the past several decades. They note healthcare spending continues to grow rapidly, and models seem to save little or nothing so far. Additional article: https://www.modernhealthcare.com/insurance/mh-insurers-value-based-care-unitedhealth-cvs/ (Some articles may require a subscription.) #obbba #medicaid #exchanges #coverage #healthcare #ruralhealthcare #vbc https://www.modernhealthcare.com/politics-regulation/mh-republicans-health-insurance-2026-election-midterms Lilly Threatens To Withhold 340B Discounts Brand drug maker Eli Lilly says it will cut off providers from discounts under the 340B drug discount program if participating providers fail to

Trump Administration Issues Work Requirements Regulation The Trump administration issued draft regulations today that implement work requirements in Medicaid under the One Big Beautiful Bill Act (OBBBA). Able-bodied and non-pregnant adults aged 19 to 64 will be subject to the requirements, with exemptions in place for the medically frail, disabled, and others who are unable to meet the mandates. Individuals can meet the requirement by working, completing community service, or participating in a work program for at least 80 hours per month. States must implement the requirements prior to 2027. The rule includes broader than expected definitions for “medically frail” people, who are exempt from the mandate. Individuals can also self-attest that they’re exempt once before states require documentation. Critics argue that most on Medicaid work and that the mandate will lead to eligibility loss due to paperwork and a lack of knowledge of the requirements. States will also spend

Uninsurance Rate Holds Flat in 2025 The Centers for Disease Control and Prevention (CDC) reports that the uninsurance rate remained flat in 2025. This was despite the continuing insurance losses in Medicaid and the Exchanges. Last year, 28 million or 8.3% of Americans were uninsured – just up 0.1% from 2024. More people are likely to lose coverage due to coming healthcare spending cuts. #uninsured #healthcare #coverage https://www.healthcaredive.com/news/uninsurance-rate-steady-2025-cdc/821488/ Elevance Health Gets Another Sanction Reprieve Elevance Health has gotten yet another reprieve from deep sanctions over its handling of risk adjustment in Medicare Advantage (MA). The Centers for Medicare & Medicaid Services (CMS) said the company has made progress in complying with regulations and must fulfill additional key steps by June 30 or face the sanctions. Additional article: https://www.fiercehealthcare.com/payers/cms-set-suspend-enrollment-elevance-healths-medicare-advantage-plans (Some articles may require a subscription.) #medicareadvantage #regulations #sanctions #radv #riskadjustment #elevancehealth https://www.modernhealthcare.com/insurance/mh-elevance-medicare-advantage-enrollment-cms United To End Many Children’s Auths; Mass Sues Over

Clover Wins Star Suit In a stunning decision, a federal judge in Georgia ruled in favor of Clover Health in its lawsuit challenging its 2026 Medicare Advantage (MA) Star Ratings. What’s more the judge seemingly has thrown out 20 measures in the program. The judge ordered just Clover’s 2026 ratings, impacting 2028 payments, to be recalculated. But it is hard to see how this could not impact all contracts if the ruling is upheld. Clover’s ratings dropped considerably in Star Year 2026, with 93% of its members enrolled in plans with ratings below four. This cost Clover $120 million in bonus revenue. Clover’s two-prong argument that the court agreed with was that the Centers for Medicare and Medicaid Services (CMS) did not have the authority to collect data and score some measures and did not adequately notice changes for others. The Supreme Court recently threw out the so-called Chevron doctrine