dreamers

What Is On GOP Menu For Subsidies? A good article in The Hill on Thanksgiving breaking down the GOP dilemma on what to do with the Exchange enhanced subsidy expiration that is looming. The issue pits moderate Republicans against conservative ones. There are competing proposals across the House and Senate. The dilemma: Extend the subsidies and endorse Obamacare or let the subsidies expire and deal with the electoral fallout in 2026. This could be major in dozens of moderate Republican swing districts in the House and several seats in the Senate. Here are some bills percolating on the Republican side: Moderates in both parties in House: One bill would extend the enhanced subsidies for two years but make some changes to assuage conservatives. Those earning less than $200,000 per year for a family of four would keep their subsidies and those earning between $200,000 and $300,000 for a family of four would

Deeper Dive On 2025 Medicare Drug Price Negotiations The Trump administration announced the results of the second round of Medicare drug price negotiations, taking credit for the 2025 process that it says led to much deeper price reductions than in 2024’s process. The 2025 set prices will go into effect in 2027. The administration said $12 billion in federal savings would occur due to the negotiations in 15 drugs. That is computed at 44% off of net (after rebates) costs, compared with 22% or $6 billion under Biden’s negotiations in 2024 for ten drugs. Under another calculation, the 2025 savings is $8 billion or 36%. Consumers would save an estimated $685 million in out-of-pocket costs. The medications are used by about 5.3 million Medicare beneficiaries. The negotiated savings range from 38% to 85% off the drugs’ list prices. Total spending on the drugs is about $42.5 billion. The administration reached agreement with brand drug makers

CMS Revamps Star Program For Medicare Advantage The Centers for Medicare and Medicaid Services published a draft Medicare Advantage (MA) and Part D rule for 2027 that would make sweeping changes in the MA Star program. Beginning primarily in the 2027 measure year (MY) or Star Year (SY) 2029, CMS proposes to remove 12 (really 14) measures, largely focused on administrative processes or those that no longer show variability in quality among plans. (The call center measures will be removed in MY 2026/SY 2028.) These are: Administrative/Operational measures removed: No longer showing variability: The above has the effect of transferring so-called Star power to clinical, drug, and remaining CAHPS survey and HOS survey measures. The Excellent Health Outcomes for All (EHO4all, the former Health Equity Index), will not be implemented for SY 2027 (MY 2025). The Reward Factor would be maintained for consistently high-performing plans. CMS also proposes to introduce

White House To Unveil Exchange Subsidy Compromise The White House is expected to reveal a plan to address rising medical costs as well as the expiration of the enhanced Exchange subsidies. It was expected today but was delayed to address concerns by GOP conservatives. The plan is said to include an extension of the premium subsidies for two years but would include income limits for the subsidies and minimum premium requirements. Incomes are said to go as high as 700% of the poverty limit to still get a subsidy. The plan also would call on Congress to appropriate funds for cost-sharing reductions (CSRs). These were defunded by Trump 45 and led to increases in Silver premium subsidies, actually a greater cost to the government. The plan also would endorse a conservative approach where Americans would have an option to receive part of their tax credit in a tax-advantaged savings account

GLP-1 Drug Makers Go Direct With Employers Seeing the changes that are coming on drug prices, GLP-1 brand drug makers Eli Lilly and Novo Nordisk plan to sell their popular obesity drugs direct to employers rather than using the traditional drug sales channel that includes pharmacy benefits managers (PBMs) and rebates. In part, this is because price deals with President Trump drop drug costs considerably in Medicare and rebates will go away there. As well, this is to boost sales and get employer groups to keep or expand to obesity coverage for the drugs as opposed to use just for other disease states. The drug makers will offer Zepbound and Wegovy to companies starting Jan. 1 through Waltz Health, a firm that helps employers purchase cheaper medications. Lilly and Novo already sell direct to cash customers. While I have applauded the president on his drug agenda, I have doubted parts

Dems Want Medicare Drug Negotiations Expanded Democrats in the House have introduced a new bill that would expand Medicare’s ability to negotiate drug prices. The Lowering Drug Costs for American Families Act would allow Medicare to negotiate prices for more drugs each year, moving from 20 to 50, and make them applicable to the commercial market. #drugpricing #ira #branddrugmakers #medicare #partd #commercial #employercoverage https://www.fiercehealthcare.com/regulatory/house-democrats-introduce-bill-expand-drug-price-negotiation-commercial-market Hospitals See Claim Denials Increase MDaudit has found that average amounts of hospital’s denied inpatient and outpatient claims have increased by 12% and 14%, respectively. In addition, there has been an increase in payer’s audits. MDaudit looked at the first three quarters of 2025 data from its network of more than 1.2 million providers and 4,500 facilities. #healthplans #hospitals #claimsdenials https://www.fiercehealthcare.com/finance/payer-audits-denial-amounts-rise-again-2025-vendor-data-show PBM Reform Expected To Move Senate Finance Chair Mike Crapo, R-ID, and Ranking Member Ron Wyden, D-OR, plan to reintroduce a bipartisan package regarding pharmacy

Fiery Senate Hearing Casts Doubt On Subsidy Extension Democrats and Republicans battled at a Senate Finance Committee hearing today on the future of the enhanced Exchange subsidies set to expire at the end of the year. The tone and tenor of the GOP suggested that a clean extension was very much in doubt, at least without major sweeping conservative changes to healthcare, if it happened at all. Republicans largely indicated they wanted to see the subsidy enhancements expire and instead work on conservative reforms, including expansion of Health Savings Accounts to allow individuals to purchase healthcare of their choice. This comports with President Trump’s views that subsidies should be sent to Americans directly. Sen Bill Cassidy, R-LA and Chair of the HELP Committee, has proposed pairing beefed up HSAs with low-level, high-deductible Bronze Exchange plans. HSAs currently cannot be used to pay for premiums. Democrats argue the HSA payments would

Trump Says He Wants Direct Subsidies In Healthcare President Donald Trump declared on social media that he would only consider approving legislation that provides direct healthcare payments to Americans. “THE ONLY HEALTHCARE I WILL SUPPORT OR APPROVE IS SENDING THE MONEY DIRECTLY BACK TO THE PEOPLE, WITH NOTHING GOING TO THE BIG, FAT, RICH INSURANCE COMPANIES, WHO HAVE MADE $TRILLIONS, AND RIPPED OFF AMERICA LONG ENOUGH,” Trump wrote on Truth Social. “THE PEOPLE WILL BE ALLOWED TO NEGOTIATE AND BUY THEIR OWN, MUCH BETTER, INSURANCE. POWER TO THE PEOPLE! Congress, do not waste your time and energy on anything else. This is the only way to have great Healthcare in America!!! GET IT DONE, NOW,” he added. Senate Minority Leader Chuck Schumer, D-NY, dismissed Trump’s statement as “unhinged ramblings” that will “do nothing to lower” costs. He added the president has no idea how anything works. Meanwhile, Senate Health, Education, Labor,

Capitol Hill Abuzz With Exchange Negotiations Washington, D.C is abuzz with at least some compromise talk on finding a way to extend the enhanced Exchange subsidies Dr. Mehmet Oz, administrator of the Centers for Medicare and Medicaid Services (CMS), said that the Trump administration is “willing to look at all options” regarding the subsidies. “But we have some major flaws with the way these COVID-era subsidies were added. And just so everyone’s on the same page in this issue, our goal is to get people covered,” he added. At the same time, President Donald Trump wants to send payments to Americans directly instead of to insurers and allow them to purchase their own insurance. The president said he has been talking with Democrats about a direct health care payment plan as one way to tackle rising health insurance premiums. “The insurance companies are making a fortune,” he said. “Their stock is

Aetna Delays And Changes Downcoding Policy After major pushback from lawmakers and providers, Aetna is easing a controversial “downcoding” policy for inpatient Medicare Advantage (MA) claims. The insurer said the policy’s start date has been delayed to Jan. 1, 2026 and that its severity review would now apply to urgent or emergent inpatient hospital stays that include at least one midnight but fewer than five. As part of the reimbursement approach, Aetna will approve these inpatient stays without a medical necessity review and cover the claim at a rate that aligns with observation services. Stays of five or more midnights will not be subject to a severity review in the updated policy. Additional articles: https://www.fiercehealthcare.com/payers/american-hospital-association-urges-aetna-rescind-new-inpatient-policy-payment and https://www.modernhealthcare.com/insurance/mh-aetna-medicare-advantage-downcoding-policy/ (Some articles may require a subscription.) #aetna #hospitals #claimsdenials #priorauthorization https://www.beckerspayer.com/payer/aetna-delays-new-inpatient-reimbursement-policy/ Exchange Subsidy Saga President Donald Trump’s Domestic Policy Council and senior health officials have been meeting privately on how to address the expiration