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MA Star Cut Points Rise Good Healthcare Dive article on the release of Plan Preview 2 information for Medicare Advantage Stars and the new cut points. As the article discusses, assessing what will happen to overall Star ratings is hard to do. Tougher cut points can or cannot be a sign that things will go up overall. My companion blog tends to think that some of the increases tie to true initiatives on performance improvement and others to MA plan exits. I think if things do go up overall, it will be modest. That blog is here: https://www.healthcarelabyrinth.com/two-star-blogs-in-one-what-will-cms-do-next-on-stars-and-despite-cut-point-moves-widespread-overall-ratings-hikes-unlikely/ #medicareadvantage #partd #stars #quality https://www.healthcaredive.com/news/medicare-advantage-stars-cutpoints-2027-cms/829963 Federal Exchange Enrollees To Receive Rebate The White House announced that it will issue $500 refunds to close to a million people enrolled in the federal Exchanges. The administration says the rebates are tied to overcharges collected in the Biden administration through user fees intended to fund

Impact Of OBBBA Cuts Two new analyses describe the looming impacts of the Medicaid and Exchange cuts in the One Big Beautiful Bill Act (OBBBA). Upcoming statutory limits on providers’ state-directed payments (SDPs) in Medicaid are expected to cost states tens of billions of dollars for state match and lower spending by double that or more. The analysis published in Health Affairs says 17 hard-hit states could see impacts of 10% to 25% of total annual Medicaid spending. The analysis outlined at least $51.8 billion in reductions across 36 states. A proposed rule would expand reductions beyond what is outlined in the OBBBA to all such SDPs. Federal policy changes and budget cuts are forcing states to scale back Medicaid benefits for immigrants. Because of looming cuts, California, Colorado, Illinois, Minnesota, New York, Washington and the District of Columbia have scaled back state-funded coverage for immigrants. The changes will also

States Turning To Managed Care For Medicaid Long-Term Care An excellent Modern Healthcare article on Medicaid long-term care. Twenty-four states contract with Medicaid managed care organizations to cover people who need long-term services and supports. This is a remarkable shift from decades ago when managed care covered largely only TANF welfare and related populations. States have turned to private delivery to save costs and reduce trends. However, some states are actually rolling back long-term managed care. Indiana and Nebraska recently ended insurer contracts amid provider concerns. #medicaid #longtermcare #managedcare https://www.modernhealthcare.com/insurance/mh-medicaid-managed-care-long-term-services State Initiatives To Reduce Healthcare Costs Growing Another interesting Modern Healthcare article on state efforts to reduce healthcare costs. Eight states have established cost growth targets. Enforcement ranges from hard penalties down to performance improvement plans and reporting. Some states are also looking to cap certain healthcare services and payer types. So far, there have been mixed reviews on state

Cuban Offers Ideas On Affordability Entrepreneur Mark Cuban, founder of Cost Plus Drugs, appeared before the Texas Legislature with affordability and reform ideas. They include: #healthcare #healthcarereform #cuban https://www.fiercehealthcare.com/regulatory/mark-cubans-recipe-affordable-healthcare-includes-these-5-policy-changes Cambia And Arkansas BCBS Affiliation Approved The Arkansas Insurance Department approved Arkansas Blue Cross and Blue Shield’s affiliation with Cambia Health Solutions, effective Oct. 1. The partnership will bring Cambia’s membership to nearly 6 million enrollees across six states. #bcbs #mergers https://www.modernhealthcare.com/insurance/mh-arkansas-blue-cross-cambia-health-approval — Marc S. Ryan

Hospitals Say Revenue Losses Will Mount With More Changes Hospital lobbies are turning up the heat on lawmakers given multiple funding reductions that threaten hospital finances. Impacts of the One Big Beautiful Bill Act will be $340 billion through 2034. But new rules proposed by the Trump administration would reform site neutral payments for imaging and enact reductions to drug reimbursement in Medicare for those with 340B status. That would mean another $681 billion loss over ten years. While I favor site neutral payments and some 340B reforms, it seems clear that all the reductions threaten to undermine providers. #hospitals #obbba #340b #siteneutral #medicaid #exchanges https://www.politico.com/news/2026/09/02/hospitals-say-coming-regulations-worse-than-medicaid-cuts-01060086 Centene To Exit Some Commercial Markets Centene subsidiary Health Net is pulling out of the commercial employer group market in California and Oregon. Additional article: https://www.modernhealthcare.com/insurance/mh-centene-california-oregon-commercial-group-plans/ #centene #employercoverage https://www.beckerspayer.com/payer/centenes-health-net-to-exit-commercial-group-market-in-california-oregon/ ICHRAs Now CHOICE The Centers for Medicare and Medicaid Services (CMS) has announced the rebranding

More Crippling News On Employer Healthcare Costs I told you about a number of business surveys projecting huge increases in healthcare costs in 2027. The bad news continues. A new survey underscores the trend. Marsh, formerly Mercer, says employers’ healthcare costs are projected to spike again in 2027. Without intervention, the hike would be 11%. With benefit adjustments and other interventions, the hike will be 8.2%. This echoes the Aon survey which said costs will rise 9.5%. In other news, only 60% of employer health plans cover GLP-1 drugs for obesity, down from 72% last year. This is from the Business Group on Health. Additional articles: https://www.fiercehealthcare.com/payers/employers-health-benefits-costs-could-rise-82-2027-marsh-survey and https://www.modernhealthcare.com/insurance/mh-employer-health-plans-glp-1-coverage/ #employercoverage #healthcare #coverage #costs https://thehill.com/policy/healthcare/6066452-employer-health-costs-spike-2027 Elevance Will Exit LA Medicaid Elevance Health’s Healthy Blue joint venture will close at year’s end, impacting 290,000 Medicaid enrollees. Louisiana will run a special enrollment period from Oct. 15 to Nov. 16 for impacted members.

United To Cut 1,700 Codes From PA To fulfill its commitment to eliminate 30% of prior authorizations, UnitedHealthcare says it will make 1,700 codes exempt from the process as of October 1. Most of the eliminations are in commercial and individual plans. Additional article: https://www.fiercehealthcare.com/payers/unitedhealthcare-nix-prior-auth-1700-services-oct-1 and https://www.modernhealthcare.com/insurance/mh-unitedhealthcare-prior-authorization-requirements-codes/ #unitedhealthcare #healthplans #priorauthorization https://www.beckerspayer.com/policy-updates/unitedhealthcare-to-drop-prior-authorization-requirements-for-1700-services/ Hospitals Continue Attacks On Hospital Rule Hospital groups closed out the comment period on a proposed rule with additional attacks, arguing that the Centers for Medicare and Medicaid Services’ proposals to expand site neutral payments and reduce reimbursement to 340B facilities would have disastrous consequences. It argues it does not have the legal ability to make the 340B change. #hospitals #340b #siteneutral #medicare https://www.fiercehealthcare.com/providers/hospital-groups-rail-against-cms-proposed-340b-changes-site-neutral-payments JAMA Says More Complex Disenroll From MA Researchers from Johns Hopkins University have concluded that development of any new complex medical condition is linked to a 3.3 percentage-point increase in Medicare Advantage (MA) disenrollment, with

Trump Strikes New Drug Deals Nine additional pharmaceutical companies will offer significant drug price concessions, including agreeing to introduce new drugs at most-favored nation (MFN) pricing and extending such lower costs to the Medicaid program. The nine new companies represent mid-size biotech and drug companies. The new agreements with the Trump administration mirror earlier deals, including selling at discounts on the TrumpRx website. A Harvard Medical School and Urban Institute analysis estimates the Medicaid program could save states more than $8 billion annually if applied to 82 high-cost brand-name drugs. The companies will not be subjected to MFN in Medicare (at least immediately) or new tariffs. They too will invest in America and provide active ingredients directly to the U.S. The White House says the 26 companies so far represent 90% of the domestic pharmaceutical market. It also took credit for prescription drug prices falling 3.1% over the 12 months ending

Proactive Enrollment Caps Could Be Used in MA in 2027 The Centers for Medicare and Medicaid Services (CMS) is now allowing Medicare Advantage (MA) plans to file for prospective enrollment caps in 2027 that could be used as a way to limit financial exposure. It could be yet another tool in the toolbox for plans seeking to stay in an area but fearful of too much risk. CMS says it will help stem further exits in areas. It appears existing regulatory authority is being used, perhaps more expansively. Previously, CMS only approved caps after an insurer’s enrollment ballooned to a point at which members’ health and safety was jeopardized. Network Health has applied for such a cap in 2027. Several protections exist in the regulation. #medicareadvantage #enrollment https://www.modernhealthcare.com/insurance/mh-medicare-advantage-enrollment-caps-2027-cms/ Hospitals Bemoaning Expansion Of Site Neutral Payments A number of hospitals are bemoaning the potential impact on the expansion of site neutral

Prominent Health Plan, PBM, And Provider Fraud Lawsuits A number of alleged fraud lawsuits have been filed recently, including the following: The Villages (Fla.) Health, a primary and specialty care provider group, has agreed to pay $541.5 million to resolve allegations it violated the False Claims Act (FCA) by submitting improper Medicare Advantage (MA) diagnosis codes. Similarly, Monogram Health agreed to pay $2.4 million to resolve allegations that it violated the FCA by submitting false diagnosis codes to increase payments in MA. Maryland’s attorney general filed a lawsuit against UnitedHealth Group and Optum, seeking $380 million in damages stemming from alleged issues administering Medicaid behavioral health. Florida’s attorney general sued Express Scripts and Prime Therapeutics, alleging arrangements between the two pharmacy benefits managers allowed Prime Therapeutics to improperly cut pharmacy payments by up to 20% and pass on savings to Express Scripts. Additional articles: https://www.beckerspayer.com/legal/villages-health-to-pay-541-5m-to-settle-medicare-advantage-fraud-allegations/ and https://www.beckerspayer.com/legal/maryland-sues-unitedhealth-for-380m-over-medicaid-administration-issues/ and https://www.healthcaredive.com/news/the-villages-health-medicare-overbilling-settlement-doj-humana/828915/ and https://www.modernhealthcare.com/insurance/mh-express-scripts-prime-therapeutics-florida-antitrust/ and https://www.modernhealthcare.com/legal/mh-villages-health-system-doj-settlement/ and