employers

MA Plans Object To Flat 2027 Rates The Medicare Advantage (MA) community was shocked by the near-flat rates that the Centers for Medicare and Medicaid Services (CMS) proposed for 2027. MA plans are now laying out the potential impacts in comments on the proposed regulation. The rate hike was computed at just 0.09% due to two new risk adjustment reforms – one embedded in the new v28 model and another that bars risk scoring unless diagnoses also appear on submitted provider encounters. The changes wiped out the economic growth increase. Various MA plan trade groups were unanimous in saying that the rate as is could undermine the program yet again. Major health plan trade group AHIP said in comments to the proposed rule that the flat rate “risks undermining CMS’ goal of providing beneficiaries with stable, affordable choices during the annual enrollment period.” It noted sharply rising medical costs and

SOTU Has Little On Healthcare President Trump touted his accomplishments in his State of the Union address Tuesday but spent little time on affordability in healthcare. In the speech he did hit two main topics, but just for a total of five minutes of the marathon speech. I was not impressed with the vagueness of his health insurance coverage proposal but have given Trump a great deal of credit on moving the drug price needle. No one has been able to really do the latter before. #trump #healthcare #coverage #drugpricing https://www.healthcaredive.com/news/trump-state-of-the-union-healthcare-2026/812962 GoodRx Launches Employer Direct Program GoodRx announced it will launch Employer Direct, a new program that will allow employers to offer workers lower costs on branded products. Through the program, firms can select branded drugs and subsidize the cost for the cash-pay price available through GoodRx. The idea is that employers can lower employee costs by leveraging GoodRx existing

CBO: Medicare Part A Trust Fund Bust in 2040 The Congressional Budget Office (CBO) has updated its estimates around the solvency of the Medicare Part A Trust Fund and now expects the fund to go bust in 2040. The balance will grow each year through 2031, but then spending will begin to overtake revenue until it eventually runs out in 2040. This is 12 years less than the last estimate. The culprits are: The CBO’s projection is better than the Medicare’s trustees’ last projection, which said the fund would be depleted by 2033. Additional article: https://www.fiercehealthcare.com/regulatory/cbo-estimates-medicare-trust-fund-will-run-out-2040 #medicare #spending #insolvency https://www.healthcaredive.com/news/medicare-trust-fund-expire-2040-cbo-gop-obbb/812937 UnitedHealthcare Expands Referral Requirements Starting May 1, enrollees in UnitedHealthcare health maintenance organization (HMO) Medicare Advantage (MA) products will need a referral from a primary care provider to go to many specialists. This brings back an old-school managed care lever to reduce costs. The prerequisite has already been in place

Exchange Enrollment Expected To Drop While actual enrollment during the open enrollment season in the Exchanges did not drop a great deal, the cost of not extended enhanced subsidies is now appearing to take hold. State Exchanges as well as health plans are reporting cancellations as well as lack of premium payments, which could send rolls dropping dramatically throughout the year. As one example, the biggest Exchange plan nationwide, Centene, says it expects its rolls to drop over one-third this quarter. Cigna, Elevance Health, Molina Healthcare, and UnitedHealthcare anticipate collectively losing approximately 3.4 million exchange members by the end of 2026.  (Article may require a subscription.) #exchanges #enrollment #healthplans #coverage https://www.modernhealthcare.com/insurance/mh-aca-exchanges-membership-premium-payments No Suprises Battles A Modern Healthcare article covers the ongoing battle between insurers and providers regarding the No Surprises Act arbitration process. Physician groups, hospitals, and air ambulance companies have filed millions of claims seeking higher reimbursement from insurers

Congress Inches Toward Site Neutral Payments Congress didn’t pass site neutral payments in Medicare but did make some incremental progress toward the reform in the FFY 2026 appropriations bill that was recently passed. This could lead to cuts to the tune of billions of dollars in hospital reimbursements in the future. The bill requires health systems to obtain unique National Provider Identifiers, or NPIs, for their outpatient departments by 2028. This will have the effect of giving the government detailed information about outpatient care provided at hospital-owned facilities — and its cost — to support broader site-neutral policies. The Trump administration did implement site neutral payments for drug administration via regulation this year. That follows some other modest reforms several years ago. Site neutrality pays the same rate to provider regardless of the site the service is performed at – physician office, ambulatory surgery center, off-campus hospital outpatient department, or

SNPs Up; Major Plan Terminations In MA Two new articles on the 2026 open enrollment season in Medicare Advantage (MA). A Modern Healthcare analysis says membership in Special Needs Plans, or SNPs, is now 8.2 million as of Feb. 1, up 12.2% from a year before. While enrollment growth overall slowed from 2025 to 2026, SNP growth actually went up. SNP growth was 10.1% in 2025. About a quarter of all enrollees are now in SNPs. A study in JAMA examined the major contraction in MA and rates of forced moves. It found that one in 10 MA enrollees were forced to disenroll from their current product choice heading into 2026 due to insurer exits or contractions. That is a ten-fold increase from historic averages and is up from 6.9% in 2025. Among the 28.6 million MA enrollees that were part of the study sample, 2.9 million were forced to

More Bad News On Affordability Front A new Commonwealth Fund report finds that middle-income workers and their families are spending an average of 10.1% of median income on their health premiums and deductibles. The 2024 data from the employer-sponsored insurance market show that premium contributions for family coverage ranged from an average of $5,584 in Oregon to $9,148 in California. In 19 states, the average premium and deductible contribution topped 10% of that state’s median income. Costs varied by region, industry, and employer size. Five states’ costs breached the affordability metric under the Affordable Care Act (ACA), which could trigger coverage in the Exchanges. The researchers recommend employers adjust out-of-pocket requirements and premiums based on the income of employees. The report also notes one of my key reform recommendations – a shift in the broader trends around healthcare pricing and spending. #healthcare #coverage #affordability https://www.fiercehealthcare.com/payers/family-premiums-account-10-income-19-states-commonwealth-fund Payers Continue Convincing Investors All

UHG Still Made The Most Despite major financial challenges, UnitedHealth Group still made the most of the major national health plan vertically integrated behemoths in 2025. UHG brought in just over $12 billion in earnings for 2025. That was followed by Cigna at about $6 billion, with Elevance Health at almost $5.7 billion. CVS Health was at about $1.8 billion and Humana at about $1.2 billion. Centene lost $6.7 billion. Most of the plans see 2026 as yet another transition year with improving results. #healthplans #margins https://www.fiercehealthcare.com/payers/unitedhealth-group-was-most-profitable-payer-difficult-2025-industry Rural Providers Criticize End To Reform Pilot A program to enhance primary care, especially in rural areas, is being shuttered just a year into its launch due to early savings efforts by the Trump efficiency program DOGE. The model, Making Care Primary (MCP), was supposed to improve primary care at nearly 700 practices in eight states by providing flexible and quality bonus payments

GOP Worried On Affordability Some Senate Republicans are worried that the GOP leadership is not doing enough on the affordability issue as the 2026 midterms approach. Right now, the House is almost assuredly going back to the Democrats, while the Senate is favored for the GOP but getting too close for comfort. Sen. John Kennedy, R-LA, has been urging Republicans to pass a second reconciliation bill to pass additional healthcare measures. President Trump has dismissed the idea of yet another bill, but House Republicans want to pass a second one as well. Lawmakers could still do so over the president’s objections. #healthcare #coverage #midterms https://thehill.com/homenews/senate/5738150-republicans-affordability-midterms FTC Loses Enhanced Disclosure The Federal Trade Commission’s (FTC’s) antitrust rule requiring parties to submit additional information to regulators ahead of a planned merger was overturned by a federal judge. The judge agreed with business interests that the FTC’s rationale that it needed additional information

2026 Medicare Advantage Enrollment Finally Published After a long delay, the Centers for Medicare and Medicaid Services finally published results for January and February for Medicare Advantage (MA). While many predicted that the program would contract, I had said that enrollment would be flat or one of the lowest growths we had seen recently. Some analysts suggested that there would be a decline because of the mass exodus of large plans from certain markets and efforts by them to shed huge enrollment. But despite the huge challenges in the program, MA showed some resiliency. Enrollment in February 2025 was 34.941 million. In December 2025, MA had 35.700 million members. In February, we saw 35.814 million. January numbers showed a contraction from December of about 400K. We know January 2025 numbers had some issues. That could also be the case for January 2026. But February 2025 to February 2026 numbers showed