first100days

Medicare Advantage Will See Huge Changes Again in 2027 The Trump administration is putting the best spin possible on a continuing retrenchment in the Medicare Advantage (MA) industry. The Centers for Medicare & Medicaid Services (CMS) announced that weighted average MA premiums are projected to fall more than 16% from 2026 to 2027, with MA prescription drug (MA-PD) premiums set to decrease by 38% year-over-year. Additionally, CMS said average premium for standalone Part D prescription drug plans is projected to rise by less than $1 per month in 2027. The industry certainly has a different narrative. While it is true that MA remains broadly available, there is little doubt that benefits are being further diminished and that more plan terminations are occurring. This is evident in the landscape file release. A Becker’s Payer article gives an overview of the retrenchment still occurring. MA choice will go down in 29 of

Trump Admin Strikes Deal With 42 States On Improving Medicaid Quality The Trump administration has announced that 42 states will partners with the Centers for Medicare & Medicaid Services to rethink how quality is measured in Medicaid and the children’s health program (CHIP). CMS said the partnership will put health outcomes “at the center of how success is defined” and streamline hundreds of reporting requirements. The initial state participants have about 56 million Medicaid and CHIP beneficiaries and account for roughly $701 billion in fiscal 2024 Medicaid spending. At the center will be streamlining quality measure inventories, adopting digital quality measurement with near-real-time data when possible, and aligning financial accountability with outcomes measures. The program lines up incredibly well with efforts to boost lagging Medicaid outcome performance, interoperability, as well as migrate all government programs to a universal foundation of measures. Additional articles: https://www.fiercehealthcare.com/regulatory/37-states-partner-cms-initiative-rethink-medicaid-quality-measures and https://www.cms.gov/newsroom/press-releases/cms-refocuses-medicaid-quality-health-outcomes-launches-innovative-partnership-37-states #quality #medicaid #cms https://www.beckershospitalreview.com/legal-regulatory-issues/cms-launches-medicaid-quality-pledge-with-37-states/

Will Vertical Integration Be A Focus? An interesting Becker’s Payer article indicating vertical integration will become a strong focus. Recently, late-night TV host John Oliver tore into the inner workings of huge vertically integrated company UnitedHealth Group. The article notes that UnitedHealth is now the fourth-largest company in the world by revenue, taking in $447 billion last year, up 11.8% year over year. It reported ten significant subsidiaries down from a reported 2,700 a short time ago. Vertical integration is not unique to United. While health plan execs have defended vertical integration it is increasingly being looked at by Congress and federal agencies. Sens. Elizabeth Warren, D-Mass., and Josh Hawley, R-Mo., introduced the Break Up Big Medicine Act, which would prevent companies from simultaneously owning a health insurer or pharmacy benefit manager and a provider or management services organization. #verticalintegration #healthplans #unitedhealthcare https://www.beckerspayer.com/payer/as-vertical-integration-scrutiny-grows-unitedhealth-takes-center-stage/ Oz Says AI Will Cost More In

MedPAC Chair Defends MA Analysis Dr. Amol Navathe, the new chair of congressional Medicare policy arm MedPAC, defended the work and Medicare Advantage over-reimbursement estimates of his organization. He doubled down on MedPAC’s view that MA is reimbursed 14% more than what is spent in traditional fee-for-service (FFS). Critics of MedPAC, including me, stand by our assessment that MedPAC is relying on old data that does not recognize risk adjustment reforms and updates. In addition, MedPAC has picked up some spurious academic analyses on so-called favorable selection and has essentially adopted them as fact. The chairman himself is an academic and his defense of this process is expected. Republicans in Congress are challenging MedPAC’s way of thinking, considering a bill to force MedPAC to broaden its viewpoints, including definitively setting aside the favorable selection argument. As MedPAC always does, it says it will open the doors and encourage engagement, but

Trump Admin To Disenroll 760K From Exchange The Centers for Medicare and Medicaid Services (CMS) canceled 315,000 health insurance Exchange enrollments covering more than 760,000 people. CMS says these enrollments were unlawful and that the rescissions are part of its anti-fraud campaign. The agency said the government will save $2.2 billion in premium subsidies.  In addition, CMS said it will terminate more than 200 agents and brokers that have failed to comply with enrollment standards. Additional articles: https://www.fiercehealthcare.com/regulatory/cms-cancel-aca-coverage-760k-crack-down-brokers-latest-anti-fraud-push and https://www.modernhealthcare.com/politics-regulation/mh-cms-aca-enrollment-fraud/ and https://www.modernhealthcare.com/politics-regulation/mh-aca-broker-enrollment-freeze/ and https://thehill.com/policy/healthcare/6104381-vance-oz-aca-obamacare-crackdown/ #exchanges #healthcare #coverage #enrollment https://www.beckershospitalreview.com/finance/cms-cancels-aca-policies-for-760000-people-freezes-broker-registrations/ Appeals Court Sides With Plans In NSA Suit A federal appeals court ruled that a plastic surgery practice cannot sue Cigna to collect more than $3 million it won through the No Surprises Act’s (NSA) arbitration process. The court says the No Surprises Act gives providers a right to be paid but leaves enforcement to the Labor Department, the Treasury Department,

ICHRAs Slated To Grow Demonstrably Federal officials have rebranded individual coverage health reimbursement arrangements (ICHRAs) as CHOICE arrangements. While the name change is recent, new news that ICHRAs are slated to grow demonstrably. Oscar Health CEO Mark Bertolini projected during the company’s investor day that the ICHRA market will reach 2.5 million members by 2029, a 400% increase. It stands now at about 500,000. States are passing laws to encourage the provision of healthcare. Three states are offering tax credits to employers providing ICHRA funds to workers, while other states are considering different methods to drive adoption. #ichras #healthcare #coverage https://www.modernhealthcare.com/insurance/mh-ichra-choice-mehmet-oz-indiana-georgia/ NSA Arbitration Crippling Employer Groups A new study from the ERISA Industry Committee finds that self-funded employers are facing the brunt of costs from the poorly designed and very provider-friendly No Surprises Act (NSA) arbitration process. Almost 90% of decisions are made in favor of providers and awards are

More Signs of Medicare Advantage Retrenchment A number of plans have already signaled more retrenchment in Medicare Advantage (MA) in 2027. More exits are now being announced. Molina Healthcare will no longer sell Medicare plans in Connecticut, Mississippi, and Nevada. Earlier it said it will get rid of all mainstream, non-Special Needs Plans (SNPs) in 2027. It will also drop SNPs in those three states. In addition, Health Care Service Corp. (HCSC) plans to exit the Connecticut, New York and District of Columbia MA next year. HCSC will cut its Healthspring-branded MA footprint to 450 counties in 2027 from 580 this year. HCSC reported a $4.57 billion underwriting loss last year. Not too many years ago, HCSC purchased the MA line from Cigna. It may exit 11 additional markets. Last, CMS will allow MA plans to expand their service areas midyear when acquiring a competitor. The change is out of

House GOP Wants MedPAC To Be More Favorable To MA A new bill from Ways and Means Republicans that passed on a party line vote would require the Medicare Payment Advisory Commission (MedPAC) to study the topic of overpayments in Medicare Advantage (MA) more favorably for insurers. I support the bill as MedPAC has shown major bias against MA over the years, undertaking twisted analyses and citing dubious research studies to further the idea that MA is markedly over reimbursed. #medicareadvantage #overpayments #riskadjustment https://www.statnews.com/2026/09/16/medicare-advantage-overpayments-analysis-medpac-change-apples-to-apples-act/ CMS Gives In To Texas In a rather blatant political move, the Centers for Medicare and Medicaid Services has given in to Texas and extended a hospital and other provider funding plan. The state, which did not expand Medicaid, will have about $12 billion restored just as CMS is reining in provider taxes and similar payments. #texas #medicaid #hospitals https://www.beckershospitalreview.com/finance/cms-approves-12b-in-texas-medicaid-funding-after-monthslong-dispute/ Healthcare Agentic AI Boom Outpacing Governance

PBM Law Could Impact Drug Entities In The Shadows A new law with restrictions on and reforms to pharmacy benefit managers (PBMs) will have a major effect throughout the drug channel. The law requires greater transparency and will likely expose various transaction fees between PBMs and rebate aggregators, group purchasing organizations, and others related entities. #pbms #transparency https://www.modernhealthcare.com/insurance/mh-pbm-reform-drug-rebate-aggregators NCQA Releases Plan Ratings Healthcare quality organization NCQA released its annual Star rating for health plans. Eighteen plans scored a perfect 5 Stars for 2026, up from 11 in 2025. There are no for-profits among them. Of large plan entities, CVS Aetna had the best average rating across plans of 4.009. Additional article: https://www.beckerspayer.com/rankings-ratings/the-best-rated-health-plans-of-2026-ncqa/ #ncqa #quality #healthplans #stars https://www.healthcaredive.com/news/ncqa-plan-ratings-2026-nonprofits-outperform/830521 — Marc S. Ryan

ACCESS Program To Expand The new tech-based chronic disease management ACCESS program will expand the diseases and conditions eligible for enrollment. The Centers for Medicare and Medicaid Services (CMS) announced that new clinical tracks will be added next Spring, including heart failure and substance use disorders. CMS Administrator Dr. Mehmet Oz also said he eventually wants the model adopted in Medicare Advantage (MA) and Medicaid. Right now, it services traditional Medicare enrollees. The initiative has CMS contracting with technology organizations, which team up with Medicare physicians to use tech to track and improve outcomes for people with certain cardio-kidney-diabetes disease states, anxiety and depression, and musculoskeletal conditions. The new disease states include health failure, chronic obstructive pulmonary disease, substance abuse, and tobacco cessation. Additional article: https://www.modernhealthcare.com/health-tech/mh-cms-access-model-chronic-care-tracks/ #medicare #chronicdisease #caremanagement #access https://www.beckershospitalreview.com/finance/cms-expanding-access-model-4-things-to-know/ Younger Gens Do Not Trust Insurers A new survey finds that member trust in insurers is on the decline