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The Two Sides Of Drug Prices After Negotiations

The discounted Medicare drug prices makes progress but much more has to be done In A Tale of Two Cities, Charles Dickens famously started his novel with: “It was the best of times, it was the worst of times.” In many ways, the adage could well describe the current state of Medicare drug price negotiations. Medicare drug price negotiations background Medicare drug price negotiations became possible with the passage of the Inflation Reduction Act of 2022. The law required Medicare to begin negotiating drug prices with brand drug manufacturers. These drugs largely lack generic competition. Eligible drugs are phased in over time, with the first ten already set to have discounted pricing as of January 1, 2026. The next fifteen drugs subject to negotiation will be announced in February 2025, with final negotiated prices taking effect on January 1, 2027. The bill over time covers both Part D retail and

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National Healthcare Expenditure Data Issued for 2023: What Does It All Mean?

2023 saw a major surge in healthcare spending coming out of the COVID pandemic One of my Christmas traditions is to write about the release of the Centers for Medicare and Medicaid Services (CMS) Actuary’s National Healthcare Expenditure Data (NHED) for a given calendar year. This usually is released in the middle of December each year for the prior year. It literally takes CMS about a year to capture, calculate, and categorize all the data for a year given the size and labyrinthine complexity of our healthcare system. Each year as well, usually in the first half of June, the CMS Actuary updates healthcare spending projections for ten outyears. Why is this so important? First, it is the main comprehensive source of data for calculating the history and future of healthcare spending. Most other studies rely in some form on the CMS Actuary’s NHED reports. Second, it is a treasure trove

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November To December Medicare Advantage Enrollment Statistics Signal Some Trends For 2025

Some evidence that MA enrollment is slowing and big national plans realigning The 2025 enrollment season for Medicare Advantage (MA), known as the Annual Election Period (AEP), has come to a close as of Dec. 7, with some getting through Dec. 31 due to plan terminations. In this period, people can make changes between the traditional fee-for-service (FFS) program and MA or between MA plans. Standalone Part D (PDP) can be added or switched as well. Then, from Jan. 1 to Mar. 31, we have the perhaps misnamed MA Open Enrollment Period (MA OEP). In these three months, only those in MA can switch back to FFS and add a Part D plan or switch MA plans. Those enrolling in an MA Part C only plan can also add a standalone Part D plan. We are in a very odd time. Plan terminations and geographic contractions were major. Benefit cutbacks,

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Be Level-Headed On Medical Loss Ratio Rules

CMS’ MLR proposals are understandable, but caution is needed In a parting shot at the private managed care industry, the Biden administration’s Centers for Medicare and Medicaid Services (CMS) issued a 2026 Medicare Advantage (MA) and Part D proposed rule for 2026 that would make major changes to the minimum medical loss ratio (MLR) requirements in the Medicare managed care program.  This comes as Capitol Hill is shining a light on a number of MA program issues, including overpayments, risk adjustment abuses, supplemental benefits, marketing, poor Star performance, and the vertical integration of top national health insurers. These top national players control about three-quarters of all MA enrollment right now. Minimum MLR explained Most lines of business now have MLR requirements except self-funded employer plans. In these cases, businesses are at risk for healthcare expenditures as opposed to insurers. Insurers will still administer such plans usually for a set administrative

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Stories From Open Enrollment Show The Problems With Our Healthcare System

My work with everyday consumers shows how irrational and broken the healthcare system really is. I am known as the healthcare guy to family and friends. For the past many years, I have had a bit of a part-time job in Q4, unpaid as it is. Given my background, I receive calls from a rather extended network of people seeking my aid and advice on the enrollment seasons – traditional Medicare with Medicare Supplement, Medicare Advantage (MA), Medicare Part D, the Federal Employees Health Benefit Program (FEHBP), the Exchanges, and employer group coverage. In retirement I plan to expand this free service for a variety of reasons, all of which I have learned from the past decade working with people. Here are some of this year’s cases in hopes that some of them resonate (sometimes unfortunately) with your friends and family and you can offer some advice as well.  In

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I Am Shocked By The Vitriol Post UnitedHealthcare Executive’s Assassination

Somehow the overall failings of the healthcare system are the fault of health plan executives I wade into this debate with some anxiety, but I am frankly astonished by the online vitriol since the blatant assassination of UnitedHealthcare CEO Brian Thompson. Law enforcement believes the killing was clearly targeted, especially given the inscriptions on shell casings which said “delay, deny and defend.” Terribly, some have celebrated Thompson’s death or argued that he deserved to die given his business’ practices. Others have used the tragedy to attack health plans as evil entities that seek simply to deny or delay care. The social media comments single health insurers out as the sole bogeyman in the national healthcare debate. Far-left groups’ posts speculate about soon-to-be-unearthed sinister plots and treachery that are at the heart of the assassination. To me, all the comments are unfortunate and lack important perspective. Bruce Japsen, a writer for

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Medicare Advantage and Part D Star Changes From 2026 Proposed CMS Rule

New measures and major Star changes coming The just released 2026 Medicare Advantage and Part D rule from the Centers for Medicare and Medicaid Services (CMS) has a number of important Star program measure and policy updates. As promised, here is my thorough assessment of the Star changes from the rule. See Monday’s blog here for the rest of the proposals in the rule: https://www.healthcarelabyrinth.com/large-ma-and-part-d-rule-issued-for-2026/ . Will the changes really go into effect? What will happen to these proposals is anyone’s guess right now. The Biden administration did not publish the rule in time to finalize it before the current president leaves office. That will allow the incoming Trump administration the ability to delay final publication and remove significant portions if it wants to. I don’t expect the new administration to disturb some of the technical changes and customary roll out of Star measures, but it likley will stop some

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Large MA And Part D Rule Issued For 2026

2026 Medicare Advantage and Part D rule has major changes to the programs The Biden administration issued its draft 2026 Medicare Advantage (MA) and Part D rule last week. A draft is available, but the Federal Register indicates the rule was pulled back for additional clarifications and would be reposted on December 10. Due to its late posting, the rule will not be finalized before the Trump administration takes office and therefore could simply be revamped rather than be rescinded. In some ways, the rule does not have some of the mega changes that some expected in the areas of Star, risk adjustment, and more. This could be due to some sensitivity to the current financial woes of the MA industry. But there is plenty for the industry to object to. I have read the 700-plus page draft rule and reviewed the Centers for Medicare and Medicaid Services (CMS) Fact

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Constitutional Checks And Balances Working

The Gaetz withdrawal shows the Constitution is being taken seriously Another quick deviation from healthcare in the interest of democracy this Thanksgiving weekend. On November 18, my blog covered the issue of recess appointments. I said that the Senate has to fulfill its constitutional functions and resist the concept of recess appointments as recommended by President-elect Donald Trump. Days after taking office, President-elect Trump urged the Senate to allow him to make such recess appointments to get his cabinet and other key officials in place quickly. I argued that this would amount to an abrogation of the Senate’s duty to vet and approve key officials. Yes, recess appointments are mentioned in the Constitution, but the provision was included for good reason in bygone days when Congress was not in session year-round. It helped ensure government could function properly by giving the president some latitude to appoint officials when Congress was

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Healthcare Coverage Under Trump 47

Medicare Advantage (MA) could benefit under Trump, Kennedy, Oz With the nominations of Robert F. Kennedy Jr. as Health and Human Services Secretary and Mehmet Oz as Administrator of the Centers for Medicare and Medicaid Services (CMS), a slightly clearer picture has emerged as to what we can expect for healthcare policy and coverage. Admittedly, there is a lot still in question. Kennedy likely focuses on his core concerns If he does get confirmed, Kennedy is likely to focus on his passions of reforming the health regulatory agencies and bringing greater transparency to drug and food regulation.  In addition, he wants to impact chronic disease in a big way. Kennedy is a known vaccine skeptic. Under him will serve Dr. Marty Makary as Commissioner of the Food and Drug Administration (FDA) and Dr. Dave Weldon, Director of the Centers for Disease Control and Prevention (CDC). Both Makary and Weldon are

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