improperpayments

MA’s Value Underscored In New Study A new ATI Advisory analysis conducted on behalf of the Better Medicare Alliance finds that Medicare Advantage (MA) enrollees spend less on average than those in traditional Medicare fee-for-service (FFS) and yet have similar satisfaction rates. Looking at files from 2021 to 2023, ATI found that MA enrollees spent $2,824, or 36%, less out-of-pocket on average in 2023 compared to those in FFS. That difference has increased over time, with savings 16% higher in 2023 than in 2022. Just 12% of MA enrollees said they faced a significant cost burden, or spent more than 20% of their income on healthcare, compared to 24% of those in FFS. MA too cares for more lower income people – 54% in MA are at or below 200% of the federal poverty level vs. 30% in FFS. More than three-quarters of MA members have three or more chronic

Warning Signs For Hospitals On Exchange Enrollment Falloff For-profit hospital chains HCA and Tenet reported earnings for Q2 2026 and within the disclosures are tough news on Exchange revenue that could impact all hospitals. HCA reported that its overall loss due to Exchange enrollment declines will go from an estimated $1 billion to a new projection of $1.2 billion in 2026. HCA says volume declines of 15% are in line with original guidance estimates, but its assumption that 80% to 85% of the patients who lose Exchange coverage would become uninsured has been off. The number is closer to 100%. HCA’s admission decline for Exchange enrollees has been between 25% and 28% for the first half of the year. The Exchange issues alone have caused a $400 million impact on adjusted EBITDA in Q2. Similarly, Tenet Healthcare saw a 17% year-over-year decrease in Exchange-related revenue in Q2 and a 13.5%

Stars Redo Boosts 47 Contracts’ Ratings Centers for Medicare and Medicaid Services’ (CMS) data show that 47 contracts received recalculated 2026 Medicare Advantage that are higher than the original calculation. Thirty-six of those contracts secured at least four out of five stars to qualify for a quality bonus of 5%. Aetna and United Healthcare are two big plans that collected more revenue from the rescoring. The CMS Recalculation has driven several lawsuits. Elevance Health argues some of its contracts should be calculated based on what Clover Health was (CMS’ recalculation differed for other plans). Scan and Alignment Healthcare argue that they should be rated on an even more steamlined set of measures because CMS ignored part of the Clover ruling. (Article may require a subscription.) #cms #stars #quality #medicareadvantage https://www.modernhealthcare.com/insurance/mh-aetna-unitedhealthcare-medicare-advantage-star-ratings Congress Moves Healthcare Changes House and Senate committees approved a series of bills that would strengthen transparency requirements for providers

CMS Appeals Clover Decision Two major things in the past few days: The Centers for Medicare and Medicaid Services (CMS) updated the Medicare Plan Finder website and landscape files with the “better of” recalculated measures vs. original. This tells us exactly how many contracts got increases and impacts. Previous estimates suggested about 10% got an increase, with others the same or held harmless. CMS has appealed the Clover decision. We don’t have details yet but I will update as more is known. This was totally expected. We will see if they have appealed on both the statutory and regulatory deficiencies or just regulatory. Additional articles: https://www.fiercehealthcare.com/regulatory/cms-appeals-court-decision-behind-2026-ma-star-ratings-recalculations and https://www.healthcaredive.com/news/cms-appeals-clover-health-medicare-advantage-stars-lawsuit-cms/826003/ and https://www.beckerspayer.com/legal/cms-appeals-clovers-medicare-advantage-star-ratings-win/ (Some articles may require a subscription.) #cms #medicadvantage #stars #quality https://www.modernhealthcare.com/insurance/mh-cms-appeal-clover-medicare-advantage-ratings/ Commercial Insulin Cost-Sharing Cap Advances A bipartisan bill to cap the cost of insulin at $35 for people with private health insurance advanced through a key Senate committee Wednesday. Its

CMS Proposes Additional Medicaid Provider Tax Rule Based on the passage of the One Big Beautiful Bill Act (OBBBA), the Centers for Medicare and Medicaid Services (CMS) proposed another rule to implement certain Medicaid provider tax changes. The taxes, which help fund state matches for Medicaid spending, are used in almost all states. Under the OBBBA, beginning Oct. 1, all states are prohibited from imposing new provider taxes or increasing ones in effect on or after July 4, 2025. State “hold harmless” allowances are replaced by provider- and state-specific thresholds based on taxes that were effective July 4, 2025. The proposed rule would implement the legislation reducing the indirect hold harmless threshold by 0.5 percentage points every year from 2028 to 2032, when the thresholds reach 3.5% — the allowable levy. (Article may require a subscription) #medicaid #providertaxes https://www.modernhealthcare.com/politics-regulation/mh-cms-medicaid-provider-tax-restrictions/ HHS Defers $1 Billion In Funding To CA, MN The Department

New Poll Puts Healthcare Affordability As Top Of Mind Recent polling by healthcare policy group KFF says healthcare affordability is top of mind for voters going into the midterms. KFF says that a majority of Democratic and independent voters say it is “extremely important” that candidates talk about healthcare costs (60% and 55%), with 55% of Republican voters saying it is “extremely important” for candidates to discuss fraud in government health programs.  Across party lines, six in 10 adults say they are “very” (27%) or “somewhat worried” (35%) about affording healthcare costs for themselves and their families. In other news, a new bill would create the Medicare Exchange health plan, a government-run public health insurance option on the Exchanges. The bill would also permanently extend the expired enhanced premium subsidies. The public plan would be at the Silver and Gold metal tier levels, waive all cost-sharing for primary care, and

Health Plans Backing Away From Voluntary PA Reforms Just one year after promising major prior authorization (PA) reforms on a voluntary basis, some health plans appear to be backing away from the commitments to the Trump administration that have been heavily touted by both plans and regulators. Some plans have been resistant to proceed on the pledge to implement certain reforms. Critics says progress has been slow despite health plan trade group AHIP claiming 6.5 million prior authorizations for patients—equal to an 11% reduction – have been eliminated. Critics also say claims denials are on the rise. The administration threatened regulatory action if plans did not agree to come to the table with reforms. Bills on PA reform appear to be moving in Congress. (Some articles may require a subscription.) Additional article: https://www.fiercehealthcare.com/payers/insurers-hedge-trump-backed-pledge-improve-denials-process #healthplans #priorauthorization https://www.modernhealthcare.com/insurance/mh-prior-authorization-reform-pledge-insurers-pullback/ Smaller PBMs Tout Alternative Strategies To Save Costs Smaller pharmacy benefits managers are touting

UnitedHealth Raises Guidance As Profits Spike UnitedHealth reported a profit spike to $5.5 billion in Q2 2026, driven by the recovery in its insurance unit, UnitedHealthcare. As well, United’s Optum services business had a nice recovery. UnitedHealthcare posted an 86.7% medical loss ratio (MLR) in Q2, improving year over year. Medicare Advantage (MA) turned around as well. Costs are running high but below the 10% it projected. The company expects its Medicare plans to generate a 3% operating margin this year. United lost a planned 965,000 members in a retrenchment, but was somewhat lower than the 1.1 million expected. United urged Congress and the administration to reform what it says is a broken No Surprises Act (NSA) arbitration process that is driving prices higher. Additional articles: https://www.healthcaredive.com/news/unitedhealth-q2-results-beat-2026-guidance-raise/825385/ and https://www.beckerspayer.com/payer/unitedhealthcare-no-surprises-arbitration-system-needs-to-be-reformed/ and https://www.beckerspayer.com/financial/unitedhealth-posts-5-5b-profit-in-q2/ and https://www.modernhealthcare.com/insurance/mh-unitedhealth-earnings-guidance/ (Some articles may require a subscription.) #healthplans #margins #unitedhealthcare https://www.modernhealthcare.com/insurance/mh-unitedhealth-earnings-unitedhealthcare-medicare-optum/ Judge Blocks Certain ACA Marketplace Rule Provisions

Elevance Stumbles A Bit In Q2 But Recovering Elevance Health is kicking off another round of quarterly earnings results for health plans. The results are a mixed bag – with ongoing signs of recovery but signals that challenges and uncertainty remain for big insurers and plans in general. Elevance posted $1.5 billion in profit for Q2 and revenue of $50.5 billion, but profit was down from Q2 2025. Elevance is still meeting guidance to investors (and is upping it), but investors wanted more. Here are some of the troubling signs, which are expected in other big plans too for Q2. Some good news is the settlement on Medicare Advantage (MA) risk adjustment. Elevance will face no sanctions. Additional articles: https://www.fiercehealthcare.com/payers/elevance-healths-stock-slides-premarket-even-it-beats-street-15b-q2-profit and https://www.modernhealthcare.com/insurance/mh-elevance-health-earnings-state-medicaid-markets/ and https://www.healthcaredive.com/news/elevance-medicaid-exits-q2-2025-2026-earnings-raise/825217/ and https://www.beckerspayer.com/financial/elevance-reports-1-5b-profit-in-q2-membership-dips/ (Some articles may require a subscription.) #healthplans #margins #medicareadvantage #elevancehealth https://www.modernhealthcare.com/insurance/mh-elevance-earnings-profit-guidance 340B Costs Hit $100 Billion More news that will likely mean regulatory or

Trump Admin Proposes Major Medicare FFS Reform Rule The Trump administration continues its efforts to reform Medicare and make its mark on healthcare reform. A new Medicare fee-for-service (FFS) reform proposal will significantly impact many areas of the sprawling traditional program. The proposed rule would make changes to Medicare accountable care organizations (ACOs), transition away from the physician Merit-based Incentive Payment System (MIPS) to an enhanced value-based care (VBC) pathways program, and update physician payment policies to better reflect modern clinical practice. In part the ACO changes would establish more predictable spending targets to improve planning and participation as well as increase some shared saving rates and make benchmark and other calculation adjustments. Notable quality reporting changes are also proposed. The MIPS successor would also have three new value-based pathways on diabetes, hypertension, and hospital-based care. Physician reimbursement would generally shrink a bit in 2027. Remote patient monitoring would also