overpayments

Utilization and poor rate hikes are crushing health plan margins Big Healthcare has been going through some major financial woes of late. Many of these big companies reported poor 2024 financials and some bad news is now popping up in 2025. Recently, UnitedHealth Group reported rising utilization, especially in its Medicare Advantage (MA) line. What was surprising is that United was bullish on MA for 2025 and added significantly to its rolls during the recent enrollment season while some other big companies contracted in MA. United also had to back off its 2025 investor guidance. So, what is up here? First, utilization has gone up considerably recently. A good share of this ties back to the tremendous drop in normal medical utilization during COVID. Utilization began recovering in 2022 but has really taken off since then. And there appears to be no sign of a significant slowdown right now. Second,

Trump executive order on drug pricing is both populist and shows policy sophistication Despite his drug price proposals during his first administration, many felt like President Donald Trump would shy away from attacking Big Pharma and potentially even work against the Inflation Reduction Act’s Medicare drug price negotiations. After all, he went back and forth on the issue in the presidential campaign. But since re-taking office, Trump has sent clear messages he wants to pursue drug price reform for America. First, after taking office, the Centers for Medicare and Medicaid Services (CMS) issued a statement indicating it was readying and taking seriously round two of negotiations, although it wanted greater transparency and input. Next, on Super Bowl Sunday, Trump appeared on Fox News bemoaning the price of GLP-1s. He even quoted statistics that GLP-1s in America were ten times more than prices in the U.K. Now, he has issued an

A lot changed in the final rule, but not in the final announcement NOTE: This Medicare Advantage Stars blog is co-published with Lilac Software ( https://lilacsoftware.com and https://lilacsoftware.com/guide-to-the-2026-medicare-advantage-part-d-star-final-announcement/ ). On April 7, the Centers for Medicare and Medicaid Services (CMS) issued the 2026 Final Announcement for Medicare Advantage (MA) and Part D plans. This annual announcement outlines the rates and other technical rate-setting details for the coming year as well as the final Star measures and details for Star Year 2026. In addition, the notice outlines potential changes to Star and display measures moving forward. Little changed of significance between the January Advance Notice and the April Final Announcement on the Star front except for renaming the Health Equity Index (HEI). Substantive comments were included in the final announcement. Although we wrote about this before, we have combed the final announcement and slightly altered our summary and analysis below for

I was touched by a recent New York Times opinion piece that Sen. John Fetterman, D-PA, wrote. Fetterman is the much-maligned senator elected in 2022 in a contest with Dr. Mehmet Oz, now administrator of the Centers for Medicare and Medicaid Services (CMS). Fetterman had a stroke during the campaign. He had clear trouble understanding questions during the campaign and equally had a hard time responding. He used technology-based assistive devices to get through debates and other appearances during the election. After winning rather handily in the end, the senator checked himself into a hospital for clinical depression shortly after assuming office. I said he was much-maligned because during the campaign and after, Fetterman was attacked as being unfit to hold the office of senator. It actually went beyond criticism to being mocked by some for his stroke and clinical depression. Too, he has come under intense criticism for his

Rates surge to relief of Medicare Advantage (MA) plans On April 7, the Centers for Medicare and Medicaid Services (CMS) issued the 2026 Final Announcement for Medicare Advantage (MA) and Part D plans. This annual announcement outlines the rates and other technical rate-setting details for the coming year as well as the final Star measures and details for Star Year 2026. In addition, the notice outlines potential changes to Star and display measures moving forward. This blog covers the non-Star issues in the Final Announcement – largely rates for 2026. On Monday, I will publish a blog in conjunction with Lilac Software on the final announcement from the standpoint of Stars changes. This will detail all the final Star measure changes, updates, and information discussed in the 2026 final MA and Part D Rule (released April 4) and the April 7 Final Announcement. 2026 MA rate proposal When the outgoing

Trump administration does not adopt much of Biden’s proposed 2026 rule As expected, the Trump administration has finalized some but not all of the former Biden administration’s massive proposed 2026 Medicare Advantage (MA) and Part D rule it issued in late November shortly before Biden’s term ended. In many ways, the proposed rule from Biden was a shot across the bow to Trump, laying out Biden’s views on key policy issues within MA and Part D. As is customary, succeeding administrations tend to scrutinize rules proposed or finalized late in the previous administration’s term and usually rescind, change, or modify proposals. This is because of philosophical differences as well as the sheer volume of rules that a new administration needs to go through in the first few months of settling in to govern. It is clear in the final rule for 2026 MA and Part D that the new Trump

The GOP’s annoyance regarding benefit and coverage rich states could drive some budget reconciliation cuts President Donald Trump and GOP leaders in Congress have seemingly ruled out or at least backed away from major changes to Medicaid that would impact coverage. And sentiment seems to be turning away from deep Medicaid cuts. The House’s large GOP budget reconciliation healthcare spending reduction bogey is being challenged by the Senate, which has drafted a reconciliation framework with reductions that would be much smaller. But many GOP leaders and conservative think tanks still want to rein in the program. Conservatives don’t love Medicaid. Their philosophy is that it is a handout. In their minds, healthcare is a commodity — something you budget for and earn over time as your income climbs. If they were to cover someone’s illness, it is done behind the scenes (through Medicaid slush funds to powerful hospitals in big

There is no question the size of government and workforce needs to be pared, but the outright attacks on and ongoing insinuation about the role of federal workers is troubling. Many of you wrote in to thank me for my dispassionate take on President Trump and his assertion of executive power on his return to office. As always, I appreciate the comments and reactions. Many of you felt I put what was occurring in context with what other presidents have done on both sides of aisle. As well, you appreciated the balanced assessment of what was happening. In that blog, I concluded that, while some of what Trump was asserting is not unreasonable, the speed and scattershot nature of the endeavors were issues and that major fallout could occur on many fronts, including on services to Americans. You can see that full blog here:  https://www.healthcarelabyrinth.com/trump-tests-limits-of-power-by-stretching-article-2-of-the-constitution/ . If you prefer podcasts,

Are the doubters or supporters right about Medicare Advantage? The Cigna Group officially closed its $3.3 billion sale of its Medicare lines of business to Health Care Service Corporation (HCSC) on March 19. The deal includes Medicare Advantage (MA) lives, Medicare Part D lives, its Medicare supplement business, and its CareAllies physician entity. HCSC jumps to 950,000 members from about 240,000 members as of March 1, 2025. It is a phenomenal development for HCSC, a mutual non-profit Big Blue in the Midwest. It is now the seventh largest MA plan by membership. If you look at the old Cigna enrollment and the old HCSC enrollment, they largely do not overlap and HCSC now has a nice national MA footprint. What does this tell us about MA? But what does this big MA life sale tell us about the industry and its perceived value to insurers? The sale certainly shows a

SNPs are seeing huge growth despite the financial crisis hitting MA The Medicare Advantage (MA) industry is going through very tough financial times. A variety of factors, including rate cuts, an increase in utilization, and a new risk scoring model, forced plans to reduce benefits and exit many geographies in 2024 and 2025. Even a proposed slight increase in rates in 2026 (unless changed by the new Trump administration) will likely lead to more benefit reductions and contraction in 2026. What MA plans did was shed unprofitable geographies and products, including more rural and suburban areas of the country and certain more-expensive preferred provider organization (PPO) products. But along the way, MA plans have doubled down on Special Needs Plan (SNP) investments. The investment in SNPs is driven by a few factors: So, SNPs offer MA plans the ability to improve health outcomes while also registering a healthy margin. But