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CMS Finalizes Sweeping Exchange Rule The Centers for Medicare and Medicaid Services (CMS) finalized its sweeping 2027 Affordable Care Act and Exchange rule today. While a few items were not finalized, most of the major items that will dramatically change offerings were. The agency says the rule is an effort to bring down premiums, increase choice, and address fraud. Critics say it will erode enrollment and benefits. The changes include: (Article may require a subscription.) #exchanges #aca #obamacare #trump #regulations #coverage #healthcare https://www.modernhealthcare.com/politics-regulation/mh-cms-aca-exchange-rule-2027-final Plans, Providers Want A Targeted Fraud Approach In response to a request for information on stemming fraud in government programs, providers and payers are each urging some caution. Providers say the Centers for Medicare and Medicaid Services (CMS) should move cautiously to implement its anti-fraud strategy rather than apply a uniform approach across the board. They want reforms focused on high-risk activities so as not to further

Internal CMS Memo Shows Growing Exchange Falloffs NOTUS obtained an internal Centers for Medicare and Medicaid Services (CMS) memo that says more Americans are dropping out of Exchange coverage than usual. The memo says more than one in five people who enrolled in health insurance through the federal Exchanges during open enrollment and in the weeks following were dropped from coverage for failing to pay their first month’s premium. This rate is significantly higher than the rate from last year, which was 12%. The administration attributes most of the drop to efforts to root out fraud. That could be some of it, but companies also report dropping enrollment since January due to non-payment. Premiums surged when enhanced subsidies lapsed. This occurred for those subsidized as well as more generally as companies increased rates across the board to mitigate an anticpated increase in risk and surging utilization costs. (Article may require

Plans Launch New Ad Campaign On NSA Disputes A new health plan ad campaign takes aim at the No Surprises Act (NSA) law and its arbitration component. It says that the dispute processes “create a ‘fox guarding the hen house’ dynamic.” Data show that providers are far more likely to win (87% of the time) and earn significantly higher payouts than payments before the law. It is driving overall healthcare costs up. Further, it is subject to abuse, with five organizations accounting for 63% of disputes in the first half of 2024: Team Health, SCP Health, Radiology Partners, AGS Health and HaloMD. Plans have sued but it will take the courage of Congress to fix his problem. #nosurprisesact #transparency https://www.fiercehealthcare.com/payers/new-payer-backed-ad-campaign-pushes-no-surprises-act-idr-reform Administration Attacks Fraud The Centers for Medicare and Medicaid Services (CMS) announced two fraud initiatives. First, CMS and the Department of Health and Human Services (HHS) issued an ultimatum to

Makary Resigns At FDA Food and Drug Administration (FDA) Marty Makary, M.D, is out at the agency, having resigned under pressure from Health and Human Services (HHS) Secretary Robert F. Kennedy, Jr. The move was approved by the White House. The last straw appeared to be Makary’s reluctance to approve fruit-flavored e-cigarettes given the potential for abuse by minors. Critics argued that Makary lacked government experience and did not lead the agency well. Others say he rightfully pushed back on certain administration initiatives he deemed wrong-headed. I won’t get into the saga, only to say that Makary was dealt a poor hand, with layoffs and huge cutbacks at a time of great political volatility for the agency. Such appointments don’t always work out for the principled person. I am a supporter of Makary, who I have been connected with for over five years now. (He endorsed my book when it

United Moving To Transparency For Its PBM UnitedHealth Group Inc. said it will change its profit structure at pharmacy benefits manager (PBM) Optum Rx. The company handled about 1.7 billion prescriptions last year. Optum Rx plans to shift to a more transparent fee structure that gives clients clarity into payments the PBM gets from drug makers. CVS Health Corp’s Caremark earlier said it would change how it pays pharmacies to make it simpler and more transparent. Cigna’s Express Scripts late last year said it will phase out rebate payments in many private health plans. (Article may require a subscription.) #pbms #drugpricing https://www.modernhealthcare.com/insurance/mh-unitedhealth-optum-rx-pbm-model Kaiser Q1 Profit Down Kaiser Permanente’s Q1 operating performance took a step back in 2026 compared to Q1 2025, although investments and other sources of income offset the bad news. Non-profit Kaiser booked over $2 billion in profit. The integrated delivery system and health plan reported operating income

Exchange Insurers Report On Program Challenges First quarter results for insurers with Exchange lines of business had two trends. First, there generally was lower enrollment because people exited the market due to surging premiums and expiring subsidy enhancements. Second, people moving to less costly and trimmer Bronze and Catastrophic plans. The health insurance companies expect aggregate Exchange enrollment will shrink by at least 20% over the course of the year as more drop out due to affordability. Oscar Health bucked the trend in terms of enrollment growth. Additional articles: https://www.fiercehealthcare.com/finance/aca-exchanges-dominated-q1-earnings-calls-heres-what-payer-health-system-execs-had-say (Some articles may require a subscription.) #exchanges #healthplans https://www.modernhealthcare.com/insurance/mh-aca-enrollment-centene-molina-cigna-oscar Various Rx Studies and Reviews A number of blogs and white papers on various pharmacy developments: Additional articles:  https://www.healthaffairs.org/content/forefront/understanding-cms-s-proposed-rule-regarding-prior-authorization-drugs and https://www.healthaffairs.org/content/forefront/most-favored-nation-drug-pricing-anchoring-moving-target and https://www.healthaffairs.org/content/forefront/amgen-s-retreat-denmark-repatha-and-collision-course-us-mfn-pricing-policy (Some articles may require a subscription.) #priorauthorization #mfn #drugpricing #medicaid #medicare #medicareadvantage #partd https://www.kff.org/medicaid/a-look-at-the-generous-model-and-factors-that-could-impact-medicaid-drug-costs/ — Marc S. Ryan

CMS Could Auto-Enroll Seniors In MA or ACOs STAT reports that the Centers for Medicare and Medicaid Services (CMS) is currently mulling a plan that would automatically enroll beneficiaries into either Medicare Advantage (MA) plans or traditional Medicare Accountable Care Organizations (ACOs). The House GOP has shown interest in the proposal as have a number of right-leaning think tanks. The move would be consistent with CMS’ desire to radically expand value-based care (VBC) penetration in Medicare. #medicareadvantage #acos #vbc https://www.medpagetoday.com/publichealthpolicy/medicare/121161 Wash Post Covers Medicaid Enrollment Drops The Washington Post says Medicaid enrollment continues to drop. Medicaid enrollment has declined by about 3.4 million between January 2025 and January 2026. The newspaper says that application approval timing is taking longer and procedural related reasons for disenrollment were up. As well, applications are down. The immigration crackdown could be part of the reason. All of this is before the changes in the