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Proposed Rule Reforms Provider Directories, PBMs The Centers for Medicare and Medicaid Services (CMS) proposed a far-reaching rule that tackles years-long issues with Medicare Advantage (MA) networks and provider directories, medication compliance, and pharmacy benefits manager (PBM) compensation. These provisions were largely in the 2026 appropriations bill. In terms of provider directories and networks, CMS proposed these reforms for MA plans: PBM reforms include: Regarding medication adherence, the rule codifies a reduction in generic drug copayments for dual eligibles at or below the federal poverty limit from a $1 maximum to $0, beginning Jan. 1. The removal is expected to improve medication compliance. Additional articles: https://www.fiercehealthcare.com/regulatory/cms-proposes-ma-ghost-network-pbm-transparency-requirements and https://www.beckershospitalreview.com/legal-regulatory-issues/cms-proposes-public-scores-for-medicare-advantage-provider-directories-flat-fee-limits-for-pbms/  and https://www.cms.gov/newsroom/fact-sheets/medicare-program-implementation-sections-6219-6220-6224-consolidated-appropriations-act-2026-cms #medicareadvantage #healthplans #pbms #providers #dualeligibles #partd #providerdirectories #networks #transparency https://www.modernhealthcare.com/politics-regulation/mh-cms-medicare-advantage-provider-directory-pbm/ Centene Expands CHOICE For Employees, Enrollees Centene is going all in on the Custom Health Option and Individual Care Expense Arrangements (CHOICE) healthcare program, which was formerly known as Individual

Medicare Advantage 2027 Retrenchment Examined In a new analysis, actuarial and consulting firm Wakely finds that more than 6.3 million Medicare Advantage (MA) members (almost 19%) are affected by plan terminations or crosswalks for 2027. Wakely says approximately 3 million members (about 9%) are enrolled in plans that will close without an automatic transition to another plan. Others had their plan ended, but moved to another plan within the sponsor. In some cases, those plans fit the members’ needs. In other cases, they may not. Wakely also reported on the major growth in Chronic Care Special Needs Plans (C-SNPs). They increased 34% from 2026 to 2027, following 56% growth in 2026. These are disease specific plans that do not have all of the strict compliance rules that Dual Eligible SNPs (D-SNPs) have. The government wants to force the C-SNPs to obey many of the same rules as D-SNPs. Wakely also

Trump Admin Continues Culling Exchanges The Trump administration announced two initiatives to further reduce Exchange enrollment. A new proposed rule would set stricter definitions of who qualifies for tax credits, toughen eligibility verification requirements, and further narrow access to financial assistance for noncitizens. Under the proposal, the federal government would not extend subsidies to people who lose Medicaid coverage due to noncompliance with the work requirements, regardless of income. Further, the Trump administration announced it has cut subsidies for 189,000 people after it found duplicate beneficiaries on Medicaid and Medicare as well as enrollees who were deceased. About $738 million will be saved in improper payments. Another 3,500 could be culled. Last, healthcare policy group KFF finds that enrollment on the Exchanges dropped by more than 4.5 million people over the past year. Enrollment fell from 25.2 million in 2025 to 20.5 million in June 2026, an 18 percent drop.

UnitedHealth Group Reports Strong Financials UnitedHealth Group, the nation’s largest insurer, reported $4.1 billion in profit for Q3 2026, up from $2.3 billion in Q3 2025. And YTD 2026 profit is now $15.9 billion vs. $12 billion through Q3 2025. Revenues dipped slightly year over year in Q3 to $112.7B, in part due to lower Medicare Advantage (MA) enrollment. Revenue is up through three quarters. United saw improvement in its medical loss ratio (MLR) in Q3, reporting 88.4%, driven by medical cost management, benefit design changes, pricing discipline, and care delivery enhancements such as integrated value-based care. Services subsidiary Optum’s earnings increased 48% to $3.7 billion. Executives said they are confident heading into MA’s open enrollment and see opportunities for growth in lucrative markets, including Special Needs Plans (SNPs). United sees great pressures from the No Surprises Act arbitration process. In other news, Humana will enter into a joint venture

Stars News: Clover Gets Special Treament; Alignment Sues Coming off of Thursday’s 2027 Star Ratings release, two major developments have occurred: (1) Clover Health got special treatment in Star Year (SY) 2027 calculations and (2) Alignment Healthcare is suing the Centers for Medicare and Medicaid Services (CMS) over its 2027 ratings. In a release, Clover Health noted that CMS calculated its 2027 Star rating for its PPO plan by excluding the 20 measures a judge struck in Clover’s 2026 Star Ratings lawsuit. It was the only Medicare Advantage (MA) contract to get such treatment. All others were rated on all 45 measures. CMS hid the change from other plans until it became known in the Clover release. Clover received a 5.0 rating for the contract. Alignment Healthcare sued CMS today over its 2027 ratings, alleging they were determined “in flagrant violation” of statute. Alignment has filed in the same federal

AHA Sues On 340B Pilot The American Hospital Association (AHA) has again sued a federal regulator to block the second 340B rebate pilot, set to begin January 1. Hospitals say it will cost them more than $1 billion because the regulation underestimates labor hours and implementation expenses. The first pilot was struck by a court. The government issued a second regulation. All 340B covered entities will be in the pilot for certain in-scope drugs. Studies suggest the facilities do not pass on discounts to needy Americans. The suit seems like a stretch, but who knows what will happen in a post-Chevron legal world. #340b #drugpricing https://www.modernhealthcare.com/politics-regulation/mh-aha-hrsa-340b-rebate-pilot-lawsuit/ Stars Results Details More news on the 2027 Medicare Advantage (MA) Stars front since Thursday’s release. I will have a deep-dive blog on Monday. Humana, which suffered a major ratings collapse two years ago, saw its percentage of members in 4+ Star plans skyrocket to

SY 2027 Medicare Advantage Star Ratings Released Medicare Advantage Star Ratings are out for SY 2027 and the news is not great. In general, the industry performed somewhat lower than SY 2026 despite those surges in cut points coming out of Plan Preview 2. The data below compares Sy 2027 to the revised “better of” ratings for SY 2026. Additional article: https://www.beckerspayer.com/payer/medicare-advantage-plans-with-5-stars-in-2027/ #medicareadvantage #stars #quality #cms https://www.fiercehealthcare.com/payers/cms-about-71-mapd-plan-enrollees-coverage-four-or-more-stars-2027 Medicare Advantage Reform Researchers at RAND surveyed Medicare Advantage experts about potential policy ideas and reforms. Showing the complexities of reform, the survey didn’t identify a single policy proposal that rose to the top and would benefit the three stakeholder groups surveyed. Three themes did rise to the top in terms of benefiting enrollees without significant disruption for plans or the government. #medicareadvantage #reform https://www.fiercehealthcare.com/regulatory/look-stakeholder-perspectives-medicare-advantage-reform Other Healthcare News A number of other healthcare topics from today: Prime Therapeutics, one of the largest pharmacy