pepfar

Judge Strikes Piece of Work Requirements Regulation A federal judge backed a coalition of states in an ongoing lawsuit over the rollout of Medicaid work requirements. It struck the Trump administration’s definition of “medical frailty” for critical exemptions. The judge said a regulation unlawfully limited the group of people who would qualify as “medically frail” and would thus be exempted. The Centers for Medicare & Medicaid Services (CMS) regulation said that the frailty exemption would apply when a “physical, mental, or other behavioral health condition significantly impairs the individual’s ability to comply with the community engagement requirement.”  States will receive a six-month enforcement stay on medical frailty determinations, as the ruling may require changes to verification systems. The remainder of the work requirements rule stays intact for a Jan. 1 implementation timeline. Additional articles: https://www.fiercehealthcare.com/payers/26-states-sue-cms-over-final-medicaid-work-requirements-rule and https://www.beckerspayer.com/payer/medicaid/judge-rules-cms-overstepped-on-medically-frail-definition-for-medicaid-work-requirements/ and https://thehill.com/policy/healthcare/6182258-judge-strikes-trump-medicaid-definition/ #medicaid #workrequirements https://www.modernhealthcare.com/politics-regulation/mh-court-cms-medicaid-medical-frailty Trump Admin Finalizes PBM Reform For Employers The

CMS Will Grant Flexibility In Implementing Medicaid Work Requirements Notwithstanding the fact that the Trump administration cheers its passage of work requirements in Medicaid, the Centers for Medicare and Medicaid Services (CMS) is now offering states flexibility to ease implementation. A new CMS memo outlines steps states can take to get federal approval for mitigation plans to address readiness gaps. The plans states submit must outline the risks they see and how they will indeed implement the requirements. States are required to have Medicaid work requirements in place by Jan. 1. #medicaid #workrequirements https://www.modernhealthcare.com/politics-regulation/mh-cms-states-medicaid-work-requirements Exchange Footprints Modern Healthcare outlines the expansions and contraction in the Exchanges nationally. Centene, Oscar Health and Elevance Health are expanding their footprints for 2027 while others are cutting back. At least 1,200 counties will have two or fewer insurer options for 2027, up from roughly 800 this year. #exchanges #enrollment https://www.modernhealthcare.com/insurance/mh-centene-elevance-oscar-aca-exchange-2027 Insurers, Employers Want Hold

Two More Stars Suits CVS’ Aetna has become the sixth health plans to sue the Centers for Medicare and Medicaid Services (CMS) over SY 2026 and/or SY 2027 Star ratings. Aetna filed suit Monday in Georgia’s Southern District Court, the same that had the Clover suit. Aetna says 28 measures were “unlawfully adopted” and should have been excluded. The measures were adopted without notice-and-comment rulemaking and 12 also relied on data sources outside CMS’ statutory authority. The suit for SY 2027 challenges the 28 measures across 43 contracts. It relies on a great deal of the Clover decision. Aetna says the CMS actions will likely cost it $2 billion in 2028 quality bonus payments and rebate retention. Aetna asks the court to declare the inclusion of the 28 measures unlawful, order CMS to raise its scores, and award $2 billion in additional bonus payments. Scan also sued Monday on SY 2027.

Humana’s Stars Rebound Modern Healthcare has a good article on Humana’s Stars rebound. Always a great performer, it collapsed over the last few years and now is back on top of major health plans in Medicare Advantage (MA). It will gain $3 billion in 2028. Humana elevated its Star ratings by distributing its plans across many contracts, steering members toward top-rated plans and making high scores an enterprise-wide priority. #medicareadvantage #stars #humana https://www.modernhealthcare.com/insurance/mh-humana-medicare-advantage-star-ratings-2027 Republicans Embattled On Healthcare An article in The Hill speaks to the struggles Republicans are having on the stump as Democrats attack them on affordability of healthcare. As I say in a blog this coming Thursday, it could decide the election. The GOP bungled the issue. #midterms #congress https://thehill.com/homenews/state-watch/6169587-democrats-attack-obbb-medicaid-cuts — Marc S. Ryan

Centene Files Stars 2027 Lawsuit We had four 2026 Stars measure lawsuits — Clover, Elevance, Scan, and Alignment.We now have three 2027 Stars measure lawsuits — Alignment, Healthfirst, and Centene. Centene has become the latest insurer to sue over its Medicare Advantage 2027 Star ratings. Centene has filed in the same Georgia southern district as Clover and Elevance did in SY 2026. Centene argues that CMS violated the Administrative Procedure Act in determining its 2027 ratings. Centene says that CMS ran afoul of “core statutory safeguards” in deploying 17 measures. Because of that, Centene says its 4 Star and greater enrollment dropped from 18% to 9% and cost the company $448 million in quality bonus payments for payment year 2028. Centene’s lawsuit parallels the Clover one. Most importantly, Centene makes this fabulous point: CMS tacitly admits its methodology is wrong because it applied a different calculation to Clover in both

Employees See Healthcare Costs Surge Healthcare policy group KFF’s annual employer survey finds that employees now pay $7,471 on average annually for family health coverage, up 9% or $621 from 2025. Overall premiums combining employer and employee shares increased 5% or $1,310 to $28,303. Employees at small firms with less than 200 workers contribute $9,687 annually toward family coverage. That’s $2,847 more than workers in large firms. KFF finds that family premiums and workers’ contributions have risen at similar rates (28% and 26%, respectively) since 2021. This is comparable to wage and inflation growth. The average deductible for U.S. workers is approaching $2,000 before insurance kicks in. In other news, the Commonwealth Fund’s biennial insurance survey finds that the uninsured rate for working age American increased to 11.2% from 8.9%. The uninsured rate of young adults (19-34) increased from 11% to 16% over the past two years. Decreases in Medicaid

Elevance Reports Q3 Financials Elevance Health is boosting its outlook for the year as it beat The Street for Q3 2026. Elevance earned $1.4 billion in profit for the quarter, up slightly from $1.2 billion a year ago. Profits through the first nine months of the year were $4.6 billion, down year-over-year from $5.1 billion. Revenues were $50.4 billion in Q3, about the $50.1 billion from the prior year quarter. Revenues through three quarters were $149.8 billion, up from $148.3 billion a year ago. Elevance says 2026 is a “trough year” for the company’s Medicaid business and that there are positive signs in 2027. Medicaid is now ahead of outlook. But Medicaid is facing looming turbulence from the massive budget cuts that have passed impacting the next ten years. The overall medical loss ratio for the quarter was 90.6%, compared to 91.7% a year ago. The insurance unit was slightly

House Bill Would Overhaul Medicare Advantage Stars A House bill calls for the overhaul of the Medicare Advantage (MA) Stars program. Rep. Mike Kelly, R-PA, is sponsoring the Medicare Advantage Strengthening Transparency and Accountability in Rating Systems Act (MA STARS Act). It directs the federal government to rewrite Star ratings policy beginning with the 2031 contract year. CMS would have to exclude any measure that is unrelated to clinical quality, outcomes, or experience. Member surveys would be reformed. Measures that no longer distinguish performance among most contracts would be barred. New measures could be added only if they relate to clinical quality, outcomes or experience. The truth is that the Centers for Medicare and Medicaid Servies (CMS) has implemented most of the bill’s parameters. It has promulgated a rule that eliminates operational measures as well as those that do not have substantive differences between contracts. The CMS Stars restructure is

Healthcare On The Trail The midterms are two weeks away and Becker’s Payer covers how Democratic candidates are working healthcare issues into their policies and messaging and Republicans are defending themselves. Healthcare changes being discussed on the stump include: On the last issue, a Century Foundation survey of voters from earlier this year found that 67% think preventing hospitals from charging excessive prices should be a top federal priority when it comes to cutting costs. About 66% of Republicans and 71% of Democrats believe this. A Modern Healthcare articles says Republicans are attacking fraud, waste, and abuse in Medicaid and the Exchanges as a key healthcare message. A healthcare policy group KFF poll finds that the messaging resonates with 44% of voters. At the same time, Florida and Texas have about 40% of all Exchange enrollments and the GOP could be hurt here due to enrollment losses. Additional article: https://www.modernhealthcare.com/politics-regulation/mh-republicans-healthcare-fraud-midterm-elections/

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