pricetransparency

MA plans may cheer the delay on supplemental benefits notifications, but it could work against them over time The Centers for Medicare & Medicare Services (CMS) announced in a short notice published in the Health Plan Management System (HPMS) that it is delaying enforcement of Medicare Advantage (MA) supplemental benefits notification requirements. It says it will reconsider the regulatory requirements. Background on recent reforms In light of the ongoing controversy over the surge of rebates in the rate-setting program and the inability to determine how much of the extra dollars are truly spent on added benefits, CMS instituted two key reforms. First, it clarified ambiguity about whether supplemental benefits must be submitted as encounter data. It now requires all benefit utilization to be submitted as such. This has led to a very complicated directive from CMS to MA plans on how to submit such data. Many supplemental benefits are not

Price disparity with other countries underscores need for reform A quick blog on a recent Peterson-KFF Health Tracker Chart Collection comparing U.S. healthcare prices and utilization against those in other developed nations. I like these periodic looks at prices and utilization throughout the developed world because it reveals at least one of the biggest reasons our healthcare system is in crisis or at least tumbling toward it. In my book, The Healthcare Labyrinth, I make the case that three key reforms are needed to the healthcare system – price reform, affordable universal access, and a pivot to primary care and care management. In many ways, the three go together. As an example, price reform is needed to ensure affordable universal access. And only with affordable universal access can we really get back to the rebuilding of primary care, wellness, and prevention. Wellness and prevention mean care at lower cost settings,

A new risk adjustment study could lead to momentum to pass reforms I have written about Medicare Advantage (MA) risk adjustment (RA) overpayments before, but a new study has me thinking again whether the time really has come for RA reform. Many studies paint MA overpayments with a broad brush, saying the entire system is over-reimbursed. But a new study backs up something I have said for a long time – that a small number of larger MA plans receive a disproportionate benefit from these RA overpayment schemes by using aggressive or even fraudulent coding. The study by the Alliance of Community Health Plans (ACHP), a group that represents local and regional nonprofit payers, finds something similar to a few other studies that have zeroed in on the real culprits giving all of MA a bad name. ACHP’s study finds that UnitedHealthcare, the biggest MA insurer, collected up to $785

I am beginning a Medicare Advantage contraction counter as we move toward open enrollment and 2026 Given the ongoing financial challenges for insurers in general but specifically in Medicare Advantage (MA), we have already seen announcements of many high-profile contractions for 2026. In my August 14 blog here ( https://www.healthcarelabyrinth.com/what-is-in-store-for- medicare-advantage-in-2026/ ), I tell you all about the challenges and my prediction that contraction will be heavy but not what it was in 2025. I am already thinking my prediction could be wrong here given the recent announcements. We could in fact see contraction that comes close, rivals, or even exceeds what we saw in 2025. Thus, periodically I will write a quick blog – here is installment 1 – tracking the announced MA contractions for 2026. 2025 contraction overall To refresh your memory on what happened in 2025, here are some important statistics for an alarming downsizing by plans:

The GOP is not wrong about the need to bring accountability to government programs I have taken the position that most of the reductions to healthcare in the One Big Beautiful Bill Act (OBBBA) were simply bad policy, but a number of you have asked me about my comments throughout the budget saga that some changes were reasonable. Others have asked why I have been mentioning the conservative Paragon Health Institute quite a bit. Paragon’s cadre of staff and fellows have populated key healthcare positions in the White House and healthcare agencies under Trump 45 and 47. Many of the reductions in the OBBBA came from Paragon positions. Let me answer the second question first. While I may not agree with everything Paragon trumpets, the think tank has rigorous policy discipline, and you have to respect that. They, too, are an influential player and I would be foolish not to

While the No Surprises Act is helping Americans avoid surprise bills, it is fundamentally flawed and driving costs Since the No Surprises Act (NSA) was passed in late 2020 and went into effect beginning January 1, 2022, I have argued that the baseball-style arbitration process in the law is heavily stacked against health plans and favors providers. While the bill certainly stops Americans from receiving surprise bills, there is little question to me that the bill itself has and will continue to increase costs in the healthcare marketplace. A few new studies show the pros and cons of the bipartisan legislation. Let’s take a look at them. The pros As I note, the NSA has saved so many from exorbitant out-of-network (OON) bills. That is a good thing. While not every surprise bill has been stopped (e.g., ground ambulances), OON abusive billing for all emergency care and most surgery or procedures

Two big forces are coming together to erode coverage and increase the uninsured and underinsured It has been on my mind of late that two forces are coming together to further erode coverage in America. Surging utilization The first is surging utilization. Some of it can be explained – a return to normal post pandemic utilization, increased expensive drug introductions, aging and more. But some of it cannot. While healthcare actuaries anticipate a slowing of annual healthcare growth in a few years, I think we could be in a new era of even more robust annual spending. After all, right now we are seeing cost spikes of 6% to 9% a year. This is especially true for employer and commercial coverage. When utilization spikes, as much as employers try to protect employees, more costs are foisted upon workers or coverage evaporates. OBBBA’s impact The second is the coverage losses in

Trends impacting health plans point to the need for major transformation It is summer and people are awaiting the one last respite of Labor Day before the hustle and bustle of life and work increase again. So, I will keep this week’s blogs short – short that is for me. The truth, though, is that the hustle and bustle have already hit healthcare this summer, which is certain to complicate many of our lives this Fall. Healthcare changes impacting health plans With all that has gone on since Donald Trump returned to office, I thought it might be good to summarize the health plan landscape. Here goes: What will the coming impacts be? Plans already had a relatively long road to financial recovery, but the OBBBA, MA risk adjustment audits, other possible MA risk adjustment changes, and the all-LOB PA reforms could create even more overall uncertainty even with the

Washington continues with talk of a second budget reconciliation bill coming sometime later this year. The impetus comes from a few things. There is pressure within the two Republican caucuses to seriously deal with rising deficits and enact deeper spending cuts. The One Big Beautiful Bill Act (OBBBA) cut healthcare by over $1 trillion. But due to new tax cuts and extensions, the deficit over the ten-year budget horizon goes up by $3.4 trillion, more if you include interest costs. The debt limit was actually increased by $5 trillion in the bill. And the U.S. government has just hit total debt of $37 trillion. The other issue is a political one. Conservative members of the GOP caucuses say they got explicit promises that they will have a shot at passing deeper healthcare cuts later this year. They indicate the commitments came from the president and their leaders in each chamber

A quick blog to tell you about enrollment growth in Medicare Advantage (MA) from July 2025 to August 2025. MA growth slowed down from 2024 to 2025 because of the financial woes of the MA industry. But the rolls are still growing due to aging and the popularity and value of MA compared with the archaic traditional Medicare (fee-for-service) program. What do the latest statistics show? Growth from January 2024 to February 2025 was 4.39% or 1.468 million. (I used February 2025 because of issues with the January 2025 statistics). Enrollment in MA reached 34.941M in February 2025. In August 2025, it reached 35.528M. MA enrollment grew about 91K from July to August and about 587K from February to August. How did Big MA do? From January 2024 to February 2025, Big Plan MA enrollment performed very poorly because of retrenchment among some of these plans. Big MA grew by