publicoption

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

Hospitals Penalized For Readmissions The Centers for Medicare and Medicaid Services (CMS) announced that 2,334 hospitals, about 80% of those evaluated, are being penalized under the Hospital Readmissions Reduction Program in fiscal 2027. CMS said 244 hospitals, or 8.4%, received penalties of 1% or more. Ten hospitals will face the maximum 3% penalty, with 34 facing penalties of 2% or more. Most hospitals — 71.8% — will see penalties below 1%. The share of hospitals receiving no penalty will drop to 19.8% (578 hospitals) from 21.8% (641) in 2026. The Fiscal 2027 round of penalties used both Medicare Advantage and fee-for-service data, but penalties continue to apply only to traditional Medicare payments. The performance period included discharges from July 1, 2023, to June 30, 2025. #hospitals #quality #readmissions https://www.beckershospitalreview.com/finance/cms-penalizes-2334-hospitals-for-high-readmissions-6-things-to-know/ Health Plan Enrollment Declines Health insurers’ membership declined 2.8% year-over-year to about 312.5 million people in 1H 2026. Losses in the

Insurers Backing Away From Medicaid Given the looming budget cuts to hit Medicaid over the next decade, there are signs that some health plans are backing out of certain Medicaid managed care contracts. Insurers such as Centene and Elevance Health have walked away from Medicaid managed care contracts as costs rise. This has led to other plans picking up the slack in affected states. Providers complain that successors may not have enough providers in their network. Plans have said there are some good signs coming from certain states who are increasing rates to deal with financial problems in managed care. Louisiana increased rates. It appears that Arkansas and D.C. may have done so as well. #medicaid #managedcare #obbba https://www.modernhealthcare.com/insurance/mh-centene-elevance-medicaid-states-providers/ Optum and Express Scripts Grow Pharmacy benefits managers (PBMs) Optum Rx and Express Scripts each hold 23% of the PBM market, up from 21% and 17%, respectively. CVS Caremark fell from

Stricter Price Transparency The Trump administration finalized its proposed rule that would make the data files mandated under price transparency regulations more usable. The Centers for Medicare & Medicaid Services said the regulation will improve the standardization, accuracy, and accessibility of the data plans and hospitals submit. It also would hold healthcare entities accountable for submitting incomplete or inaccurate data. In addition, Federal Trade Commission (FTC) Chairman Andrew Ferguson said his agency will crack down on hospitals that are not providing complete and accurate price data, whether or not they are compliant with CMS’ transparency requirements. The FTC noticed 24 large hospitals and health systems for potential violations of consumer protection laws. In part, the regulation removes the submission of junk data tied to  infrequently applied rates or ghost networks. The administration did not finalize certain proposals that would have made price disclosures even more robust. Additional articles: https://www.fiercehealthcare.com/regulatory/cms-finalizes-updates-price-transparency-regulations-aim-improve-usability and

PDP Premium Increases And Hidden Hurt Healthcare policy group KFF examined the standalone Part D (PDP) market. Of course, the Trump administration says the end of the suspect premium stabilization program will not mean major impacts to beneficiaries, but hidden hurt can be seen in the details. KFF finds that PDP availability and premiums for 2027 show a mixed picture. There are modest premium increases for many Part D enrollees for their current plan, but steeper increases are in store for others. There also is a reduction in the number of PDP options for the fourth year in a row. KFF’s key takeaways include: In related news, Devoted Health has garnered major financing for expansions of their Medicare advantage business. Additional article: https://www.beckerspayer.com/payer/medicare-advantage/devoted-health-closes-1-2b-financing-deal-amid-expansion-push/ #partd #pdp #kff #medicare https://www.kff.org/medicare/many-medicare-part-d-stand-alone-drug-plan-enrollees-will-see-modest-premium-increases-for-2027-but-others-could-pay-much-more-if-they-dont-switch-plans/ 340B Pilot Proceeds After an initial failure and a second published rule, the Health Resources and Services Administration is ready to launch

More MA Retrenchment News Articles and analyses continue on the recent release of the landscape files and now with the go live of 2027 benefits on the Medicare Plan Finder. These new assessments continue to speak to the commotion under the seeming stability. Of large plans, only one, Molina, is fully exiting Medicare Advantage (MA) mainstream coverage. It will continue to offer Special Needs Plans (SNPs). Second-place Humana has the largest county footprint (2,694) followed by leader UnitedHealthcare (2,655). But all of the major plans are paring considerably in certain counties, while growing in others. For the most part, most big plans have modestly smaller overall offerings, with Centene being an outlier. Analyses now seem to say that the largest number of people ever will face terminations of their existing plans. Numbers vary, but the impact loosk to be 3 million or more. MA plans argue they are preserving core

GLOBE Model Finalized The Centers for Medicare and Medicaid Services (CMS) finalized GLOBE, a mandatory five-year model linking Medicare Part B drug prices to cost benchmarks in 19 developed countries. The program starts in January and lasts for five years. The model targets drugs in oncology, rheumatology, immunology, ophthalmology and endocrinology. The parallel Part D program is not yet finalized. The models build on various initiatives undertaken by the Trump administration. Two problems here: GLOBE will reduce fee-for-service costs and effectively reduce Medicare Advantage payments without giving plans any lower costs. This could further reduce benefits in the program over time. As well, the final rule exempts from the model drug manufacturers in the parallel GENEROUS model for Medicaid. Drug makers struck price deals in Medicaid with the president. While I support Trump’s overall efforts, I think that is a mistake. Additional articles: https://www.modernhealthcare.com/politics-regulation/mh-cms-globe-medicare-part-b-drug-model/ and https://www.beckershospitalreview.com/pharmacy/cms-finalizes-new-drug-pricing-model-7-notes/ #drugpricing #partb #partd #medicare

More On MA Retrenchment More details on the Medicare Advantage (MA) landscape files and the depth of retrenchment for 2027. In total, the number of MA plans to be offered will only drop from 5,553 in 2026 to 5,532 in 2027. But that hides the impacts of adds and cuts. The number of impacted enrollees looks much bigger than anticipated. A Modern Healthcare analysis finds that the number of individual MA with Part D prescription drug coverage (MA-PD) products will decline 8% in 2027. Further, it says that there will be 181 counties with no plans next year, up from 67 this year. And at least 3.8 million people will be forced to select new coverage after their insurers terminate a plan. Various analyses peg 2026 impacts at between 2.9 million and 4.6 million. I think the 2027 impact will be closer to 3M — still a shock for me.