republicans

Proactive Enrollment Caps Could Be Used in MA in 2027 The Centers for Medicare and Medicaid Services (CMS) is now allowing Medicare Advantage (MA) plans to file for prospective enrollment caps in 2027 that could be used as a way to limit financial exposure. It could be yet another tool in the toolbox for plans seeking to stay in an area but fearful of too much risk. CMS says it will help stem further exits in areas. It appears existing regulatory authority is being used, perhaps more expansively. Previously, CMS only approved caps after an insurer’s enrollment ballooned to a point at which members’ health and safety was jeopardized. Network Health has applied for such a cap in 2027. Several protections exist in the regulation. #medicareadvantage #enrollment https://www.modernhealthcare.com/insurance/mh-medicare-advantage-enrollment-caps-2027-cms/ Hospitals Bemoaning Expansion Of Site Neutral Payments A number of hospitals are bemoaning the potential impact on the expansion of site neutral

Prominent Health Plan, PBM, And Provider Fraud Lawsuits A number of alleged fraud lawsuits have been filed recently, including the following: The Villages (Fla.) Health, a primary and specialty care provider group, has agreed to pay $541.5 million to resolve allegations it violated the False Claims Act (FCA) by submitting improper Medicare Advantage (MA) diagnosis codes. Similarly, Monogram Health agreed to pay $2.4 million to resolve allegations that it violated the FCA by submitting false diagnosis codes to increase payments in MA. Maryland’s attorney general filed a lawsuit against UnitedHealth Group and Optum, seeking $380 million in damages stemming from alleged issues administering Medicaid behavioral health. Florida’s attorney general sued Express Scripts and Prime Therapeutics, alleging arrangements between the two pharmacy benefits managers allowed Prime Therapeutics to improperly cut pharmacy payments by up to 20% and pass on savings to Express Scripts. Additional articles: https://www.beckerspayer.com/legal/villages-health-to-pay-541-5m-to-settle-medicare-advantage-fraud-allegations/ and https://www.beckerspayer.com/legal/maryland-sues-unitedhealth-for-380m-over-medicaid-administration-issues/ and https://www.healthcaredive.com/news/the-villages-health-medicare-overbilling-settlement-doj-humana/828915/ and https://www.modernhealthcare.com/insurance/mh-express-scripts-prime-therapeutics-florida-antitrust/ and https://www.modernhealthcare.com/legal/mh-villages-health-system-doj-settlement/ and

Plans, Providers Urge Rejection Of State-Directed Payments Rule Health plan and provider groups are joining together to oppose the Trump administration’s draft regulation implementing state-directed payment reforms and limitations in Medicaid. Changes were made in the One Big Beautiful Bill Act (OBBBA), but opponents say the draft rule goes well beyond what the statute outlines. The plans and providers may be right about the rule exceeding statutory authority. At the same time, the use of state-directed payments have been abused and do need to be reined in. #medicaid #obbba #coverage https://www.modernhealthcare.com/politics-regulation/mh-cms-medicaid-state-directed-payments-rule-pushback/ NSA Dispute Costs $22 Billion A new analysis from Georgetown University finds that total costs associated with the No Surprises Act’s dispute resolution process reached $22.4 billion at the end of 2025 after four years of the law. About $15.6 billion came from payments to providers that exceeded in-network rates. In addition, $4.2 billion came from administrative costs. About

Medicaid GLP-1 Program Getting Little Traction President Donald Trump’s deal offering states discounted pricing on GLP-1 drugs for Medicaid patients is getting little traction. Only Indiana has publicly signed on, while 29 state Medicaid programs have said they will not participate and 14 more did not respond. States are citing budget costs if they joined. #glp1s #weightlossdrugs https://www.beckerspayer.com/payer/medicaid/states-reject-trumps-discounted-medicaid-glp-1-deal 2025 Health Plan Losses An analysis by Mark Farrah Associates says health insurers collectively lost $10.4 billion on underwriting in 2025 in the individual, employer-group, Medicare Advantage (MA) and managed Medicaid segments, a dramatic deterioration from $1.7 billion the year before. The individual and MA segments accounted for the bulk of the underwriting losses. The analysis represented about 80% of the industry. #healthplans #margins https://www.beckerspayer.com/financial/health-plan-underwriting-losses-balloon-to-10-4b-report Coming Medicaid Woes Despite some financial stability in 2026 at Medicaid health plans, the story could soon change as Medicaid work requirements and coming limits on state

Moody’s Calls Health Plan Recovery Uneven And Challenging Bond rater and investment analyst Moody’s published a report on health plan finance and it echoes much of what I concluded from Q2 financial announcements — there are positive signs coming out of the results but pressures and challenges remain. Overall, Moody’s says health plans surpassed investors’ expectations and most boosted their outlook, but high medical costs are still a key factor in recovery. Margin recovery and executing on financial plans to meet investor demands remains a challenge and is uneven across plans. Interestingly, it notes that “… a significant portion of the quarter’s margin improvement reflected favorable prior-year reserve development and non-recurring items rather than solely underlying trend.” Moody’s notes that Medicare Advantage (MA) is one of the biggest challenges, with exits from underperforming markets and retrenchment focused on higher margin populations. Products and benefits have been repriced. It opines that

Scan Execs Frame What Needs To Be Done With Stars A great Healthcare Forefront blog by Scan CEO Sachin Jain and his chief legal officer discussing the current state of Medicare Advantage (MA) Stars, the various litigation, what is wrong with the Centers for Medicare and Medicaid Services’ (CMS) approach, and what the agency should do about it. They argue CMS has made the program such that sophisticated plans cannot reliably reconstruct how a score is produced. It notes the legal quandary CMS finds itself in post the Clover decision. The Scan execs argue that CMS needs to step back and remake the system based on a smaller number of clinical measures and member experience. As they note, CMS is moving toward this with the SY 2029 restructure. CMS now needs to correct the legal and regulatory deficiencies. #medicareadvantage #stars #quality #cms https://www.healthaffairs.org/content/forefront/stars-docket-medicare-advantage-quality-ratings-trial CMS Pushing Exchange Disenrollments The Centers for

More Carriers To Reduce MA Footprint in 2027 Humana and Centene both announced they will reduce their Medicare Advantage (MA) footprint in 2027. Centene will exit in Oklahoma, Tennessee, and Hawaii, cut 158 counties and cancel 133 plans, impacting 340,000. Humana will reduce its county penetration and impact 600,000. All this is tied to a retrenchment to get to profitability. #medicareadvantage #margins #enrollment https://www.modernhealthcare.com/insurance/mh-centene-medicare-advantage-plans-states Aon Says Employer Healthcare To Rise Almost 10% A clear data point that healthcare costs remain out of control. Aon estimates that employer healthcare costs will rise 9.5% in 2027, averaging more than $19,000 per employee. Aon says the surge is tied to higher patient volumes, more individuals with chronic conditions, and more expensive prescription drugs. Hikes were 9.5% in 2026, 9% in 025 and 8.5% in 2024. Additional article: https://www.modernhealthcare.com/insurance/mh-employer-healthcare-costs-2027-aon/ #employercoverage #costs #healthcare https://www.beckerspayer.com/financial/employer-healthcare-costs-to-top-19k-per-worker-5-things-to-know/ Oregon Approves Huge Exchange Premium Surge Oregon regulators approved an average 21.6%