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CMS Reins In Part D PDP Premium Stabilization Program The Centers for Medicare & Medicaid Services (CMS) released preliminary technical Medicare Part D bid information for contract year 2026. It released the national average monthly bid amount (NAMBA) and base beneficiary, which are used in bid preparation. CMS also announced it was again funding a special premium stabilization demonstration started in 2025 to keep premiums from rising dramatically. The culprit for rising premiums is largely the passage of cost-sharing limits in Part D in the Democrats’ Inflation Reduction Act. The Democrats did not adequately fund the changes and therefore pushed many of the costs to plans, which then had to increase premiums and cost-sharing and make other reductions. The IRA changes have badly impacted the financial stability of the standalone Part D offerings (PDPs). For 2026, the generosity of the demonstration will be less. In 2026, CMS is reducing the uniform base beneficiary premium

Centene Reports Huge Loss in Q2 After pulling its earnings guidance several weeks ago, Centene announced today a $253 million loss in the second quarter as it navigates significant cost pressures. Financials will be challenging in 2026 due to Exchange and Medicaid reductions in the recent budget bill. Its medical loss ratio (MLR) was 93%. It also received lower risk adjustment transfers in the Exchange than anticipated. Through the first six months of the year, the company brought in $95.4 billion in revenue and $1.05 billion in profit. Centene will update rates for the Exchange given higher adversity and the impact of the budget bill. It also hopes for higher Medicaid rates. Centene is the largest Exchange plan, with 5.8 million members in 29 states, and the largest Medicaid plan, with 12.8 million members in 30 states. Additional articles: https://www.fiercehealthcare.com/payers/centene-posts-253m-loss-amid-aca-marketplace-woes and https://www.modernhealthcare.com/insurance/mh-centene-earnings-medicaid-cuts-aca-market/ and https://www.beckerspayer.com/payer/centene-posts-253m-loss-in-q2/ (Some articles may require a subscription.) #centene

Could Bipartisan Healthcare Reforms Be In The Making? Senate Republicans say they are working on a bipartisan healthcare package to lower drug and health insurance costs. Democrats say they have not been brought into the process and are skeptical. Sen. Bill Cassidy, R-LA, who leads the HELP Committee, is leading the talks, with pharmacy benefit managers reform and stopping upcoding practices in the Medicare Advantage (MA) risk adjustment program at the top of the list of reforms. Further, a group of Republican senators, including Lisa Murkowski of Alaska, are pushing to extend the expiring Exchange enhanced premium subsidies. It appears that even conservative Senate Finance Chair Michael D. Crapo, R-Idaho, who chairs the Senate Finance Committee, is involved. #healthcare #riskadjustment #medicareadvanage #pbms #drugpricing https://rollcall.com/2025/07/23/republicans-plan-bipartisan-health-package-as-democrats-demur Prominent Insurer Executives Cover Major Issues A Modern Healthcare webinar had a number of prominent Medicare Advantage (MA) executives outlining concerns regarding recent announcements. First, they distanced themselves

With Friends Like These: No Love From GOP For Medicare Advantage At a House Ways and Means Committee’s joint oversight and health subcommittee hearing, GOP lawmakers declared that the Medicare Advantage (MA) program needs an overhaul and private plans need to be reined in. The primary complaints were risk adjustment upcoding and prior authorization abuses. They also argued MA is not saving money as promised. The hearing was contentious and could lead to either accelerated reforms from the Centers for Medicare and Medicaid Services (CMS) or possible inclusion of cuts in a future budget bill. But admittedly, so far Congress has not wanted to pull the trigger on MA reforms given the popularity among seniors. In other news, a good article on the Trump administration proposal to begin some site neutral payment reform in Medicare. Some hospital-owned outpatient facilities (just off-campus outpatient facilities) would be paid the same to administer

Oscar Health Slashes Earnings Guidance The trend continues of large health plans surprising The Street with major slashes in guidance with little or no notice. While its Q2 investor call is not until August 6, Oscar Health announced today it is slashing its full-year guidance by about half a billion dollars. The insurer expects a loss from operations of $200 million to $300 million just months after estimating earnings from operations of $225 million to $275 million. Elevated utilization is a big culprit. Oscar’s medical loss ratio is climbing to between 86% and 87%, more than 5% higher than initially forecast. Oscar had an operating loss of about $230 million in Q2, when analysts expected an operating profit of $55.5 million. Oscar is a 100% Exchange plan. Revenue and margin concerns likely will continue given the expiration of the enhanced premium subsidies and enrollment tightening in a new rule and

Final Budget Score In From CBO: 10 Million To Lose Coverage The One Big Beautiful Bill Act that President Donald Trump signed into law on Independence Day will add $3.4 trillion to the national debt from 2025 to 2034. This is from the final scoring of the bill from the Congressional Budget Office (CBO). The estimated deficit rise reflects $1.1 trillion in cuts to direct spending and a $4.5 trillion government revenue loss due to extended and new tax cuts. CBO also projects the number of uninsured individuals will increase by 10 million by 2034 due to the Medicaid and Exchange reductions in the bill. This is about 2 million less than previously estimated due to some provisions being ruled unallowable by the Senate parliamentarian. Adding the expected 4.2 million to lose coverage when the enhanced Exchnage subsidies expire December 31 as well the 900,000 to lose coverage due to

Humana Loses Stars Lawsuit Humana’s lawsuit on Star calculations was thrown out of court this week. The judge indicated that the plan did not exhaust internal appeals processes at the time of the filing and thus the suit did not have standing. The suit could be refiled, though. The Centers for Medicare and Medicaid Services (CMS) later rejected Humana’s appeal. Humana’s suit was far-reaching and pointed. It said CMS did not follow its own regulations in its methodology for calculating ratings and said the agency does not provide plans the necessary data to calculate aspects of Star ratings. As an example, Humana said it could not replicate 60% of CMS’ cut point calculations. Humana’s average Star score fell from 4.37 in 2024 to 3.63 for 2025. Despite the lawsuit outcome, Humana is not wrong in its premise that inadequate data and a lack of transparency pervades the Star process. While