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The Health Plan Landscape And Coming Impacts

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

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August 22, 2025

EU-U.S. Tariff Accord Has Drug Tariffs The EU-U.S. trade accord has established a 15% tariff rate for pharmaceuticals from the EU area. The vast majority of brand drugs consumed in the U.S. (60-75% based on value) are imported from the EU. Pharmaceuticals account for roughly a quarter of U.S. imports from the EU as measured by value. Generic drugs are exempt from the new agreement but remain subject to an earlier 2.5% tariff rate. The new tariff takes effect September 1. President Trump has indicated that he plans on drug tariffs of as much as 250% over time to promote onshoring. He indicated tariffs would start slowly but eventually rise to that level. Drug costs in the U.S. will likely rise on the brand side due to the tariffs. #drugpricing #tariffs #brands #generics https://abcnews.go.com/Business/us-eu-release-details-tariffs-cars-pharmaceuticals/story?id=124843094 A Second Budget Reconciliation Bill With Healthcare Cuts Conservatives in and out of government are looking

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August 21, 2025

HHS Creates Federal Healthcare Advisory Committee The Department of Health and Human Services (HHS) announced the creation of a Federal Healthcare Advisory Committee, which will drive reforms to restore patient-centered care in the healthcare system. The committee would be a group of experts charged with delivering strategic recommendations to improve how care is financed and delivered across Medicare, Medicaid and the Children’s Health Insurance Program (CHIP), and the Health Insurance Marketplace. Further, the committee would find ways to cut waste, reduce paperwork, expand preventive care, and modernize CMS programs with real-time data and accountability. CMS is currently accepting nominations for committee members and is looking for experts in chronic disease management, financing in federal health programs, and delivery system reform. Individuals can either be nominated by an organization or submit a nomination for themselves. The advisory committee will focus on developing: Additional article: https://www.cms.gov/newsroom/press-releases/hhs-drives-reform-restore-patient-centered-care-announces-request-nominations-members-serve-federal #cms #hhs #medicare #medicaid #chip #healthcarereform

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Healthcare Cuts 2.0: Will There Be A Second Budget Bill?

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

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August 20, 2025

CVS Caremark Loses Whistleblower Suit CVS Caremark, the pharmacy benefits manager (PBM) of CVS Health, has been ordered to pay more than $289 million in damages stemming from a 2014 false claims lawsuit. The court originally set damages at $95 million after finding in favor of the whistleblower and finding CVS Caremark pushed insurers to overbill the Medicare Part D program. The judge has now tripled the settlement because the company’s actions were financially motivated and eroded public trust. CVS Health said it would challenge the decision. Additional articles: https://www.modernhealthcare.com/legal/mh-cvs-caremark-medicare-overbilling-lawsuit-2/ and https://www.beckershospitalreview.com/pharmacy/cvs-caremark-ordered-to-pay-290m-in-false-claims-suit/ (Some articles may require a subscription.) #cvshealth #fwa #partd #aetna https://www.fiercehealthcare.com/payers/pennsylvania-judge-hits-cvs-289m-fine-whistleblower-suit Health Plans Turn To Variable Copay Plans To Lower Costs More health plans are turning to variable copay plans to reduce costs and offer lower cost alternatives to employers and avoid passing on more premium and deductible costs on employees. MN-based HealthPartners said it will offer a

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August 19, 2025

Employer Healthcare Costs To Soar After multiple years of high spending hikes for employer coverage, employers are facing perhaps a near-term record trend in 2026. The Business Group on Health released its annual survey and found that business firms are bracing for median cost increases of 9% in 2026. In the past two years, costs exceeded forecasts. And employers expect an 11% to 12% increase in pharmacy costs heading into 2026. Ongoing demand for GLP-1s and other medications for weight loss is a significant cost driver. About 72% said that GLP-1s are impacting their 2025 healthcare costs to either a “great” or “very great” extent, up from 56% who said the same a year ago. The survey indicates that the number of employers covering these medications for weight loss may “stagnate” in an effort to control costs. Employers will also put on more guardrails like prior authorization. Some may end

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August 18, 2025

Healthcare Lawsuits Galore A good article from Modern Healthcare on various Medicare Advantage (MA) and Affordable Care Act (ACA) lawsuits. Aetna, Elevance Health, and Humana are being sued by the federal government ove alleged kickback schemes to marketing organizations to steer beneficiaries to their plans. Democratic-controlled states are suing the Trump administration over a new Exchange rule that tightens enrollment processes in the Exchanges. There is an ongoing suit over the dispute resolution process under the No Surprises Act. The suit in part involves how the median in-network rate is calculated. The Supreme Court largely sided with the government on the legality of free preventive services under the ACA but returned some issues to a lower court. (Article may require a subscription.) #aca #obamacare #medicareadvantage #exchanges #prevention #preventiveservices #nsa #nosurprisesact #marketing #fwa https://www.modernhealthcare.com/politics-regulation/mh-medicare-advantage-aca-lawsuits-regulation BCBSMA Reports Q2 Loss Blue Cross and Blue Shield of Massachusetts reported a net loss of $129.7 million on revenue

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July to August 2025 Medicare Advantage Enrollment

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

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August 15, 2025

Medicare Beneficiaries To See Part D Premium Hikes Medicare enrollees in standalone Part D plans (PDPs) will see premium hikes in 2026. Premium hikes could be up to $50, although most will see something less. Increases might also hit those who enroll in a Medicare Advantage (MA) Part D. The premium hikes occurred in 2025 and to a lesser degree in 2024. Spikes will be higher in 2026. The reason for the premium hikes include: The Trump administration was in a tough spot, inheriting a mess from the Biden CMS. The move to continue the stabilization program but at lower levels is not unreasonable despite the impact on enrollees. #medicare #medicareadvantage #partd #pdp https://kffhealthnews.org/news/article/medicare-part-d-premiums-rising-reasons/ On Drug Tariffs And Onshoring Eli Lilly is speaking out against proposed tariffs on pharmaceuticals, saying they could increase drug costs and restrict patient access. I would agree this is the case on generic drugs for sure.

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August 14, 2025

Humana And DrFirst Team Up On Care Gaps Humana and healthcare technology company DrFirst announced an expansion of their relationship aimed at closing care gaps. Humana suffered a huge loss of Star power in 2025. The focus initially will be boosting the use of statins among eligible members who are diabetics or have cardiovascular disease. DrFirst embeds in a physician’s electronic medical record system. Additional article: https://www.fiercehealthcare.com/payers/humana-taps-drfirst-new-program-aimed-gaps-care-patients-chronic-needs #medicareadvantage #quality #stars #humana https://www.beckerspayer.com/payer/humana-drfirst-partner-on-program-targeting-chronic-conditions Interoperability And Digital Health Goals Complicated The Trump administration wants to modernize healthcare through the use of interoperability and digital health, but it faces a number of policy issues and challenges. Experts applaud the commitment but say that a clear set of priorities are needed. The proposals are far-reaching, and prioritization is key to making progress. It also must settle some simmering unanswered challenges with clear policies, such as patient privacy, security, information blocking, and more. #interoperability #healthcare

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