taxexemption

FTC Settles With Cigna’s Express Scripts The Federal Trade Commission (FTC) and Cigna’s Express Scripts pharmacy benefits manager (PBM) reached a settlement that resolves allegations that the PBM artificially drove up prices for insulin. Cases continue against CVS Caremark and OptumRx. Express Scripts will implement a number of reforms, including: The FTC expects the settlement to lower out-of-pocket costs for drugs by $7 billion over a decade. Additional articles: https://www.fiercehealthcare.com/regulatory/ftc-evernorth-near-settlement-case-over-insulin-prices and https://www.healthcaredive.com/news/express-scripts-ftc-reach-settlement-insulin-lawsuit/811369/ and https://www.beckerspayer.com/legal/ftc-deal-over-insulin-prices-forces-cignas-express-scripts-to-overhaul-policies/ (Some articles may require a subscription.) #pbms #drugpricing #employers https://www.modernhealthcare.com/insurance/mh-cigna-express-scripts-ftc-pbm-lawsuit CMS Hypes ACO Growth And Potential The Centers for Medicare and Medicaid Services (CMS) issued a fact sheet regarding latest statistics around Medicare Accountable Care Organizations (ACOs). As of January 2026, 14.3 million Medicare beneficiaries are estimated to receive care coordinated by ACOs, up from 13.7 million in 2025 or a 4.4% increase. This includes those in Medicare Shared Savings Program ACOs and entities participating in

Partial Shutdown Over The House voted 217-214 to approve a final spending package for FFY 2026 — 21 Republicans defected from and 21 Democrats supported the bipartisan measure. President Trump has already signed the bill. A number of key healthcare reforms are included. I reported on a list of them in the Newsfeed on January 30. Among the big items are a set of pharmacy benefit manager (PBM) reforms, including extensive reporting, transparency, and government oversight as well as requirements to pass rebates earned from drug makers to health plans, employers, and patients. PBMs will now have to charge a set fee for services. The bill requires the groups to report detailed data on drug pricing, rebates, pharmacy reimbursement, and payments retained by PBMs and their affiliates and authorizes audits and enforcement/recoupment actions. In addition, telehealth was extended for two years and acute hospital-at-home by five years. Additional articles: https://www.modernhealthcare.com/politics-regulation/mh-congress-government-funding-bill-pbm-telehealth/

Government Funding Bill Still Not Passed; Due Up Tuesday in House With Democrats off the Senate funding package to end a partial government shutdown, Speaker Mike Johnson, R-LA, is still expressing optimism about the House approving a funding package Tuesday. The Rules Committee is now meeting to pass a rule, which then clears the way to have a party-line vote on the Senate package. But with the ability to lose but one vote given a slim majority, Johnson’s optimism may be a bit too, well, optimistic. However, Johnson says he is not asking President Donald Trump to call those Republican holdouts to get the deal over the finish line. This package and an earlier one funds all but the Homeland Security department through September 30. That is funded for two weeks, giving time for Democrats and Republicans to discuss concerns over ICE and Homeland Security conduct. Additional article: https://thehill.com/homenews/house/5719277-johnson-trump-gop-holdouts-funding/?tbref=hp #governmentshutdown

Partial Government Shutdown Will Occur Despite Deal But Could Have Limited Impact — Hopefully! The Senate passed a compromise provision to fund the government for all agencies yet to be funded and two weeks for the Department of Homeland Security. That will give time for parties to negotiate over some constraints on immigration officers. The Senate passed legislation Friday on a strong bipartisan vote. The government technically shuts down at midnight tonight, but the House will be back on Monday to vote on the amended package. House Speaker Mike Johnson, R-LA, wants to suspend the rules to take up the bill to get funding moving quickly Monday. That requires a two-thirds vote, requiring about 70 Democrats to sign on in support. In part, Johnson wants to do this because he could have defectors among conservatives and he is challenging Democrats politically to oppose the measure. If he cannot suspned the

Exchange Enrollment Down About 23M have enrolled in Exchange coverage as open enrollment has all but closed out. That’s down about 5% from 2025 but more than the 21.3M in 2024. Interestingly, the reduction is not what many thought it would be after the expiration of the enhanced premium subsidies. About 3.4 million are new enrollees, while 19.6 million are returning. About 15.8 million people enrolled on the federal Healthcare.gov platform, while 7.2 million enrolled on the state-based Exchanges. Some states that stepped in with subsidies of their own saw strong growth, as did others who did not – such as Texas. Nine states had enrollment growth, while 41 saw declines. For the 30 HealthCare.gov states, the data is through Jan. 15. For the 20 state-based exchanges plus D.C., the data is through Jan. 10. There are a few states that extended open enrollment and thus the enrollment numbers could

Elevance Reports Caution, But Better News Than United Elevance Health reported 2025 financial news today and its status is better than imploding UnitedHealth Group. That led to a recovery to some degree in its stock price today. Elevance beat The Street on profit in Q4 2025 but missed on revenue. The company reported $547 million in profit for Q4, up from $418 million in Q4 2024. However, its $49.3 billion in Q4 revenue fell short. It did have almost 10% growth year over year. For the full year, Elevance Health brought in $197.6 billion in revenue, up 12.8% from 2024’s $175.2 billion. Profits were down by 5.3% compared to 2024, decreasing from $6 billion to $5.7 billion. Elevance did report that it will see declining revenue in 2026, though. And profit could be constrained as well. This is tied to shedding of membership to right the financial ship as well as governmental

CMS Defends Flat Rates But Contraction Coming; UnitedHealth Crashes The Trump administration’s top Medicare official is defending the meager proposed Medicare Advantage (MA) increase for 2027, saying the administration is a big supporter of MA. Large plans stocks dropped dramatically today after the after-hours’ announcement yesterday. Analysts, trade groups, and plans are saying that yet another major contraction could occur in 2027. Benefits, products, and geographies began contracting in 2024, with major changes in 2025 and 2026. While the economic growth rate was generous, the administration proposed two risk adjustment changes that will take nearly all of the 5% trend away. Some expect a contraction of enrollment from the 2026 enrollment season when statistics come out soon. I have doubted this, but it very well could happen. Trump officials justify the risk adjustment changes and flat hike as an effort to combat overpayments in the program. In other news, UnitedHealth

MA Hit Hard By Proposed 2027 Rate Hike The Trump administration threw Medicare Advantage (MA) for a loop tonight as it issued the 2027 Advance Notice of rates and set a meager projected hike. MA plans just weathered a three-year phase-in (2024 to 2026) of the new v28 model. By my calculation, that took about 7% out of rates. With skyrocketing utilization, plans had hoped for a 2027 hike that exceeded the rough 5% hike in 2026. But Trump’s Center for Medicare and Medicaid Services (CMS) has now proposed two new risk adjustment reforms that take the almost 5% economic growth inflationary hike down dramatically – almost to 0. This will send stocks of major insurers dropping tomorrow for sure. The draft calls for a 0.09% payment increase. That is an increase of roughly $700 million in MA payments for 2027 compared with $25 billion in 2026! When considering estimated

CareFirst Sues on Star Ratings The now annual tradition of a Medicare Advantage (MA) plan suing over Star ratings continues. CareFirst BlueCross BlueShield is suing the Centers for Medicare and Medicaid Services (CMS) over its 2026 Star Ratings, alleging improper calculations cost the insurer an estimated $32 million in quality bonus payments. The plan says CMS departed from its own guidance when it used corrected patient safety data released after the close of the plan preview period to calculate Star Ratings. CareFirst says it received a 3.5-star rating instead of 4 Stars for a contract with about 30,000 enrollees. CareFirst says its Drug Plan Quality Improvement Measure for the contract was impacted by CMS contractor Acumen updating data after the close of the Plan Preview period. CMS has a hard rule that issues must be raised by plans before or during Plan Preview 1 and CareFirst says that CMS should

Health Plan CEOs Grilled On Affordability It was a bipartisan bashing of health plan CEOs on Capitol Hill today as both parties sought to protect themselves from healthcare affordability fallout. While the GOP was more sympathetic to the plan executives, they engaged in a great deal of attacks as well. The issues covered included the following: In other news, the House passed its final four appropriations bills and they now go to the Senate. This needs to happen soon to avoid a partial shutdown. Further, lawmakers accused CVS Health of violating antitrust laws by restricting independent pharmacies from working with digital pharmacy competitors to protect its market position. Last, Cigna said its plan to end drug rebates will reduce earnings by $500 million to $600 million. Additional articles: https://www.modernhealthcare.com/politics-regulation/mh-health-insurance-ceo-hearings-live-updates/ and https://www.bloomberg.com/news/articles/2026-01-21/cvs-health-may-have-violated-antitrust-laws-republican-lawmakers-say and https://www.fiercehealthcare.com/payers/insurance-ceos-set-back-back-congressional-hearings-affordability and https://www.beckerspayer.com/payer/house-committee-accuses-cvs-of-impeding-pharmacy-competition/ and https://www.modernhealthcare.com/insurance/mh-cigna-earnings-drug-rebates/ and https://www.beckerspayer.com/payer/vertical-integration-is-destroying-peoples-ability-to-access-care-payer-ceos-face-bipartisan-congressional-grilling/ and https://www.beckerspayer.com/payer/cvs-health-cuts-prior-authorizations-expands-rebate-sharing/ and https://thehill.com/homenews/house/5701980-house-government-funding-bills/ and https://www.healthcaredive.com/news/house-budget-committee-healthcare-affordability-consolidation/810149/ (Some articles may require a