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Health Plans Backing Away From Voluntary PA Reforms Just one year after promising major prior authorization (PA) reforms on a voluntary basis, some health plans appear to be backing away from the commitments to the Trump administration that have been heavily touted by both plans and regulators. Some plans have been resistant to proceed on the pledge to implement certain reforms. Critics says progress has been slow despite health plan trade group AHIP claiming 6.5 million prior authorizations for patients—equal to an 11% reduction – have been eliminated. Critics also say claims denials are on the rise. The administration threatened regulatory action if plans did not agree to come to the table with reforms. Bills on PA reform appear to be moving in Congress. (Some articles may require a subscription.) Additional article: https://www.fiercehealthcare.com/payers/insurers-hedge-trump-backed-pledge-improve-denials-process #healthplans #priorauthorization https://www.modernhealthcare.com/insurance/mh-prior-authorization-reform-pledge-insurers-pullback/ Smaller PBMs Tout Alternative Strategies To Save Costs Smaller pharmacy benefits managers are touting

UnitedHealth Raises Guidance As Profits Spike UnitedHealth reported a profit spike to $5.5 billion in Q2 2026, driven by the recovery in its insurance unit, UnitedHealthcare. As well, United’s Optum services business had a nice recovery. UnitedHealthcare posted an 86.7% medical loss ratio (MLR) in Q2, improving year over year. Medicare Advantage (MA) turned around as well. Costs are running high but below the 10% it projected. The company expects its Medicare plans to generate a 3% operating margin this year. United lost a planned 965,000 members in a retrenchment, but was somewhat lower than the 1.1 million expected. United urged Congress and the administration to reform what it says is a broken No Surprises Act (NSA) arbitration process that is driving prices higher. Additional articles: https://www.healthcaredive.com/news/unitedhealth-q2-results-beat-2026-guidance-raise/825385/ and https://www.beckerspayer.com/payer/unitedhealthcare-no-surprises-arbitration-system-needs-to-be-reformed/ and https://www.beckerspayer.com/financial/unitedhealth-posts-5-5b-profit-in-q2/ and https://www.modernhealthcare.com/insurance/mh-unitedhealth-earnings-guidance/ (Some articles may require a subscription.) #healthplans #margins #unitedhealthcare https://www.modernhealthcare.com/insurance/mh-unitedhealth-earnings-unitedhealthcare-medicare-optum/ Judge Blocks Certain ACA Marketplace Rule Provisions

Elevance Stumbles A Bit In Q2 But Recovering Elevance Health is kicking off another round of quarterly earnings results for health plans. The results are a mixed bag – with ongoing signs of recovery but signals that challenges and uncertainty remain for big insurers and plans in general. Elevance posted $1.5 billion in profit for Q2 and revenue of $50.5 billion, but profit was down from Q2 2025. Elevance is still meeting guidance to investors (and is upping it), but investors wanted more. Here are some of the troubling signs, which are expected in other big plans too for Q2. Some good news is the settlement on Medicare Advantage (MA) risk adjustment. Elevance will face no sanctions. Additional articles: https://www.fiercehealthcare.com/payers/elevance-healths-stock-slides-premarket-even-it-beats-street-15b-q2-profit and https://www.modernhealthcare.com/insurance/mh-elevance-health-earnings-state-medicaid-markets/ and https://www.healthcaredive.com/news/elevance-medicaid-exits-q2-2025-2026-earnings-raise/825217/ and https://www.beckerspayer.com/financial/elevance-reports-1-5b-profit-in-q2-membership-dips/ (Some articles may require a subscription.) #healthplans #margins #medicareadvantage #elevancehealth https://www.modernhealthcare.com/insurance/mh-elevance-earnings-profit-guidance 340B Costs Hit $100 Billion More news that will likely mean regulatory or

Trump Admin Proposes Major Medicare FFS Reform Rule The Trump administration continues its efforts to reform Medicare and make its mark on healthcare reform. A new Medicare fee-for-service (FFS) reform proposal will significantly impact many areas of the sprawling traditional program. The proposed rule would make changes to Medicare accountable care organizations (ACOs), transition away from the physician Merit-based Incentive Payment System (MIPS) to an enhanced value-based care (VBC) pathways program, and update physician payment policies to better reflect modern clinical practice. In part the ACO changes would establish more predictable spending targets to improve planning and participation as well as increase some shared saving rates and make benchmark and other calculation adjustments. Notable quality reporting changes are also proposed. The MIPS successor would also have three new value-based pathways on diabetes, hypertension, and hospital-based care. Physician reimbursement would generally shrink a bit in 2027. Remote patient monitoring would also

Another Stars Lawsuit — This Time From Alignment High-performing MA plan Alignment Healthcare has joined the lawsuit fray on the Clover decision. Alignment has the same argument as Scan. Both indicated CMS erred by including ten measures in the CMS Recalculation scenario when a judge ruled these measures did not go through the correct regulatory vetting process. Alignment says three of its contracts currently rated 4.0 should be at 4.5, netting an additional $50 million. If you are adding up the numbers from lawsuits, here is the total: –Clover = $120M–Elevance Health = $115M–Scan = $125M–Alignment = $50M TOTAL = $410M I had earlier estimated the total costs to be over $1 billion. Alignment lawsuit: https://lnkd.in/entBMgHn #cms #stars #quality #medicareadvantage https://www.healthcaredive.com/news/scan-alignment-sue-cms-ma-star-ratings-recalculation-clover-lawsuits/825091 Plans Oppose No Surprises Bill A health plan group has launched a campaign challenging a congressional bill that would implement even more friendly provider elements in the No Surprises

Scan Now Sues Over Clover Lawsuit And CMS Recalculations A new lawsuit has been filed by non-profit Scan Health Plan. Scan argues that CMS inappropriately recalculated Star Rating for 2026 after the Clover Health decision. Clover received an exact calculation based on the judge’s ruling throwing out 20 measures based on two legal arguments (10 measures were not statutorily allowed and another 10 measures were not properly promulgated via regulation). However, CMS’ recalculation measure set adopted part of the ruling by throwing out some of the judge’s measures, while retaining others. As well, CMS removed some measures not even struck by the court. Elevance Health was the first to sue, arguing it is entitled to a calculation based exactly on what the judge ruled for Clover on the 20 measures. Scan’s suit appears different. Scan argues the court should force CMS to remove the ten measures that CMS failed to

Wearables Growing But Not Integrated The use of wearables for disease monitoring has increased dramatically. About 86% of U.S. physicians report they sometimes review data from their patients’ wearables, including heart physiology, oxygen and breathing, and sleep. But only 6% of doctors say such data is integrated into clinical workflows and that clearly limits growth and  potential. The Trump administration has in part sought to leverage technology and overcome this deficiency by announcing the ACCESS reform pilot, which contracts with technology entities to partner with physicians to monitor chronic disease states. #chronicdiseases #technology #medicare #access https://www.healthcaredive.com/news/physician-wearable-data-use-hindered-workflow-reimbursement-challenges-american-medical-association/824640/ CVS CEO Says Aetna Has Turned Corner Financially At a public speaking event, CVS Health CEO David Joyner said insurer Aetna has finally gotten a handle on medical spending after a turbulent few years. Recently Aetna’s financial reports have shown recovery. In other health plan news: Elevance Health’s Medicaid subsidiary in the District of