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Report Says MA Had $5.7B Underwriting Loss in 2024 Credit rating agency AM Best says that Medicare Advantage (MA) plans had a collective underwriting loss of $5.7B in 2024. From 2019 to 2022, MA made up 40% of underwriting gains and dropped to 20% in 2023. The agency said the losses came from the v28 risk adjustment model (being phased in from 2024 to 2026), lower Star ratings bonus revenue, and high utilization, inflation, and medical costs. About 3 out of 4 insurers with an MA concentration had a loss last year. #medicareadvantage #margins https://www.beckerspayer.com/payer/medicare-advantage/ma-struggles-cited-in-2024-5-7b-underwriting-loss-report ACA Rebates Announced Insurers are announcing the rebates they will pay back to enrollees and employers because medical loss ratios did not meet the minimum requirement of 80% or 85% as dictated by the Affordable Care Act (ACA). UnitedHealthcare announced it needs to pay out $359 million in rebates for 2024. Centene will pay out

PwC Highlights AI-Driven Change In Healthcare A blockbuster report from management consultant PwC predicts that $1 trillion of national healthcare spending could go to digital-first, personalized medical care. PwC also says healthcare is in the process of a monumental shift to artificial-intelligence-driven, consumer-centric healthcare services, which could mean simplified care models emerge that lower costs and increase quality. PwC notes that healthcare spending is expected to grow to $8.6 trillion by 2035, hitting 20% of gross domestic product. And this means health plan and provider executives must rethink care delivery. In terms of payers, PwC notes that medical cost trends are nearing double digits and that payers will be expected to deliver far more with far less. It says AI and other technologies can help build capabilities to deliver medical value and actively manage population risk within the plan and with provider partners. It says payers will increasingly serve as

Government Funding Bill Fails A government shutdown is coming closer to reality. A stop gap funding measure through November 21 passed the House on a vote of 217-212 but failed to achieve 60 votes in the Senate. Almost all Democrats and two Republicans voted together and the bill failed in the upper chamber by a vote of 44-48. Democratic Sen. John Fetterman, PA, voted with most Republicans in favor, while GOP Sens. Lisa Murkowski, AK, and Dr. Rand Paul, KY, voted with Democrats. The House is expected to be out until two days before funding expires but may now have to come back early. The measure included many critical healthcare funding and policy extensions. Additional articles: https://www.modernhealthcare.com/politics-regulation/telehealth-medicaid-dsh-stopgap-funding-bill/ and https://thehill.com/homenews/senate/5512606-government-shutdown-senate-funding-bill/ (Some articles may require a subscription.) #governmentshutdown #congress #ffy2026 #healthcare https://www.fiercehealthcare.com/regulatory/republicans-unveil-7-week-stopgap-hospital-funding-telehealth-extensions-no-aca-premiums Studies Project Impact On Hospitals From One Big Beautiful Bill Two new studies outline the financial fallout expected for hospitals

Provider Directory Rule For Medicare Advantage Medicare Advantage (MA) insurers will be required to submit provider directories to the Centers for Medicare and Medicaid Services (CMS) next year under a final rule issued Thursday. The provider information will be added to the Medicare Plan Finder. CMS will issue an operational guide to outline how to prepare and submit the directory. MA plans will have to submit their network lists by Jan. 1 and then once a year. Updates must be made every 30 days to reflect changes in provider participation. Insurers will not have to attest that they meet network adequacy standards. (Article may require a subscription.) #medicareadvantage #providers #cms https://www.modernhealthcare.com/politics-regulation/mh-medicare-advantage-plans-provider-directories-2026 CBO Again Projects Coverage Losses The Congressional Budget Office (CBO) issued a new assessment of the Exchange premium subsidy enhancements extension. It found making the enhancements permanent would cost $350 billion over ten years (added to the deficit) and boost

Stars Drama Begins Early The Centers for Medicare and Medicaid Services (CMS) will release SY 2026 results in October but appears to have botched part of the rollout. In Plan Preview 2, the agency provided insurers with a private preview of their individual ratings but may have accidentally disclosed every company’s preliminary ratings in the file. It is unknown if every plan got the ultimate sneak peek or not. CMS promptly pulled the electronic data, told plans to delete any download, and reuploaded just what it should have for each plan. It also has instructed plans not to make Stars public before October’s announcement after some did so. This led to some plans seeing increases in stock, while others who did not comment saw their stocks fall. (Article may require a subscription.) #stars #quality #medicareadvantage https://www.modernhealthcare.com/insurance/mh-unitedhealth-humana-centene-aetna-medicare-advantage-stars Optum Increases Comp For Independent Pharmacies Optum Rx, one of the big 3 pharmacy

Government Funding Stopgap House Republicans will vote this week on a shorter, 7-week funding resolution for FFY 2026 (which begins October 1) that includes some critical healthcare extensions, but nothing on extending the Exchange premium subsidy enhancements. The bill would need a simple majority in the House but 60 votes in the Senate. Congressional Democrats have suggested they may not support the measure unless it includes greater healthcare funding, including a rollback of some budget reconciliation bill cuts and extension of the subsidies. Additional articles: https://www.fiercehealthcare.com/regulatory/republicans-unveil-7-week-stopgap-hospital-funding-telehealth-extensions-no-aca-premiums and https://www.beckershospitalreview.com/finance/aca-subsidy-extension-left-out-of-7-week-stopgap-funding-bill/ (Some articles may require a subscription.) #governmentshutdown #congress #healthcare https://www.modernhealthcare.com/politics-regulation/mh-house-spending-bill-aca-subsidies-mike-johnson Hospitals Attack Aetna Proposed Inpatient Policy The hospital lobby has sent Aetna a letter urging it to rescind its planned “level of severity inpatient payment” Medicare Advantage (MA) policy, which is set to go into effect November 15. Under the policy, Aetna will approve inpatient stays without a medical necessity review but

Trump Marketing Curbs Worry Brand Drug Makers President Trump’s order to curb advertising for pharmaceutical drugs on television is creating anxiety for brand drug makers, advertising firms, and broadcasters. They say it could pose an existential threat to them. Media companies brought in $5 billion in advertising revenue from pharmaceutical companies in 2024. The order does not outright ban direct-to-consumer advertising of drugs. Trump does not have the authority to do that, but health chief Robert F. Kennedy, Jr. wants to ban them. But the administration is using its executive and regulatory authority to ensure “transparency and accuracy” in direct-to-consumer advertising, including requiring greater disclosures of side effects in television and other ads. The administration also has sent cease-and-desist letters to some large drug manufacturers to combat “egregious violations demonstrating harm” in the marketing of high-cost prescription drugs. The president is absolutely right on this one. #drugpricing #marketing #branddrugmakers https://thehill.com/policy/healthcare/5500949-trump-administration-pharma-advertising-curbs