May 21, 2025
Medicare Advantage: Ramping Up RADV Audits Clearly a Threat, But Does It Head Off Other Risks? [HUM, UNH, CVS, ELV, ALHC]
CMS’s announcement late Wednesday to turn the dial up on its risk-adjustment data verification (RADV) audits of Medicare Advantage (MA) contracts with an eye toward the entire landscape raises legitimate fears of recouping sizable past…
May 19, 2025
Expected Federal Report on Fertility Benefits: Regulatory Recommendations Likely Incremental [PGNY]
Since we are at the 90-day mark after February 18 release of the White House’s Executive Order (EO) supportive of in-vitro fertilization (IVF), there is a hope that the Trump administration’s anticipated report of potential…
May 13, 2025
[ELV, CNC, MOH, UNH, CVS] CMS Managed Care Provider Tax Proposal
Yesterday’s CMS proposal confirms our suspicion that the agency would seek to tighten state provider taxes – primarily those on managed care [ELV, UNH, CNC, MOH, CVS, CI, OSCR]– used to secure sizable federal Medicaid…
May 7, 2025
PBMs: Death by a Thousand Cuts? [CI, CVS, UNH, ELV, GDRX]
The list of potential state and federal legislative threats to pharmacy benefit managers (PBMs) [CI, CVS, UNH, ELV, GDRX] seems to be growing, even though there has not been widespread enactment of these bills. Putting…
April 10, 2025
[CVS, CI, UNH]: Senate Confirmation of 3rd FTC Commissioner Allows for Future Resumption of PBM Litigation
Today’s successful Senate confirmation of Mark Meador to join the FTC as a commissioner paves the way for the FTC to officially resume its antitrust litigation against the pharmacy benefit managers (PBMs) [CVS, CI, UNH,…
April 7, 2025
[HUM, ALHC, UNH, CNC, AGL, PRVA]: MA’s 5%+ Increase Met Our Expectations, But Longer-Term Coding and Part D Questions Remain
The final CY26 Medicare Advantage (MA) rate announcement met our previously-published optimistic expectations for a comfortable mid-single-digit YoY benchmark rate increase for MA insurers [HUM, ALHC, UNH, CVS, ELV, CNC] with CMS finalizing a 5.06% increase, largely…
April 6, 2025
[HUM, ALHC, UNH] Final Medicare Advantage Tech Changes Reg: Most Proposals Dropped Without Explanation, Await CY26 Rate Notice
CMS’s final CY26 technical changes rule for Medicare Advantage (MA) and Part D plans [HUM, ALHC, UNH, CVS, ELV, CNC] lived up to expectations of rolling back proposed restrictions in response to consumer complaints, but…
March 25, 2025
HUM, ALHC, UNH: Optimistic for Mid-Single Digit MA Rate Increase for CY26, Upcoding Remains a Longer-Term Issue
Anticipating CMS’s issuance of its final CY26 Medicare Advantage (MA) rate notice within the next two weeks (on or before Monday, April 7), we remain optimistic about near-term regulatory changes for MA insurers [HUM, ALHC,…
March 14, 2025
Oz Nomination: Moving towards Senate Confirmation, Medicare Advantage Comments Show Mixed View
Today’s Senate Finance Committee confirmation hearing of Dr. Mehmet Oz as Trump’s CMS Administrator provided limited new insights into his approach to Medicare, Medicaid, Obamacare, pharmacy benefit management reforms, health savings account adoption, and healthcare…
February 26, 2025
[CI, CVS, UNH, HUM, ELV, GDRX]: House Hearing Retreads Already Agreed-to PBM Reforms, Still Likely as Legislative Payfors
This morning’s House Energy and Commerce Health Subcommittee hearing on “needed” pharmacy benefit manager (PBM) reforms attempted to reinvigorate the past bipartisan and bicameral consensus for legislative changes to rein in the PBMs, but until…