July 28, 2025
CY26 Medicare Part D: Additional Spending but CMS Starting to Put on the Brakes
Today’s CMS release regarding its CY26 Medicare Part D program gives the impression the agency is focusing on stability in its drug benefit program with the goal to ensure 1) enrollees – especially those in…
July 16, 2025
Medicare CY26 OPPS Proposal: Hospital Outpatient Departments a Loser While ASCs a Winner
Hospitals [CYH, ARDT, UHS, THC, HCA] were on the losing end of the stick under CMS’s proposed CY26 Medicare reimbursement rule for hospital outpatient departments (HOPDs) and ambulatory surgery centers (ASCs) for a variety of…
July 2, 2025
Medicare Advantage RADV Update: Tons More PY19 Audits, UNH Has the Most For Now
CMS’s addition last week of 300+ Medicare Advantage (MA) [UNH, HUM, CNC, ELV, CVS, ALHC] contracts to be audited for risk adjustment data verification (RADV) during plan year (PY) 2019 raises the risk of larger…
June 23, 2025
Home Health: Potential Substance of Upcoming CY26 Medicare Rate Proposal [AMED, PNTG, BTSG, ADUS, AVAH]
In the upcoming CY26 Medicare payment proposal for home health (HH) agencies [AMED, PNTG, BTSG, ADUS, AVAH, UNH], which we expect within the next two weeks based on historical patterns, we think it is more…
June 16, 2025
Medicare Advantage: Filling in RADV Blanks; HUM Has Most Contracts Targeted [HUM, UNH, CVS, ELV, CNC, ALHC]
Late Friday, CMS announced the latest list of Medicare Advantage (MA) contracts to be targeted for risk adjustment data verification (RADV) audits – this time for payment year (PY) 2019 – and its associated processes…
June 13, 2025
PBMs: State Legislative Risks Persist Through Session Ends [CI, CVS, UNH, HUM, ELV, Navitus]
With many 2025 state legislative sessions having concluded, pharmacy benefit managers (PBMs) have – for the moment – successfully avoided various bills seeking to aggressively curb industry practices, except for a few new laws in…
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…