News Archive

"CMS has proposed two mandatory Medicare drug pricing models: the GLOBE Model (for Part B drugs) and the GUARD Model (for Part D drugs). Both models would link Medicare drug rebate calculations to international pricing benchmarks from 'economically comparable' countries. If finalized, the GLOBE and GUARD Models would create new and potentially significant rebate obligations for drug manufacturers."  MORE >>

"The Trump administration has introduced three most-favored-nation (MFN) drug pricing initiatives designed to link U.S. pharmaceutical costs to prices paid in economically comparable countries. Most-favored-nation pricing requires manufacturers to provide rebates when U.S. prices exceed those in reference nations—a direct response to the persistent gap between U.S. drug prices and those in other developed economies. [This article summaries three programs that] have been implemented: [1] GENEROUS (GENErating cost Reductions fOr U.S. Medicaid) Model; [2] GLOBE (Global Benchmark for Efficient Drug Pricing) Model; [3] GUARD (Guarding U.S. Medicare Against Rising Drug Costs) Model."  MORE >>

"This past year featured significant developments in prescription drug policy, most notably the continued implementation of Biden-era drug pricing reforms and changes made by the new Trump Administration.... Looking Ahead: 2026 ... IRA implementation ... Model release and operation ... Food And Drug Administration policy releases ... Vaccine policy changes ... Broader insurance market dynamics."  MORE >>

"[CMS] proposed two models aiming to implement international reference pricing approaches for drugs under Medicare ... As proposed, both models would be mandatory for any drug manufacturer wishing to participate in Medicare. Both would assess rebates for certain single-source drugs and biological products 'if the prices exceed those paid in economically comparable countries.' The models share a number of conceptual and design features, but operational differences between Part B and Part D do play out in the models' design."  MORE >>

"For economic growth to meaningfully improve America's long-term fiscal outlook, Medicare spending would need to grow more slowly than GDP. But under the program's current structure, it will continue to grow faster than GDP for the foreseeable future. Every pathway through which growth occurs -- innovation, longer lives, cost disease -- feeds directly into higher Medicare spending. The conclusion is inescapable: we cannot grow our way out of the Medicare-driven debt crisis without reforming Medicare itself."  MORE >>

"The two models -- GLOBE for Medicare Part B and GUARD for Medicare Part D -- will factor in international prices into the inflationary rebates drug manufacturers must pay to the program for certain single-source drugs and sole-source biologics that are separately payable under Medicare Parts B and D, if CMS finalizes the rule."  MORE >>

19 pages. "The need for long-term reforms to Medicare has been repeatedly raised. One is to raise the eligibility age from 65 to the Social Security full retirement age of 67, then tie it to increases in longevity.... In this paper, [the authors] estimate the coverage and spending effects of eliminating Medicare coverage for those ages 65 to 66[.]"  MORE >>

279 pages. "This proposed rule proposes to implement the Global Benchmark for Efficient Drug Pricing Model (GLOBE Model), a new Medicare payment model under section 1115A of the Social Security Act. The GLOBE Model would test whether a payment model that uses an alternative method for calculating Part B inflation rebate amounts for certain separately payable Part B drugs and biologicals products reduces costs for Medicare fee-for- service (FFS) beneficiaries and the Medicare program while preserving quality of care."  MORE >>

"CMS explains in the proposal's preamble that account-based plans are designed to provide cost savings through pre-tax contributions and reimbursements, and often supplement other coverage, rather than actually offering prescription drug coverage. Thus, the benefit design of account-based plans makes concepts such as the disclosure of creditable coverage inapplicable and unduly burdensome[.]"  MORE >>

14 pages. "[Annual Wellness Visits (AWVs)] are considerably underused, with 45 percent of Medicare beneficiaries not engaging with their AWVs.... [Fee-for-service] beneficiaries who were more engaged with their AWVs (had at least four AWVs from 2018 to 2023) had a lower annual trend in their total cost of care (TCOC) and considerably lower inpatient and emergency department spending.... [B]eneficiaries who received an AWV were associated with an average of $885 reduction in TCOC per beneficiary per year compared to years without an AWV."  MORE >>

"Under the Make America Healthy Again: Enhancing Lifestyle and Evaluating Value-based Approaches Through Evidence, or MAHA ELEVATE, model, the Centers for Medicare & Medicaid Services (CMS) will make $100 million available to support as many as 30 proposals to promote health and preventive care in three-year agreements."  MORE >>

"Medicare beneficiaries with Part B and/or Part D prescription drug coverage may face additional monthly surcharges known as the Income-Related Monthly Adjustment Amount (IRMAA). These surcharges ... are based on modified adjusted gross income (MAGI) from two years prior ... If you're navigating Medicare costs or planning for retirement, this overview can help you understand the impact of IRMAA and the steps you can take to effectively manage your premiums."  MORE >>

"[R]espondents are looking for deeper conversations with their advisors, and especially on topics including how to file Medicare benefits in the future. Fifty-six percent of respondents who work with a financial professional say they haven't received advice on how and when to file for Medicare, and 72% of all respondents, despite whether they do or do not receive guidance, plan to ask about or work with a professional who can offer Medicare advice."  MORE >>

"The Medicare Part A inpatient hospital deductible ... will be $1,736 in 2026, an increase of $60 from $1,676 in 2025.... The standard monthly premium for Medicare Part B enrollees will be $202.90 for 2026, an increase of $17.90 from $185.00 in 2025. The annual deductible for all Medicare Part B beneficiaries will be $283 in 2026, an increase of $26 from the annual deductible of $257 in 2025. "  MORE >>

"For fiscal year 2023, the federal government and six selected states -- California, Georgia, New York, Pennsylvania, Tennessee, and Texas -- paid health insurance entities at least $1.6 billion in potential overpayments or fraud for duplicate health care coverage or benefits. The payments were made on behalf of approximately 500,000 individuals who were simultaneously enrolled across multiple states in Medicaid or the Children's Health Insurance Program (CHIP) or receiving an advance premium tax credit (APTC) across multiple states." [GAO-25-106976, pub. Sep 25, 2025. rel. Nov 17, 2025]  MORE >>

"While this latest development is a relief, it is clear that the issues surrounding the funding of Medicare telehealth -- and telemedicine prescribing -- are not going away every time Congress kicks the proverbial can down the road.... In 2025, we know the consequences of letting the flexibilities expire -- providers do not get paid, access to quality care is diminished, and questions of retroactive payment create uncertainty."  MORE >>

"Recent analysis highlights that a man will need to have saved $191,000, and a woman will need to have saved $226,000 just to have a 90% chance of meeting their healthcare spending needs in retirement. As medical costs continue to rise faster than inflation and life expectancy is higher than ever, planning for healthcare in retirement ... should be viewed as a 'core liability' alongside housing, food, and other necessities."  MORE >>

"From 2021 to 2023, ... the CMS Innovation Center tested the Part D Senior Savings model, which lowered Medicare Part D insulin out-of-pocket costs to a maximum of $35 for beneficiaries in model-participating plans.... The goal of this article is ... to offer five design and evaluation considerations for future prescription drug models that the Innovation Center is interested in designing and testing. [The authors] discuss implications of each consideration for key stakeholders based on [their] interviews with participating plans, manufacturers, and beneficiaries."  MORE >>

"[On] October 21, 2025, CMS ... [directed] MACs to lift the claims hold for Medicare physician fee schedule, ground ambulance transport and federally qualified health center claims, including telehealth claims that 'CMS can confirm are definitively for behavioral and mental health services.' ... CMS directed MACs to continue to temporarily hold claims for nonbehavioral and mental health services telehealth claims and for acute hospital care at home claims."  MORE >>

"Before the Inflation Reduction Act (IRA) passed in 2022, drug manufacturers increased prices an average of 4.2 percent on more than 900 brand-name drugs ... To discourage such price hikes, the IRA requires manufacturers to pay inflation rebates to the Medicare program when they increase certain drug prices faster than inflation.... This year, 2025, will be the first in which drug manufacturers will be invoiced for any rebates they owe the federal government under the new policy."  MORE >>

"The market continues to consolidate, with fewer plan offerings and increased concentration among the top carriers. The increase in $0 premium basic PDPs may signal a shift in plan sponsor strategy, as some carriers focus on LI auto-enrollment beneficiaries. CMS’s PDP Premium Stabilization Demonstration has played a critical role in moderating premium increases and supporting beneficiary affordability, though its long-term impact on plan strategies and market stability remains to be seen."  MORE >>

"Fidelity Investments estimates a 65-year-old couple retiring in 2025 could face $345,000 in lifetime health care costs. Preparing for these expenses requires a proactive approach focused on what you can control and informed decisions about insurance and long-term care. Here's how to start."  MORE >>

"For this year's open enrollment period, [CMS] released a new tool on the Medicare Plan Finder that allows beneficiaries to enter up to 5 of their preferred providers to more easily view if their doctors are in a plan's network. The tool also lets beneficiaries sort available plans in their area by whether a 'must-have provider' is in the plan's network.... In previous years, beneficiaries.... would need to go to each plan's website to determine whether their preferred providers were in the plan's network."  MORE >>

"Considerations for employers on this topic include: Understanding MSP laws governing your size company Tapping into resources available from consultants and service providers Engaging with employees to understand their concerns about their next steps. Communicating with a strategy, including providing access to a third party who can individually consult with employees prior to age 65."  MORE >>

"The 2006 Tax Relief and Health Care Act created the Physician Quality Reporting System, which rewarded physicians for reporting on both quality and patient outcomes. The 2010 [ACA] added 'value' to the equation -- incorporating concepts of both cost and quality.... These well-intentioned efforts to improve quality have failed ... [The authors] describe the challenges in quality measurement, explain the financial incentives behind the system, and propose policy solutions."  MORE >>