News Archive

"Employers offering or considering an ICHRA must understand how these arrangements interact with Medicare -- both to structure the benefit properly and to avoid exposing their organizations to compliance risk. This article provides a practical overview of how ICHRAs work alongside Medicare, the key regulatory requirements and the compliance pitfalls employers should watch for."  MORE >>

"Medicare Part B premiums, which cover doctors and hospital outpatient services, will rise to about $5,000 a year by 2035, up from about $2,440, according to a recent report by the Senate Joint Economic Committee.... Part of the expected increase in Medicare Part B premiums -- or about $450 a year of the projected $5,000 a year premium -- would be due to overpayments made by the government to Medicare Advantage plans, the report said."  MORE >>

"[A] new survey of investors nearing, or in, retirement ... finds people are more concerned about their future; and they cite the prospects of Social Security cuts and high inflation as most harmful.... [S]ome plan to delay retirement and shift to more conservative investments. Since hedging risks comes at a cost, the greater uncertainty of today's policy environment clearly hurts older Americans."  MORE >>

"Between 2011-2019, for the nationally representative beneficiary, the share of drugs excluded from formularies increased from 7.5% to 13.4%, the share of drugs subject to administrative restrictions such as prior authorization or step therapy increased from 18.1% to 43.7%, and the share of drugs on non-preferred tiers decreased from 57.8% to 42.2%. The share of drugs with any coverage restriction increased from 69.7 to 79.0%. Health plans and drugs subject to federal coverage mandates saw much larger increases in prior authorization and increases in non-preferred status."  MORE >>

15 pages. "[CMS] released the 2027 Advance Notice, which details planned changes to the Part C and Part D capitation and risk adjustment methodology for calendar year (CY) 2027. The growth rate and risk model changes together resulted in a substantially lower estimated benchmark trend than the industry was expecting.... [B]ased on experience with benefit reductions that took place in 2026, Wakely estimates that the Advance Notice could lead to a projected 15% decline in average plan rebate dollars from 2026 to 2027."  MORE >>

"[CMS] announced the selection of 15 high-cost prescription drugs covered under Medicare Part D and, for the first time, drugs payable under Medicare Part B, for the third cycle of the Medicare Drug Price Negotiation Program. CMS also selected one previously negotiated drug for the program's first renegotiations. Negotiations with participating drug companies will occur in 2026 and any negotiated and renegotiated prices will become effective January 1, 2028."  MORE >>

"[T]he Part B premium will rise from $185 in 2025 to $202.90 per month in 2026.... Part B premiums as a share of annual Social Security benefits -- defined as the benefit for the retired workers with average pre-retirement earnings -- will reach an all-time high of 9.4 percent."  MORE >>

"In most cases, plans will follow an approach that tracks the NAIC model coordination of benefit rules -- either pursuant to state insurance requirements or plan terms designed to mirror those model rules -- to determine which plan is primary and which is secondary. Where governmental programs such as Medicare, Medicaid, TRICARE, or VA services are involved, special coordination rules apply."  MORE >>

105 pages. "UHG provided ... over fifty thousand pages of documents.... This report presents the analysis of those documents ... [which] focused on how UHG has been able to maximize its risk adjustment scores and whether CMS's strategies to account for coding intensity at the MAOs can sufficiently counteract UHG's strategies. Staff discovered that UHG uses aggressive strategies to maximize these risk adjustment scores and that UHG appears to be able to leverage its size, degree of vertical integration, and data analytic capabilities to stay ahead of CMS's efforts to counteract unnecessary spending related to coding intensity. "  MORE >>

"A new Senate report alleges that UnitedHealth Group aggressively sought diagnoses that could increase its payouts in Medicare Advantage (MA).... The report also found that other MA organizations contract with UnitedHealth to capture diagnoses.... The report also notes that when [CMS] excluded some 8,000 codes from risk adjustment, UHG was able to deploy the capabilities necessary to identify new opportunities, and their efforts could be replicated by other MA organizations."  MORE >>

"With effectuation less than a year away for IPAY 2027 prices, the announcement of these MFPs will quickly flow into financial forecasts, formulary changes, and strategic market decisions. These prices are an indicator of how future negotiations may play out given deeper discounts achieved in this cycle. Navigating competitor dynamics and second-order impacts will be crucial to all stakeholders in the supply chain given the increasing interconnectedness of different markets, continually evolving Part D landscape, and the emphasis on transparency within the pharmaceutical supply chain."  MORE >>

"Medicare Drug Price Negotiation aims to reduce the prices paid for high cost pharmaceuticals. Traditionally, biologic drug price reductions after loss of exclusivity (LOE) have occurred due to the introduction of biosimilar competitors. A recent paper ... examines whether Medicare Drug Price Negotiation enacted under the Inflation Reduction Act (IRA) is likely to reduce prices more than biosimilar entry."  MORE >>

"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 >>