News Archive

"This presentation describes CBO's February 2026 projections of federal subsidies for health insurance, with a focus on Medicare, Medicaid, and premium tax credits. Projected enrollments in those and other programs are discussed, as are the factors that prompted changes to CBO's projections since January 2025."  MORE >>

"[B]eginning July 1, 2026, through December 31, 2027 ... [e]ligible individuals enrolled in Medicare Part D prescription drug plans will be able to access these medications at a predictable and affordable cost -- $50 for a monthly supply."  MORE >>

"Creditable prescription drug coverage is defined as coverage that is equal to or greater than the actuarial value of standard Medicare Part D coverage.... Plan sponsors can determine creditable status using either a simplified determination method or an actuarial evaluation. Employer Group Waiver Plans (EGWPs) and Retiree Drug Subsidy applicants are required to use actuarial valuation.... CMS introduced a new simplified determination -- optional in 2026 and mandatory in 2027 and beyond. The only change from 2026 to 2027 is a one percentage point increase in required value."  MORE >>

"The decisions employers make in the next few months regarding Medicare Advantage and Part D will determine whether they stay ahead of the curve or get caught in a wave of volatility driven by high medical and drug cost trends, the emerging impact of GLP-1s on program budgets and ongoing reforms at the federal level to drive efficiencies within the federal Medicare system. While these forces impact all Medicare coverages, this is a structural shift that will reshape the fundamental economics of group-based retiree medical plans as we know them."  MORE >>

"Sponsors of HRAs and other account-based plans, which are typically offered alongside major medical plans, will welcome the relief from providing burdensome and potentially confusing Part D creditable coverage notices. Sponsors of plans that remain subject to the disclosure requirements should use the 2027 parameters when determining whether their plans' prescription drug coverage is creditable for that year."  MORE >>

"Strategic Roth conversions during the gap years before required minimum distributions (RMDs) begin at age 75 can keep Medicare premiums at the base rate of $202.90 per month for life, while staying above the $218,000 joint modified adjusted gross income threshold triggers IRMAA surcharges of up to $9,240 per year for couples. Retirees with large traditional 401(k) balances should execute conversions before RMDs begin using the two-year MAGI lookback window to avoid stacking conversions with future Social Security income, as SECURE 2.0 delays RMDs until age 75 for those born after 1959."  MORE >>

"The final rule codifies that account-based medical plans, specifically HRAs and ICHRAs, are no longer required to determine, document, or disclose their creditable coverage status to Part D-eligible individuals. CMS concluded that the fundamental design of account-based arrangements -- which provide tax-free reimbursements for medical expenses and individual policy premiums rather than comprehensive prescription drug benefits -- makes actuarial comparisons to the Medicare standard drug benefit inapplicable."  MORE >>

"[S]ection 1860D-13(b)(6)(B)(i) of the [Social Security Act] requires that 'entities that offer prescription drug coverage' must provide creditable coverage disclosures.... [CMS proposes] to revise Section 423.56(b)(3) so that account-based entities are not required to provide the creditable coverage disclosures.... [R]equiring account-based plans, such as HRAs, including ICHRAs, to determine if their coverage is creditable, and requiring them to report the creditable status of that coverage, unduly increases administrative burden on these entities ... After consideration of the comments received on this provision by a broad range of stakeholders, we are finalizing this policy as proposed without modification. "  MORE >>

"Last summer, the insurance industry broadly agreed to reform a major healthcare pain point: prior authorization.... Services that are no longer subject to prior authorization include those with clear clinical guidelines and consistent utilization trends for providers, per the announcement. The insurers have also worked to use more consumer-friendly language in determinations, and if an authorization is denied, make it clear what an appeal or next step could be."  MORE >>

" As part of a series of multi-year voluntary commitments announced in partnership with HHS and CMS, leading health plans committed to making specific reductions to the scope of claims subject to prior authorization  ... Health plans' efforts to reduce prior authorization across the markets covered by the commitments will result in approximately 11% fewer prior authorizations occurring in 2026 -- or 6.5 million fewer prior authorizations for patients, which includes a reduction of more than 15% in Medicare Advantage."  MORE >>

"Democrats are casting about for new health reform ideas in the hope that they can gain traction in the run-up to 2028 and be enacted afterward.... There are at least three equally important big priorities Democrats will be thinking about that are in themselves challenging and, in a world of limited dollars and political capital, will be in tension."  MORE >>

"FinCEN's Advisory provides financial institutions with an overview of how fraudsters, organized crime groups, and increasingly, transnational criminal organizations are targeting government health care benefit programs. It also highlights money laundering typologies and red flag indicators to help financial institutions identify and report suspicious activity. Today's Advisory strongly encourages financial institutions to voluntarily report suspicious activity to FinCEN and immediately notify law enforcement of such activity."  MORE >>

"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 >>