The potential for reform in Medicare Advantage (MA) is gaining bipartisan interest, with discussions around quality bonus payments, risk adjustment, and the Health Equity Index (HEI). While the Trump administration may favor MA expansion, concerns about health equity and budget cuts loom, creating uncertainty about future policies. The political landscape suggests a complex interplay between healthcare priorities and fiscal conservatism, leaving stakeholders wary of potential disruptions.
Elevance Health is suing the federal government over its star ratings, claiming that a flawed methodology led to a significant financial penalty of $375 million. The insurer argues that minor scoring variances unfairly impact its ratings, which are crucial for securing quality bonus payments and improving member benefits. Additionally, the lawsuit highlights issues with hidden data affecting other contracts, further complicating the evaluation process.
New York City has ended coverage for GLP-1 weight-loss drugs, citing an error in their inclusion, while continuing to cover them for diabetes. Meanwhile, Michigan has filed a lawsuit against PBMs Optum Rx and Express Scripts for alleged collusion with opioid manufacturers, seeking accountability for their role in the opioid crisis. Additionally, health plans are previewing their Medicare Advantage offerings for 2025, with various expansions and new benefits aimed at diverse populations.
Medicare Advantage plans received $7.5 billion in risk-adjusted payments, raising concerns over potential upcoding by major insurers like UnitedHealth Group and Humana. A federal report revealed that $4.2 billion stemmed from at-home visits, which accounted for only 13% of chart reviews in 2022, with many diagnoses lacking follow-up care. The report urged stricter oversight from CMS, highlighting that 75% of payments were linked to just 13 conditions, primarily identified through at-home assessments.
Centene has filed a lawsuit against the Centers for Medicare & Medicaid Services (CMS) over the 2025 star ratings, claiming that a miscategorized secret shopper call unfairly impacted their scores. The insurer argues that the call failure was due to CMS's software, not their service, and estimates a $73 million revenue loss from the rating drop. This legal action follows similar lawsuits from other insurers like UnitedHealth and Humana, highlighting ongoing disputes over the fairness of CMS's scoring system.
Humana is suing the Centers for Medicare & Medicaid Services (CMS) over its 2025 star ratings, claiming the agency's actions violate the Administrative Procedure Act and that it failed to disclose recalculation criteria. The lawsuit highlights issues with the scoring of customer service calls, which Humana argues were unfairly penalized due to external factors. With a significant drop in members in high-rated plans, the outcome could have major financial implications for the insurer.
Humana has filed a lawsuit against the Centers for Medicare and Medicaid Services (CMS) over the 2025 Medicare Advantage and Part D Star Ratings, claiming the agency did not adhere to its own rules and failed to provide necessary data. The complaint highlights significant changes in cut points that drastically reduced Humana's star ratings, impacting the quality bonus payments essential for lowering costs or enhancing benefits for enrollees. Humana seeks the retraction and recalculation of the ratings, emphasizing the critical importance of these ratings in the half-trillion-dollar Medicare program.
Elevance Health's CEO, Gail Boudreaux, announced the company is exploring options following a decline in its Medicare Advantage Star Ratings for 2025, which affects member enrollment in higher-rated plans. Despite improvements in nearly 60% of measures for 2026, a narrow miss on a key contract led to significant rating impacts. The situation reflects broader industry challenges, with other insurers like UnitedHealthcare and Humana also contesting their ratings amid increased cut points.
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