Payer: Page 3

  • A picture of senator bill cassidy at a senate committee hearing, raising his right hand.
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    Senators agree they need to act on expiring ACA subsidies. But they can’t nail down how.

    Hidden in Republicans’ ACA bashing during a health committee hearing last week were some signs that a clean extension of more generous subsidies isn’t completely off the table — though one still doesn’t look likely.

    By • Dec. 4, 2025
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    Joe Raedle via Getty Images
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    Covert watchdog testing finds ACA vulnerable to subsidy fraud

    The Government Accountability Office successfully enrolled 18 out of 20 fake applicants in subsidized ACA plans. Republicans jumped on the report as ammunition in the debate over expanded subsidies.

    By • Dec. 4, 2025
  • CVS pharmacy sign outside of Miami, Florida on Feb. 7, 2024
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    Joe Raedle via Getty Images
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    CVS agrees to pay $38M to settle insulin fraud claims

    For a decade, CVS knew it was skirting rules meant to limit overprescribing but did nothing to stop, according to the Department of Justice.

    By • Dec. 3, 2025
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    Humana appeals Medicare Advantage star ratings loss to 5th Circuit

    The insurer continues to try to prove that regulators acted arbitrarily in downgrading its quality scores for 2025, despite numerous setbacks in the courts to date.

    By • Dec. 1, 2025
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    Why Medicare Advantage contract negotiations are getting heated

    “There’s simply more at stake in these negotiations for payers and providers than there used to be,” one expert said.

    By Michael Brady • Nov. 26, 2025
  • Medicare enrollment form and money.
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    CMS proposes overhauling Medicare Advantage star ratings

    The agency suggested cutting a dozen quality measures where health plan performance is high and beneficiaries can’t easily distinguish between offerings.

    By • Nov. 26, 2025
  • Two prescription drug cartons stand side by side on a counter, each bearing the word Wegovy.
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    Scott Olson via Getty Images
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    CMS sets 2027 Medicare prices for Wegovy, Trelegy and 13 other drugs

    The second round of negotiations cuts spending an aggregate 44% over 2024 list prices as the federal government extends restraints over more medicines.

    By Jonathan Gardner • Nov. 26, 2025
  • A gavel rests on a pile of money wrapped with a stethoscope.
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    Trump administration appeals decision vacating Medicare Advantage audit rule

    A federal judge struck down the rule that would have clawed back billions of dollars in overpayments in September. Now, the HHS wants to take the case to the Fifth Circuit Court of Appeals.

    By • Nov. 25, 2025
  • A stethoscope rests on a pile of $100 bills.
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    CMS finalizes 2.6% outpatient pay bump, site-neutral policies

    Hospitals lambasted the final rule as inadequate, arguing the sector is facing significant financial pressures.

    By • Nov. 24, 2025
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    Andrew Harnik via Getty Images
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    Crapo, Wyden to reintroduce bipartisan PBM package

    Republicans and Democrats couldn’t be further apart on how to address the looming ACA affordability cliff. But there seems to be a path forward on curbing pharmacy benefit managers.

    By • Nov. 20, 2025
  • Bottles of medications sit on shelves at a pharmacy.
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    Eric Thayer / Stringer via Getty Images
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    Employers, workers to face healthcare ‘affordability crunch,’ Mercer warns

    A “sharp growth” in prescription drug spending, including pricey GLP-1 weight-loss medications, helped fuel the increase, the consulting firm said.

    By Ginger Christ • Nov. 19, 2025
  • Text of the word 'Medicaid' in the middle of a U.S. dollar bill
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    Urban safety-net hospitals vulnerable to Medicaid cuts: analysis

    Though the impact on rural facilities has received more focus from lawmakers, the majority of hospitals that are most susceptible to the funding cuts operate in urban communities, according to the report.

    By • Nov. 19, 2025
  • The U.S. Capitol stands in the distance as morning traffic moves along North Capitol Street Northwest on October 01, 2025 in Washington, DC. The government shut down early Wednesday after Congress failed to reach a funding deal.
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    Chip Somodevilla / Staff via Getty Images
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    Republican antipathy during key Senate hearing darkens outlook for ACA subsidy extension

    More generous subsidies for Affordable Care Act plans have helped millions of Americans afford insurance. Chances are becoming slimmer that the assistance will survive the year.

    By • Nov. 19, 2025
  • Close up of Scott Gottlieb wearing a suit and tie
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    Drew Angerer via Getty Images
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    UnitedHealth adds former FDA commissioner Scott Gottlieb to board

    UnitedHealth declined to comment on Gottlieb’s appointment, which comes as the company works to improve its relationship with federal regulators.

    By • Nov. 19, 2025
  • Epic's logo on top of its booth at HIMSS23.
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    Rebecca Pifer/Healthcare Dive
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    Epic, Humana partner to speed patient check-in and coverage verification

    The new features automatically share insurance details from more than 800,000 Medicare Advantage enrollees with providers to streamline check-in and verification.

    By • Nov. 18, 2025
  • A picture of a form that says 'Medicaid eligibility'
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    States project flat Medicaid enrollment, increased spending as cuts loom: KFF

    Total spending in the safety-net insurance program is expected to grow 7.9% in fiscal year 2026, according to the survey. Meanwhile, states are facing significant federal cuts in the wake of the One Big Beautiful Bill Act.

    By • Nov. 18, 2025
  • a medicaid insurance card on top of a small American flag
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    CMS issues guidance on Medicaid provider tax overhaul

    The agency has started to lay out how it’ll implement restrictions on the arrangements, which are used by states to finance their share of Medicaid funding, enacted in the One Big Beautiful Bill Act.

    By • Nov. 17, 2025
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    Courtesy of UnitedHealth Group
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    Optum Health names new CEO

    Krista Nelson replaces Dr. Patrick Conway, who was appointed as CEO of UnitedHealth’s healthcare delivery unit in June. Conway will stay on as CEO of the company’s broader health services division.

    By Susanna Vogel • Nov. 17, 2025
  • Medicare enrollment form and money.
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    Medicare premiums set to rise 10% next year, CMS says

    The Part B premium hike could have been worse, the Trump administration said. Still, it’s likely to pressure the pocketbooks of millions of seniors, and could drive more into Medicare Advantage plans.

    By • Nov. 17, 2025
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    iStock/dit:pixelfit

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    Sponsored by Zelis

    How health plans can boost Star Ratings with smarter member engagement

    Struggling with Star Ratings? Discover how smarter engagement can turn scores around.

    Nov. 17, 2025
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    Joe Raedle via Getty Images
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    Historic government shutdown ends, leaving ACA subsidies in limbo

    The House passed a stopgap funding bill and President Donald Trump signed it after a weeks-long impasse, reopening the government without a clear path forward on preserving enhanced subsidies for ACA plans — Democrats’ chief demand.

    By • Nov. 13, 2025
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    Health insurers in government programs can’t seem to turn a profit

    Major payers with a presence in the ACA, Medicare or Medicaid posted an average operating margin of -1.4% in the third quarter. The market “continues to be challenging,” complicating margin recovery plans, one expert said.

    By • Nov. 12, 2025
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    Democrats introduce bill to repeal Medicare prior authorization pilot

    Lawmakers argue the CMS innovation center pilot, which will implement AI-backed prior authorization for some services in six states, will add red tape and limit access to care.

    By • Nov. 10, 2025
  • The U.S. capitol building stands in front of a blue sky.
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    Win McNamee via Getty Images
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    Congress inches towards ending shutdown with no extension of ACA subsidies

    The Senate overcame a key procedural hurdle on Sunday after eight Democrats broke with their party to back a measure freeing the government from the longest funding lapse in history.

    By • Nov. 10, 2025
  • Doctor in hospital with health insurance related icon graphic interface showing healthcare people, money planning, risk management, medical treatment and coverage benefit.
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    Sponsored by Zelis

    How flexible technology is redefining healthcare compliance

    Composable tech is transforming healthcare—faster compliance, smarter savings, scalable growth.

    By Serkan Kutan, Chief Technology Officer, Price Optimization, at Zelis • Nov. 10, 2025