CMS Payment Rule
- CMS released the physician fee schedule proposed rule this week. The rule included a number of proposed changes including a modest decline for Medicare physicians (-1.19% for APM participants and -1.68% for non-APM participants). It also included changes to ACO benchmarking and financial methodology. Finally, CMS requested comments for shifting away from using the current CPT-based billing code system to an alternative system.
Lawsuits
- Stars Lawsuits – SCAN and Alignment sued CMS in federal court over their 2026 star ratings, arguing that CMS should increase their star ratings from 4 to 4.5 stars. The lawsuit is an outgrowth of the Clover lawsuit from earlier this year.
- ACA Lawsuit – ACA issuers are expecting a ruling on whether an injunction will be applied to parts of the 2027 Notice of Benefit and Payment Parameters. This is expected to be released in the next few days.
Congress
- House Republicans are trying to push through language that would allow them to pass a third reconciliation bill. They are attempting to do so before Congress is scheduled to go into recess next week.
Elevance – Elevance announced it would be exiting additional Medicaid markets in the next 12-18 months due to financial pressures and upcoming work requirements. Elevance also announced that CMS declined to impose sanctions on Elevance over alleged risk adjustment data issues.
Loss Ratio Analysis – KFF released a new analysis on medical loss ratios and MLR rebates. The analysis found that MLRs increased in the individual and small group markets in 2025, meaning issuers were less profitable in those markets.
