Medicare Lawsuits – Several major legal developments this week could impact Medicare.
- Humana RADV Hearing – A federal judge heard the appeal case of Humana v. Kennedy over HHS rules surrounding auditing Medicare Advantage plans. In 2025, a federal judge invalidated HHS’ regulation governing RADV audits. HHS appealed the decision. STAT News ($) reported that the federal appeals court appeared skeptical of HHS’ position. If the court upholds the lower court’s decision, the injunction would remain in place.
- GLOBE Challenged – The drug industry trade group PhRMA filed a lawsuit seeking to block implementation of CMS’ GLOBE model. The GLOBE model aims to reduce the prices Medicare Part B pays for certain drugs.
- Independence Blue Cross Settles with DoJ – Independence Blue Cross agreed to pay $22.5 million to settle allegations that it failed to withdraw inaccurate diagnosis codes submitted for its MA plans. The Department of Justice continues to pursue cases against MA plans and diagnosis coding practices.
New Transparency Requirements – The federal government finalized changes to the Transparency in Coverage (TiC) regulations governing health insurers and group health plans. The changes are designed to improve accessibility and useability. Notable changes include reducing unused, or ‘ghost’ rates; expanding out-of-network reporting; changing certain reporting requirements from monthly to quarterly; and requiring an attestation to the accuracy of the data. The changes will take effect over the next year.
CMS Releases Guidance on Noncitizen Verification for Marketplaces – Starting in 2027, certain legal noncitizens will lose eligibility for premium tax credits in the ACA Marketplaces. This week, CMS released details explaining how the verification process will work. The verification requirements could result in loss of premium tax credits for otherwise eligible noncitizens who fail to submit the required documentation.
