This is Jacob Emerson with the Becker's Payer
Issues Podcast.
Here is your biweekly industry news briefing for
October 14th.
Average Medicare Advantage star ratings declined for the
3rd year in a row according to new
CMS data published on October 10th.
The average MA star rating for 2025
is 3.92
stars. That's down from 4.07
in 2024.
Plans must earn a rating of 4 or
higher to receive bonus payments from CMS.
2025 star ratings affect the quality bonus payments
plans receive in 2026.
Just 7 plans received a 5 star rating
in 2025.
That's down from 38 in 2024.
Around 40% of Medicare Advantage Part D plans
received 4 stars or higher. Around 62% of
MAPD enrollees are in plans rating rated 4
or higher.
CMS did not make any major changes in
star ratings methodology.
Medicare Advantage Part d plans are rated on
40 clinical quality and member service measures.
CMS determines cut points for each per measure
each year. For 2025,
many cut points increased, meaning plans had to
perform better to get higher star ratings.
Several factors influenced the tougher cut points. The
agency removed extreme outliers from the lower end
of performance, a more compressed distribution on scores,
and an increasing number of high scoring contracts.
Potential challenges to CMS's star ratings could loom.
Earlier in October, Humana said its star ratings
for 2025 dropped significantly from last year. For
next year, just 25% of Humana's members will
be in contracts rated plans 4 stars and
above. That's down from 94%
in 2024.
UnitedHealthcare
is also challenging CMS's star ratings. The company
filed a lawsuit September 30th
challenging CMS's inclusion of a secret shopper phone
call in its star ratings that UnitedHealthcare
said never connected.
Back in June, CMS recalculated
2024 star ratings for all Medicare Advantage plans.
Judges sided with Scan Health Plan and Elavance
Health in lawsuits challenging the methodology CMS used
to calculate the ratings.
In addition to determining bonus payments, star ratings
guide beneficiaries' decision on which plans to enroll
in. Open enrollment begins October 15th.
Well, CMS is proposing new regulations on the
ACA marketplace in 2026,
which includes some aimed aimed at cracking down
on fraud.
The agency published its proposed rules for the
marketplace October 4th.
It proposed holding lead agents at insurance agencies
accountable for violations of marketplace
standards.
The agency also proposed using its authority to
suspend an agent or broker's ability to operate
on the exchange if the agency deems the
agent poses an unacceptable risk to marketplace operations.
The policy would improve security on the exchange
resulting in fewer unauthorized changes to coverage.
CMS has moved to crack down on brokers
making changes to enrollees coverage without their knowledge.
In the 1st 6 months of this year,
CMS said it received nearly 74,000
complaints about a plan being changed without the
enrollees consent and nearly 130,000
complaints about individuals
being enrolled in plans without their knowledge.
CMS has suspended at least 200 marketplace agents
for reasonable suspicion of fraud since June.
The proposed rules would also add a new
model consent form designed to help agents and
brokers better document a customer's consent to enroll
in a plan or change their coverage.
The agency is also proposing allowing insurers to
implement fixed dollar or percentage based thresholds to
allow individuals
to maintain their coverage even if they have
not paid their full monthly premium. The agency
proposed capping that amount at $5 or less.
CMS has also proposed several updates to the
risk adjustment program, which spreads out costs between
insurers in state marketplaces.
The agency proposed updating its models with data
from 2020 to 2022.
In addition to updating the models, CMS is
proposing phasing out special adjustments for hepatitis c
drugs and adding new adjustments for pre exposure
prophylaxis drugs to treat
HIV.
CMS is also seeking comment on how to
reduce the risk of insurer insolvencies in the
ACA marketplace.
In recent years, multiple plans have become insolvent,
leaving enrollees without coverage and insurers without risk
adjustment payments.
Those proposed rules are open for comment until
November 12th.
Vice president Kamala Harris has proposed expanding Medicare
coverage for home health care. Miss Harris explained
the due details of her proposal on the
daytime talk show, The View,
Campaign AIDS told NPR.
The benefit would cover the cost of in
home health aids and other home services.
Medicare usually does not cover intermittent skilled nursing
care at home or long term in home
care.
Miss Harris' campaign did not provide specific estimates
for how much the proposal would cost. The
proposal would be partially paid for by expanding
Medicare drug price negotiations.
The policy is designed to appeal to the,
quote, sandwich generation or adults who care for
both aging parents and children. More than 40%
of Americans provide unpaid caregiving.
Donald Donald Trump's campaign said the former president's
platform also includes a commitment to at home
care.
UPMC Health Plan is named Marybeth Jenkins president
and CEO. That's effective January 1st. Miss Jenkins
has also been named president of UPMC Insurance
Services Division. She served in several roles at
UPMC
since 1998, most recently as EVP and COO
at UPMC Insurance Services Division. She's replacing current
president and CEO Diane Holder, who is retiring
at the end of the year after 4
years with the organization.
And finally, CVS Health will lay off 416
employees at Aetna's headquarters in Hartford, Connecticut.
In a more notice filed October 6th, the
company said 93 employees work at the facility
in Hartford. The other employees work remotely in
several states but report to the Connecticut facility.
Most of those layoffs are effective December 7th.
If you like the latest health insurance industry
news delivered straight to your inbox every morning,
subscribe to the Becker's Payer Issues e newsletter
on our website at beckerspayor.com.