Health Plan Weekly

UnitedHealth Group is under investigation by the Dept. of Justice (DOJ) for possible criminal Medicare fraud, The Wall Street Journal reported on May 14. The WSJ report cited “people familiar with the matter” and said the exact nature of the investigation is unclear, although it is linked to the insurer’s Medicare billing practices — which the DOJ is already investigating as a civil matter. The report comes just days after UnitedHealth’s now-former CEO Andrew Witty abruptly stepped down from the position amid turmoil over the company’s first-quarter performance. UnitedHealth denied knowledge of the “supposed criminal investigation” and said “we stand by the integrity of our Medicare Advantage program.” RBC Capital Markets analysts reported in a note to investors that shares of UnitedHealth’s stock declined 8% following the WSJ story, bringing share declines to more than 50% since the insurer released its first-quarter earnings on April 17. 

When CVS Health Corp.’s Aetna said on May 1 that it will leave the Affordable Care Act exchanges next year, it sparked new concerns about the future of the marketplace under President Donald Trump. But not long after that announcement, CMS quietly issued a bulletin that policy experts say could have an even bigger negative impact on the exchanges. 

The key part of the bulletin, which was issued May 2, has to do with cost-sharing reductions (CSR), which is one of two types of subsidies provided to ACA exchange enrollees based on their income level. (The other type of subsidy is advance premium tax credits, or APTCs.) As their name indicates, CSRs help reduce cost-sharing levels — such as deductibles, copays and coinsurance — for lower-income individuals.  

CVS Health Corp.-owned Aetna plans to exit the Affordable Care Act exchange business in 2026, after projecting big financial losses from the segment this year. As the second-largest insurer in the ACA marketplace, Aetna’s withdrawal means almost 1.6 million enrollees will have to choose another insurer or become uninsured in 2026.

Aetna offered exchange plans in 16 states in 2015, but it fully exited the exchanges in the 2018 plan year, citing financial losses. After CVS acquired Aetna for $78 billion in 2018, the insurer rejoined the ACA marketplace in 2022 and has since expanded its footprint to 16 states, and it is the second-largest ACA insurer as of the fourth quarter of 2024, according to data from the Robert Wood Johnson Foundation and AIS’s Directory of Health Plans (DHP).

The three publicly traded insurtechs — Alignment Healthcare, Inc., Clover Health Investments Corp. and Oscar Health, Inc. — all had strong membership, revenue and profit growth in the first quarter. While the companies had struggled after going public a few years ago, the three have each turned around their businesses and continued their success from 2024.  

Ari Gottlieb, principal of health care consulting firm A2 Strategies and a longtime critic of the insurtechs, says he has changed his tune in the past year on them.  

The U.S. Supreme Court’s recent decision in an Employee Retirement Income Security Act (ERISA) case could open employers and health plan fiduciaries to a flood of new ERISA lawsuits, experts tell AIS Health, a division of MMIT. 

In the Cunningham v. Cornell decision, handed down April 17, the court unanimously ruled that plaintiffs can bring prohibited transaction claims without noting the exemptions, as those are up to defendants to plead and prove. 

Under ERISA section 406 (a) (1) (C), payments that ERISA-covered plans make to a service provider that could benefit that provider are prohibited transactions. The idea, generally, is to prevent self-dealing and protect plan participants and beneficiaries from conflicts of interest. Section 408 describes exceptions to this, including paying a party in interest reasonable compensation for necessary services.