Health Plan Weekly

In a development that one expert calls a “huge victory for the industry,” a federal judge has ordered CMS to recalculate UnitedHealthcare’s 2025 Medicare Advantage Star Ratings without factoring in a lone “secret shopper” call that downgraded the ratings of several of the insurer’s plans. Wall Street analysts also predicted that the ruling could be a boon for one specific MA-focused insurer: Humana Inc., which filed a lawsuit against CMS for a similar issue.

In an opinion issued Nov. 22, Judge Jeremy Kernodle of the U.S. District Court for the Eastern District of Texas partially granted UnitedHealth’s motion for summary judgment, agreeing with the insurer that CMS violated the Administrative Procedure Act (APA) when it assigned a 4-star rating to the performance of UnitedHealth’s call center.

High-deductible health plans (HDHPs), which are a popular plan-design choice among those attracted to their typically lower premiums, could be contributing to wealth disparities based on race and ethnicity, according to a recent Health Affairs study. Health policy experts tell AIS Health, a division of MMIT, that the results suggest more plan sponsors could help beneficiaries fund health savings accounts (HSAs) or other options to meet their deductibles. They also say policymakers could adopt regulations to limit out-of-pocket spending for medical care and prescription drugs.

The study authors analyzed data from the Medical Expenditure Panel Survey (MEPS) from 2011 through 2018 and evaluated 68,841 adults who had private insurance. They had access to financial information, including people’s incomes and net worths, which they defined as the sum of their assets minus any debts they owed. The assets included vehicles and houses as well as financial assets such as cash, savings accounts, retirement accounts and non-retirement investment accounts.

Merger and acquisition (M&A) activity among insurers has led to “stubbornly” high concentration in insurance markets, according to a report from the American Medical Association. And while the Department of Justice (DOJ) has put a damper on horizontal mega-mergers, many insurers are going vertical.

The report, titled Competition in Health Insurance: A Comprehensive Study of US Markets, analyzed insurance market share in 382 metropolitan statistical areas (MSAs), the 50 states, and the District of Columbia between 2014 and 2023. During that period, the share of commercial insurance markets that were highly concentrated hovered between 95% and 96%. Forty-nine percent of markets that were highly concentrated in 2014 were even more consolidated by 2023. In 89% of MSAs, at least one insurer held a market share of 30% or greater. One insurer’s market share was at least 50% in 47% of MSAs. And 69% of the markets that were not highly concentrated in 2014 experienced an increase large enough to consider them highly concentrated by 2023.

The U.S. health care system is currently ill-equipped to meet the high and growing need for behavioral health services, and states need to take efforts to mitigate related workforce shortages, according to a recent report by Georgetown University’s Center on Health Insurance Reforms (CHIR).

As of August 2024, more than a third of Americans lived in a federally designated mental health professional shortage area. The inadequate behavioral health workforce — referring to a range of clinicians and paraprofessionals who specialize in delivering or supporting mental health and substance use disorder treatments — disproportionately impacts rural and marginalized communities. Over 45% of rural counties across the nation did not have practicing psychologists in 2021, compared to 16% of urban counties.

Medicare Part D and Medicaid coverage of anti-obesity medications would increase federal and state spending by $40 billion over 10 years, CMS estimated in a proposed rule released on Nov. 26, even though Part D plans could define the disease for coverage decisions.

The policy long sought by drug manufacturers and patient groups is part of the 2026 Policy and Technical Changes to the Medicare Advantage and Medicare Part D Programs proposed rule.