Health Plan Weekly

When CMS on Oct. 4 proposed the 2026 omnibus regulation for Affordable Care Act exchange plans, the agency heavily emphasized the rule’s new safeguards to protect consumers from fraudulent changes to their health care coverage. Although those provisions are indeed noteworthy, policy experts say there are other interesting proposals — and omissions — to digest in the voluminous Notice of Benefit and Payment Parameters (NBPP). 

Emily Donaldson, a principal at Avalere Health, says she expects the health insurance industry and patient advocates alike to have much to say about CMS’s proposal to incorporate HIV pre-exposure prophylaxis (PrEP) services into the 2026 risk adjustment models “as a new, separate factor.” 

One or two hospitals or health systems controlled the entire market for general inpatient hospital care in nearly half of metropolitan areas in 2022, according to a recent KFF analysis.

Based on RAND Hospital Data and American Hospital Association survey data, the analysis found that in more than four out of five metropolitan areas across the country, one or two health systems were responsible for more than 75% of all inpatient hospital discharges in their area.

Competition can also be measured by the Herfindahl-Hirschman Index (HHI), an indicator of a market’s concentration level. Unconcentrated markets have an HHI below 1,000; moderately concentrated markets have an HHI between 1,000 and 1,800; and highly concentrated markets are those with HHIs above 1,800, according to the current merger guidelines from the Federal Trade Commission and the Dept. of Justice.

Blood-based marker tests (BBMTs) may help clinicians more accurately and easily diagnose people with Alzheimer’s disease and aid in identifying patients who could benefit from two recently approved disease-modifying therapies, according to a viewpoint article published on Sept. 30 in JAMA. The piece’s lead author tells AIS Health that BBMTs could potentially offer a “real breakthrough in access to testing” for Alzheimer’s, although she notes payers have yet to cover the tests and need more clinical evidence before paying for them. 

The FDA in July approved Kisunla (donanemab), a once-monthly, IV-infused treatment for people with early symptoms of Alzheimer’s. The agency’s decision occurred one year after it fully approved Leqembi (lecanemab), a similar Alzheimer’s drug. Kisunla and Leqembi both aim to slow the progression of Alzheimer’s by removing amyloid plaques from the brain.  

A program that provides non-medical interventions for North Carolina’s high-risk Medicaid population resulted in cost savings and fewer hospitalizations, according to a third-party analysis and speakers who participated in a recent Manatt, Phelps & Phillips LLP webinar. Heidi Chan, market president for AmeriHealth Caritas, said the Healthy Opportunities Pilots (HOP) “is truly an innovative program” and helps provide “whole-person care” for vulnerable beneficiaries who suffer from food, housing and transportation insecurity. 

Kody Kinsley, secretary of the North Carolina Dept. of Health and Human Services (NCDHHS), added that the state launched the HOP in March 2022 as part of a CMS Section 1115 waiver amid the state’s push to better serve rural and low-income residents. The state also expanded Medicaid eligibility starting in July 2021 to people between 19 and 64 years old with incomes up to 138% of the poverty level.