Health Plan Weekly

CMS released its 2025 Medicare Advantage and Part D Star Ratings on Oct. 10, following outcry and legal challenges to its calculations. After applying the Tukey outlier deletion methodology for the second year in a row and recalculating the much-contested 2024 Star Ratings, CMS revealed that 40% of Medicare Advantage Prescription Drug (MA-PD) contracts earned overall ratings of 4 stars or higher, and 62% of enrollees are in plans that will be rated 4 or more stars in 2025. Around 25% of Part D Prescription Drug Plans earned 4 or more stars, and 5% of PDP enrollees are in contracts with 4 or more stars. 

Of the major publicly traded insurers, overall ratings for CVS Health Corp. and Cigna Healthcare (which intends to sell its MA assets to Health Care Service Corp.) were largely unchanged in terms of membership estimated to be enrolled in plans rated 4 stars or higher (69% and 88%, respectively), according to an Oct. 10 research note from Evercore ISI. “This lack of [year-over-year] change provides official validation in what we learned from the MA plan finder last week and provides additional certainty around 2026 earnings and CVS’s longer-term MA margin recovery,” wrote securities analyst Elizabeth Anderson. MA plans that earn 4 stars or more qualify for quality bonus payments in 2026. 

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.