ACA marketplace subsidy verification rule would reduce enrollment starting in 2028
Proposed annual verification processes for Affordable Care Act (ACA) marketplace insurance subsidies could prove disruptive to returning enrollees. A CMS proposed rule would implement provisions of H.R. 1 (also known as the One Big Beautiful Bill Act or the Working Families Tax Cut Act) starting with 2028 open enrollment. An enrollee applying for subsidies with…
Hospital financial performance improves as Medicaid funding risks grow
Going back to early 2026, hospital and health system financials have started to reflect industry responses to H.R. 1, the One Big Beautiful Bill Act (OBBBA). In new reporting (registration required) from Strata Decision Technology on first-half 2026 trends, health system financial performance improved over the six-month period, even as margins remained tight. After falling…
2027 Medicare Advantage Star Ratings show gains in high-rated plan enrollment
More than 70% of beneficiaries in Medicare Advantage (MA) plans that include prescription drug coverage are in contracts rated at least four stars out of five, according to CMS’s Star Rating release for 2027. Those plans are in line for quality-bonus payments and in 2028 will receive higher rebates that are used to support supplemental…
Elevance Health brings commercial site-neutral payment to hospital claims
Elevance Health is moving site-neutral payment concepts into commercial reimbursement, with a Sept. 29 announcement setting the stage for constraints on hospital payment. The insurer said it would incorporate a series of new billing policies “intended to address increasingly common situations where care provided at an off-campus location is billed at a higher hospital rate.”…
Value-based care and alternative payment models: What they are and how they work
Value-based care (VBC) is an approach to healthcare that seeks to improve the quality, outcomes and experience of care while managing its cost. Rather than rewarding healthcare organizations solely for the volume of services they provide, value-based arrangements link some or all payment to measures of quality, outcomes, utilization or total cost of care. The…
James Mathews: Why site-neutral payment does not mean eliminating the IPO list
During my tenure at the Medicare Payment Advisory Commission (MedPAC), the Commission recommended that Medicare implement site-neutral payment for certain services and procedures in defined circumstances. The premise was sound at the time, but ideas about this approach have evolved in recent years — to the point that it may have led CMS to the…
CMS guidance details how states can apply the Medicaid medical frailty exemption
New guidance from CMS explains how states can operationalize the medical frailty exemption to the Medicaid work requirement. Per the guidance, the intent is for states to identify medically frail beneficiaries proactively through claims and other existing data to the degree possible, thereby alleviating the administrative burden and risk of coverage loss facing those beneficiaries.…
CMS cites ACA marketplace enrollment fraud in issuing 760,000 coverage cancellations
CMS has canceled roughly 315,000 enrollments encompassing 760,000 people in Affordable Care Act (ACA) marketplace plans, citing suspected fraud, according to a Sept. 22 announcement by the Trump administration. And the numbers soon could grow. The administration also plans to commence verification of legal residency, Social Security numbers, and income and other eligibility criteria for…
2027 Medicare lab fee schedule points to 15% cuts across many test codes
Preliminary data for the 2027 Clinical Laboratory Fee Schedule (CLFS) indicate substantial downward pressure on Medicare reimbursement for lab services. CMS released information on the 2027 payment rates ahead of final rates expected in November, projecting that the methodology used to set the rates would save $1 billion annually for Medicare. Hospital-based and freestanding labs…
Compliance audit efficiency, a new learning experience from HFMA and updates on Medicaid eligibility
Erika Grotto talks with Dawn Crump from MRO about audit efficiency. Michael Grant, HFMA’s director of learning experience, discusses updates to HFMA’s learning platform. In the news segment, Nick Hut talks with HFMA policy director Katie Gilfillan about Medicaid eligibility updates.