Managed Care & Coverage
Expert articles and analysis related to managed care & coverage.
AI Summary â Last 30 Days
CMS is continuing to push managed-care and coverage reform through targeted payment models and Medicaid innovation, including extending the GENEROUS Model application window after strong manufacturer interestâsignaling a Trump administration focus on stateâpharma contracting and Medicaid drug-cost accountabilityâwhile commentary around CMS ACCESS points to growing federal validation of safety-net value-based models. At the same time, payer utilization-management practices are facing sharper scrutiny: a Senate report found CMSâ WISeR AI prior authorization pilot is delaying Medicare care in Washington, and bipartisan House activity targeting Medicare Advantage denialsâalongside Aetnaâs $117.7 million MA false-claims settlementâraises the compliance and operational stakes for MA plans, delegated risk groups, and providers managing downside-risk populations (WISeR delays report; GENEROUS deadline extension). Evidence from the Oncology Care Model showing lower chemotherapy use and Medicare spending in poor-prognosis cancers reinforces the strategic direction toward specialty VBC models that reward appropriate care intensity, but the broader trend is a tightening balance between cost management, access protections, and audit-ready documentation across Medicare, Medicaid, and MA.
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