Payer Strategy & Models
Expert articles and analysis related to payer strategy & models.
AI Summary — Last 30 Days
Synthesis:
Over the past 30 days, the Trump administration’s CMS has intensified scrutiny of Medicare Advantage (MA) over payment practices and is considering default enrollment mechanisms, potentially bolstering plan enrollment while responding to Congressional calls to address overpayments and program integrity. Simultaneously, value-based care adoption is accelerating, driven by CMS.
Related Articles
CommonSpirit, Cigna go out of network in Tennessee, Georgia
CommonSpirit, Cigna go out of network in Tennessee, Georgia Becker's Hospital Review
Elevance expands out-of-network referral penalties to New York
Elevance expands out-of-network referral penalties to New York Modern Healthcare
She Owed Her Insurer a Nickel, So It Canceled Her Coverage
When medical bills started rolling in, a teacher’s aide in Florida wondered why her insurance suddenly wasn’t covering them. The answer? She owed a balance of 5 cents, so her insurer canceled her poli...
Platinum Plans – Strategic Design Opportunity or Repeat of Past Mistakes?
The 2027 Actuarial Value Calculator creates a timely opportunity for health plans to reintroduce Platinum products—not as broad offerings, but as targeted, condition-specific strategies that can mater...
10 Things to Know About Medicaid Managed Care
Our updated explainer provides an overview of comprehensive managed care, the most common way states deliver Medicaid services to enrollees.
Payers, hospitals pan CMS' plan to bring non-network plans to ACA exchanges
Payers, hospitals pan CMS' plan to bring non-network plans to ACA exchanges Fierce Healthcare
Elevance expands policy penalizing out-of-network referrals
Elevance expands policy penalizing out-of-network referrals Modern Healthcare
Elevance to expand 10% out-of-network penalty policy into California
Elevance to expand 10% out-of-network penalty policy into California Becker's Hospital Review
‘Non-network’ health plans see opportunity in ACA proposal
‘Non-network’ health plans see opportunity in ACA proposal Modern Healthcare
Selected Diabetes and Weight Loss Drugs Were Dispensed to Michigan Medicaid Managed Care Enrollees in Accordance With Federal and State Requirements - Office of Inspector General (.gov)
Selected Diabetes and Weight Loss Drugs Were Dispensed to Michigan Medicaid Managed Care Enrollees in Accordance With Federal and State Requirements Office of Inspector General (.gov)