Healthcare Reform News Updates

Stay up-to-date on Healthcare Reform.

Below is a summary of recent events to help you stay current on healthcare reform news all in one place.

Healthcare Reform Updates for December 11, 2025

DOJ shuts down $174 million Medicare telemarketing scam

A Missouri man was recently sentenced to 10 years in federal prison for orchestrating a large-scale scheme that billed Medicare for over $174 million in genetic testing, according to the U.S. Attorney’s Office for the Eastern District of Louisiana.

Jamie P. McNamara, 50, operated several laboratories for 18 months in Louisiana and Texas. During that time, he used the laboratories to submit hundreds of millions of dollars in Medicare claims for cancer and cardiovascular genetic tests.

Medicare paid over $55 million before the scheme was uncovered.

How the scheme worked

Prosecutors said McNamara relied on call centers and telemarketers who encouraged Medicare beneficiaries to accept genetic tests.

Orders were signed by telemedicine providers who: 

• Were not treating the patients
• Did not perform consultations
• Did not follow up after testing

McNamara also paid illegal kickbacks, disguised bribes through sham contracts, hid his ownership by using family members’ names on documents, and shifted billing between labs to evade scrutiny.

Additional violations

While on pretrial release, McNamara fled during an unrelated arrest and cut off an ankle monitor, leading to his detention until sentencing.

A 10-year sentence for Medicare fraud

In November, a federal judge imposed the maximum penalty for McNamara, which includes:

• 10 years in prison
• 3 years of supervised release
• More than $55 million in restitution
• Forfeiture of $7 million seized by the government

“Medicare fraud targets vulnerable populations, and our office will continue seeking just punishment for business owners and professionals who abuse this crucial trust-based system to steal taxpayer dollars,” said Acting U.S. Attorney Michael M. Simpson.

Healthcare Reform Updates November 20, 2025

CMS: Medicare enrollees to pay more for Part A & B in 2026

Medicare enrollees will pay more for Part A and Part B in 2026, as premiums, deductibles, and coinsurance amounts rise across both programs, according to the Centers for Medicare & Medicaid Services.

Here’s a look at the updated 2026 premiums, deductibles, and key cost-sharing amounts:

Part A cost changes for 2026

Here are the main Part A cost-sharing changes for 2026:

●     Inpatient hospital deductible: $1,736 (up from $1,676 in 2025)

●     Daily hospital coinsurance for days 61–90: $434 (up from $419)

●     Daily coinsurance for lifetime reserve days: $868 (up from $838)

●     Skilled nursing facility coinsurance (days 21–100): $217 per day (up from $209.50)

Part A buy-in premium

Some individuals age 65 and older and people with disabilities must pay a premium to enroll in Part A:

●     Reduced monthly premium: $311 in 2026 (up $26)

●     Full monthly premium: $565 in 2026 (up $47)

Medicare Part B costs for 2026

Medicare Part B covers physician services, outpatient hospital care, durable medical equipment, certain home health services, and other outpatient care.

Part B premium & deductible

●     Standard monthly premium: $202.90 in 2026 (up from $185.00)

●     Annual deductible: $283 in 2026 (up from $257)

CMS said the increases reflect projected price changes and expected utilization consistent with historical trends.

Impact of skin substitute payment changes

CMS noted that without 2026 fee schedule changes affecting skin substitutes, the standard Part B premium would have been about $11 higher per month.

●     Under the updated rule, these products will be treated as incident-to supplies beginning in 2026, reducing Medicare spending while maintaining patient access.

●     The change comes after Medicare spending on skin substitutes exploded from $256 million in 2019 to more than $10 billion in 2024.

Immunosuppressive drug premium

Beneficiaries who maintain Part B coverage only for immunosuppressive drugs after a kidney transplant will pay a standard premium of $121.60 in 2026.

Medicare Part D income-related adjustments

CMS also released the 2026 income-related monthly adjustment amounts for Medicare Part D.

●     These adjustments apply to about 8% of beneficiaries and are added to a plan’s monthly premium.

●     Part D plan premiums vary by plan, and CMS does not set a standard premium amount.

Healthcare Reform Updates for November 11, 2025

Medicare reform to save $19 billion in wound-care payments

Changes to Medicare’s payment rules for wound-care products are expected to save about $19 billion next year, according to the Centers for Medicare & Medicaid Services.

The changes outlined in the 2026 Medicare Physician Fee Schedule final rule aim to:

• Modernize payment systems
• Reduce unnecessary spending
• Improve care for older adults

“The new Medicare fee schedule delivers a major win for seniors, protects hometown doctors, and safeguards American taxpayers,” said U.S. Health and Human Services Secretary Robert F. Kennedy Jr. “It realigns doctor incentives and helps move our country from a sick-care system to a true health care system.”

From 2019 to 2024, Medicare spending for wound-care products (also called “skin substitutes”) rose from $256 million to more than $10 billion a year. Medicare attributes the 3,800% increase to abusive pricing practices and the use of products with limited clinical value.

Cutting waste in wound care

• Beginning in 2026, Medicare will pay for skin-substitute products as incident-to supplies when used as part of a covered wound-care procedure.
• This change is expected to reduce related spending by nearly 90% without compromising access or quality of care.

The final rule also includes updates to improve payment accuracy, expand preventive services, and strengthen chronic disease management for Medicare beneficiaries.

Healthcare Reform Updates for November 7, 2025

Audit: Medicare system error paid suppliers $22.7 million

Medicare mistakenly paid suppliers $22.7 million over seven years for durable medical equipment, according to a U.S. Department of Health and Human Services Office of Inspector General audit report.

Auditors found that payments were made for prosthetics, orthotics, and other supplies provided to enrollees during inpatient hospital stays. In addition, up to $5.9 million in deductibles and coinsurance may have been wrongly collected.

“Medicare overpaid suppliers because the system edits that should have prevented or detected the overpayments were not adequate,” said OIG Acting Deputy Inspector General for Audit Services Carla Lewis.

Medicare billing rules for in-patient care

Under Medicare rules, suppliers should not bill for DMEPOS items provided while a patient is admitted to a hospital or other inpatient facility. Those items must be supplied by the facility or through an arrangement with it.

“None of the $22.7 million in payments for DMEPOS items covered by this audit should have been paid,” according to the audit report.

“Because improper payments continue to be made, further review of the edits may be necessary to determine whether refinements are needed.”

Although the Centers for Medicare & Medicaid Services updated its payment system edits in January 2020 to reduce these errors, auditors found that improper payments continued.

Next steps

Based on the findings, CMS will seek to recover the $22.7 million, ensure refunds to beneficiaries, and fix billing system errors.

In 2024, auditors found that improper Medicare payments totaled $31.7 billion dollars caused by billing and documentation errors.

Healthcare Reform Updates for October 15, 2025

Arizona couple sentenced for $1.2 billion Medicare fraud scheme

A husband-and-wife team from Phoenix, Ariz., were recently sentenced to prison for orchestrating a $1.2 billion Medicare fraud scheme. 

• Jeffrey King, 46, and his wife, Alexandra Gehrke, 39, pleaded guilty earlier this year to conspiracy to commit health care fraud and wire fraud, according to the U.S. Department of Justice. 
• Last week Gehrke was sentenced to 15.5 years in prison, and King was sentenced to 14 years in prison.

The couple submitted more than $1.2 billion in false and fraudulent claims from 2022 to 2024 to:

• Medicare
• TRICARE
• Civilian Health and Medical Program of the Department of Veterans Affairs
• Private insurers

In addition to their prison sentences, King and Gehrke were ordered to pay over $1.2 billion in restitution and forfeit $410 million in assets, including luxury cars, annuities, jewelry, and bank accounts.

Behind the Medicare fraud scheme

Gehrke operated Apex Medical LLC and Viking Medical Consultants LLC, which recruited elderly and terminally ill patients for expensive, medically unnecessary wound grafts, according to the U.S. Department of Justice.

Investigators found that the couple:

• Paid untrained sales representatives to order large graft sizes to maximize reimbursements
• Received nearly $280 million in illegal kickbacks from a graft distributor
• Directed nurse practitioners to apply grafts, even when wounds were healed or infected
• Submitted over $960 million in false claims to federal health programs

Abnormal billing pattern tips off investigation

Investigators identified the fraud after detecting abnormal billing patterns for wound grafts through data analytics and coordinated audits conducted by the Health Care Fraud Strike Force.

Once the abnormal billing patterns were identified, agencies participating in the investigation included the:

• Federal Bureau of Investigation
• U.S. Department of Health and Human Services Office of Inspector General
• Department of Defense Office of Inspector General, Defense Criminal Investigative Service
• Department of Veterans Affairs Office of Inspector General

Healthcare Reform Updates for October 7, 2025

Medicare prescription drug premiums to drop 10% in 2026

About 50 million people enrolled in Medicare Part D prescription drug plans will pay lower premiums in 2026, according to the Centers for Medicare & Medicaid Services.

• Average premiums for Medicare Advantage and stand-alone Part D plans for prescription drug coverage will decrease by about 10% next year.

“Millions of Medicare beneficiaries will continue to have access to a broad range of affordable coverage options in 2026,” says CMS Administrator Dr. Mehmet Oz. “We want every beneficiary to take advantage of Open Enrollment—compare your options and choose the plan that gives you the right care at the best price.”

Lower premiums for prescription drug coverage

CMS estimates the average total premium for stand-alone Medicare Part D prescription drug plans will decline from:

• $38.31 in 2025 to $34.50 in 2026
• This is a $3.81 decrease, or roughly 10% lower than 2025 premiums.

For Medicare Advantage plans that include prescription drug coverage, the average Part D premium is expected to drop from:

• $13.32 in 2025 to $11.50 in 2026
• This is a $1.82 decrease, or about 14% lower after accounting for plan rebates.

Controlling prescription drug plan premiums

Lower premiums for Medicare prescription drug plans are partly the result of the Part D Premium Stabilization Demonstration, introduced in 2025.

• The program helps keep premiums predictable by limiting large year-to-year price increases and sharing more financial risk with private insurance companies that offer Medicare plans.
• In simple terms, it helps prevent sudden jumps in drug plan costs.

Nearly everyone enrolled in stand-alone Part D plans in 2025 are covered by private insurance companies participating in the program for 2026.

Open Enrollment begins October 15

Medicare Open Enrollment for the 2026 plan year runs from October 15 to December 7, 2025.

Healthcare Reform Updates for September 12, 2025

New eligibility rules expand access to catastrophic insurance

Catastrophic health insurance will be available to more consumers starting November 1, 2025, according to the U.S. Department of Health and Human Services.

Catastrophic health insurance is a low-premium, high-deductible plan designed to provide healthcare coverage for consumers in worst-case scenarios such as a serious illness or injury.

In 2025, only about 54,000 people purchased catastrophic health plans. That number could grow under the new HHS guidelines.

Here’s how access is changing:

• Eligibility: Previously limited to people under 30 or those with a hardship exemption. Now includes anyone who doesn’t qualify for premium tax credits or cost-sharing reductions.
• Application: Consumers who don’t receive premium tax credits can apply for a hardship exemption.
• Access: Once approved, they may enroll in a catastrophic plan, regardless of age.

“Catastrophic coverage offers affordable health insurance for younger Americans and those facing hardship to have security when they need it most,” says Secretary of Health and Human Services Robert F. Kennedy, Jr. “Expanding access to catastrophic coverage is another step in making health insurance more affordable.”

Beginning November 1, 2025, consumers can apply for the hardship exemption in two ways:

• Apply online for Marketplace coverage on gov or through a certified partner. Household income will be reviewed as part of the application process.
• Submit a hardship exemption form by mail.

For carriers: Expanded eligibility may increase demand for catastrophic plans, particularly among consumers priced out of bronze or silver coverage.

Healthcare Reform Updates for September 3, 2025

Federal announcement may extend short-term health insurance options

Last year, the federal government cut the duration of short-term health insurance to a maximum of four months (three months with a one-month extension). But that may change, according to a new announcement from the Centers for Medicare & Medicaid Services.

Federal agencies reviewing the rules of short-term health insurance include the U.S. Departments of Labor, Health and Human Services, and the Treasury.

According to a joint statement published on August 7, 2025:

• “Until future rulemaking is issued and applicable, the Departments do not intend to prioritize enforcement actions for violations related to failing to meet the definition of short-term, limited duration insurance” in the 2024 final rules, including the notice provision.

Short-term rules under review

The rules under review include limited short-term, limited-duration insurance that limits plans to an initial contract of three months and a maximum coverage period of four months.

Prior to the 2024 rules, short-term health insurance was available for 12 months in some states, and renewable two more times, for coverage up to three years.

What it may mean for consumers and carriers

• Longer coverage may return. In many states, insurers may again offer short-term plans with terms of up to 12 months, renewable to a maximum of 36 months.
• Carriers may expand offerings. With federal enforcement paused, carriers could reintroduce longer short-term health plans in states that allow them.
• State rules still apply. Some states restrict or ban short-term plans regardless of federal enforcement. Availability depends on where you live.
• Protections remain limited. Short-term insurance is not required to cover preexisting conditions or essential benefits such as preventive care, prescription drugs, or mental health services.

Healthcare Reform Updates for August 19, 2025

Medicare inpatient psychiatric facilities to receive $70 million boost for fiscal year 2026

Payments for Medicare inpatient psychiatric facilities will rise by 2.5% in fiscal year 2026, adding about $70 million in funding, according to a final rule from the Centers for Medicare & Medicaid Services.

Medicare helps cover inpatient psychiatric care for thousands of older adults and people with disabilities each year, often in rural or teaching hospitals that rely heavily on federal funding. The new payment updates will take effect October 1, 2025.

What it means for Medicare providers

• Higher payments: Rural and teaching facilities will receive larger adjustments based on updated cost data. It’s the first update to these facility-level adjustments in nearly two decades.
• Reporting changes: The Centers for Medicare & Medicaid Services is removing four quality measures on health equity, COVID-19 vaccination coverage among staff, and social drivers of health. It is also adjusting the reporting period for one measure and shortening the timeframe for requesting reporting exceptions from 90 to 60 days.
• Compliance requirements: Facilities that do not submit required quality data will face a 2 percent payment reduction.

What it means for Medicare beneficiaries

• Access to care: The payment increases are designed to help facilities remain financially stable, especially in rural areas, supporting continued access to inpatient psychiatric treatment.
• Transparency: New measures are being considered on well-being, nutrition, and digital reporting, along with a future five-star rating system to make it easier for patients to compare facilities.

“These policies will improve or maintain individual access to high-quality care by ensuring that payment rates reflect the best available data on the resources involved in inpatient psychiatric care and the costs of these resources,” according to the Centers for Medicare & Medicaid Services.

Healthcare Reform Updates for August 13, 2025

Medicare skilled nursing facility payments to increase by approximately $1.16 billion for fiscal year 2026

Medicare skilled nursing facility payments will rise by approximately $1.16 billion in 2026 under a final rule from the Centers for Medicare & Medicaid Services.

The change, effective October 1, 2025, increases payment rates by 3.2% and updates rules on patient classification, quality reporting, and the Value-Based Purchasing program for Medicare-approved skilled nursing providers.

Key changes for skilled nursing facilities include:

• Higher payment rates: Medicare’s daily payment rates for skilled nursing facilities will increase 3.2% beginning October 1, 2025.
• Better patient classification: Technical updates to Medicare’s payment classification system, known as the Patient-Driven Payment Model, will help ensure payments more accurately reflect the care needs of each patient.
• Simpler reporting: Skilled nursing facilities will no longer be required to collect and report four social determinants of health data (food, housing, utilities, and clothing) for patients admitted on or after October 1, 2025.
• Appeal rights: Skilled nursing facilities can now appeal findings of non-compliance through a formal reconsideration process.
• Value-based purchasing updates: The “health equity” scoring adjustment will be removed, and a new measure called Within-Stay Potentially Preventable Readmissions will be scored under the VBP program starting in FY 2028.

What this means for Medicare beneficiaries

For the 65 million Americans enrolled in Medicare, these updates could mean better care, more accurate facility evaluations, and less time wasted on paperwork. Here’s what’s changing:

• Potentially better-quality care: Payment and scoring changes are designed to align reimbursements with patient needs and improve outcomes.
• Greater accountability: Facilities will be rewarded or penalized based on measurable performance, such as readmission rates.
• Less red tape for providers: Streamlined reporting could allow facilities to focus more on patient care.

Healthcare Reform Updates for July 22, 2025

DOJ: Florida man sentenced for $61 million Medicare fraud scheme

A 64-year-old Florida man was recently sentenced to 12 years in prison and three years supervised release for a $61 million Medicare fraud scheme involving durable medical equipment (DME), according to the U.S. Department of Justice.

Peter Roussonicolos pleaded guilty to conspiracy to commit health care fraud and wire fraud in November 2024. In addition to the prison sentence, he was ordered to pay $21 million in restitution and forfeit $2.5 million.

Behind the Medicare fraud scheme

Roussonicolos operated five DME companies as a silent partner, concealing his involvement due to prior felony convictions that made him ineligible to enroll as a Medicare supplier, U.S. Office of Inspector General.

Investigators from the U.S. Department of Health and Human Services and the Federal Bureau of Investigation also found that Roussonicolos:

• Recruited others to serve as front owners of his companies
• Falsified Medicare enrollment forms, bank records, and other documents
• Participated in a kickback scheme involving payments to patient recruiters
• Billed Medicare for $61.5 million in false claims for medically unnecessary DME
• Received $26.7 million in improper reimbursements

“This defendant and his co-conspirators orchestrated an elaborate scheme to steal millions from Medicare through kickbacks and sham billing,” said Assistant Director Jose A. Perez of the FBI Criminal Investigative Division.

“Today’s sentencing demonstrates that those who exploit our healthcare system for personal gain will be held accountable.”

Healthcare Reform Updates for July 16, 2025

New Medicare program aims to reduce waste & improve prior authorization process

Medicare is launching a new program to reduce fraud, waste and abuse, after identifying an estimated $5.8 billion was wasted on low-value and unnecessary services in 2022. The program is also designed to improve care and the prior authorization process.

• The Wasteful and Inappropriate Service Reduction (WISeR) Model will combine artificial intelligence with clinical expertise to identify services that may be overused, offer little benefit, or expose Original Medicare patients to unnecessary risks.

CMS will work with companies using artificial intelligence to help review selected services prone to overuse, including:

• Skin and tissue substitutes
• Nerve stimulator implants, and…
• Knee arthroscopy for osteoarthritis

The WISeR Model: How it works

CMS will select companies to support the WISeR program based on geographic regions.

• Selected companies must have licensed clinicians with expertise to conduct medical reviews and validate coverage determinations.
• Artificial intelligence will be used the support the review process
• Denials for services that don’t meet Medicare coverage requirements will be reviewed and confirmed by licensed clinicians, not just computers.

“Combining the speed of technology and experienced clinicians, this new model helps bring Medicare into the 21st century by testing a streamlined prior authorization process, while protecting Medicare beneficiaries from being given unnecessary and often costly procedures,” says Centers for Medicare and Medicaid Services Administrator Dr. Mehmet Oz.

What it means for Original Medicare beneficiaries

The WISeR Model will not change Medicare’s coverage or payment criteria. Original Medicare beneficiaries will still be able to see the provider or supplier of their choice.

However, for selected services under the WISeR Model, providers will be required to either:

• Submit a prior authorization request, or
• Have the claim undergo pre-payment medical review

Providers with strong compliance records may qualify for exemptions in the future, reducing paperwork and focusing oversight on higher-risk areas.

Healthcare Reform Updates for July 8, 2025

CMS final rule reshapes enrollment, premiums and broker oversight

The Centers for Medicare and Medicaid Services recently finalized new changes to Affordable Care Act Marketplace rules. The updates affect enrollment periods, eligibility checks, plan renewals, premium payments and other Marketplace processes. Changes will be phased in between 2025 and 2028.

“This final rule also enacts permanent reforms to help the markets reset to the changing subsidy environment to improve affordability and stability over the long-term,” according to the U.S. Department of Health and Human Services.

Here’s a look at what’s changing and when the updates take effect:

Automatic re-enrollment is still the default, but premium subsidies are not.

• If you don’t take action during Open Enrollment, you’ll likely be re-enrolled in the same or a similar plan for the next year.
• However, if you received financial help through Advance Premium Tax Credits and haven’t filed or reconciled your federal tax return, you may lose that subsidy unless you update your information or resolve any tax issues, even if your plan renews automatically.

End of the monthly Special Enrollment Period…

• for people earning less than 150% of the federal poverty level (for example: less than $21,870 for a single person or $52,710 for a family of five).

Stricter verification of income and eligibility before tax credits are applied.

• Applicants without a recent federal tax return will be required to submit proof of income.

Insurers may now deny coverage due to unpaid premiums if you are re-enrolling with the same insurer.

• A previous rule limited the ability of insurers to deny new-year coverage based on past-due payments.
• The new rule reverses that position and allows insurers to base enrollment decisions on repayment of prior-year premiums.
• Insurers may also apply new payments to past-due balances before coverage begins.

Deferred Action for Childhood Arrivals will no longer be eligible for Marketplace coverage.

• This rule reverses a previous change that would have allowed them to buy health insurance through the Marketplace.

Open Enrollment Period will shift to November 1 to December 31

• Starting with the 2027 plan year for federal Marketplace states.
• States with their own exchanges can continue setting their own enrollment periods, as long as they stay within a 9-week window and close by December 31.

States will be allowed to update Essential Health Benefits benchmark plans beginning in Plan Year 2028.

• These updates can reflect sex-based differences in health needs and address care gaps such as gender-specific services or LGBTQ+ health coverage.
• However, any changes must align with nondiscrimination requirements under the Affordable Care Act and be based on clinical evidence.

Stronger oversight of agents and brokers to prevent misconduct.

• The rule gives CMS more authority to investigate and terminate agents or brokers who engage in unauthorized enrollments, falsify income, or switch plans without consent.
• The update follows a surge of complaints and fraud cases involving improper Marketplace enrollments.

The final rule takes effect 60 days after its publication, with different provisions becoming active in plan years 2026, 2027, or 2028.

Healthcare Reform Updates for June 3, 2025

CMS announces 2026 rate changes for Medicare Advantage and Part D

The Centers for Medicare & Medicaid Services recently announced key updates to Medicare Advantage and Part D plan rates for 2026 that could affect millions of enrollees.

An estimated 68 million Americans enrolled in Medicare could be impacted by the 2026 changes, which include:

• Increased payments to Medicare Advantage organizations
• A new annual cap on out-of-pocket drug costs for Medicare Part D

Medicare Advantage plan payments

According to the recent announcement by the Centers for Medicare & Medicaid Services:

• CMS will increase payments to Medicare Advantage plans by an average of 5.06% in 2026, up from a 3.7% increase in 2025.
• The rate changes are designed to “ensure accurate, appropriate payments to Medicare Advantage organizations and prevent wasteful Medicare spending,” according to the Centers for Medicare & Medicaid Services.

This payment increase helps Medicare Advantage insurers cover the cost of medical care for the estimated 35.7 million enrolled in Medicare Advantage plans.

Medicare Part D prescription drug coverage cap

As part of ongoing reforms under the Inflation Reduction Act, the Centers for Medicare & Medicaid Services will implement a $2,100 annual cap on out-of-pocket Medicare Part D drug costs beginning in 2026.

In 2025, Part D out-of-pocket costs were capped at $2,000.

While the new cap is slightly higher than in 2025, it continues to limit out-of-pocket expenses, especially for individuals who take high-cost medications.

Healthcare Reform Updates for January 10, 2025

New record: 23.6 million enroll in Marketplace plans before Jan. 15 deadline

An estimated 23.6 million people have selected plans for coverage in 2025 through the Health Insurance Marketplace before the Jan. 15 deadline, according to the Centers for Medicare and Medicaid Services.

• It’s the highest number of enrollments since 2013 when the Health Insurance Marketplace began offering health insurance plans through Healthcare.gov and state-based marketplaces. 
• Last year, 21.4 million people enrolled in plans through the Marketplace during Open Enrollment.

“We can’t lose sight of what’s behind our tremendous, record-setting progress: Millions of individuals and families who now have a critical connection to the lifeline of health care coverage,” says Centers for Medicare and Medicaid Services Administrator Chiquita Brooks-LaSure. 

By the numbers: Marketplace enrollment for 2025

• Current total enrollment: 23.6 million
• New enrollments: 3.2 million
• Returning consumers: 20.4 million

Coverage for $10 or less per month with tax credits

“To the millions more who may still need coverage: Don’t delay,” says Brooks-LaSure. “Help is still available, including tax credits that have made coverage more accessible by reducing the barrier posed by high costs.”

• According to CMS, 4 out of 5 people who meet eligibility requirements for coverage through the Health Insurance Marketplace can find plans for $10 or less per month with premium tax credits.

Open Enrollment deadlines

• Open Enrollment through the federal Marketplace ends January 15. 
• For state-based Marketplace Open Enrollment deadlines, see: When is Open Enrollment 2024-2025?
• Consumers must enroll by the published deadlines for coverage beginning February 1, 2025.

Healthcare Reform Update for December 13, 2024

California hospital to pay $10.25 million to settle false Medicare claims case

A California hospital will pay $10.25 million in a settlement agreement related to allegations of submitting false Medicare claims over a 10-year period, according to the U.S. Department of Justice.

Federal settlement: 

• Oroville Hospital, based in Oroville, Calif., will pay the federal government $9.5 million over the next five years, according to the settlement agreement.

State of California settlement:

• Oroville Hospital will also pay the state of California $731,046 as part of the settlement agreement.

“Improperly billing federal health care programs depletes valuable government resources used to provide medical care to millions of Americans,” says U.S. Department of Justice Principal Deputy Assistant Attorney General Brian M. Boynton.

“We will continue to protect these critical programs by pursuing those who knowingly claim reimbursement to which they are not entitled.”

According to court documents, the settlement is based on allegations that Oroville Hospital filed false Medicare claims between 2013 and 2023 that included:

• Using false diagnosis codes for systemic inflammatory response syndrome
• Admitting certain patients for whom inpatient care was not medically reasonable or necessary
• Offering improper financial compensation to hospitalists and emergency department physicians to admit patients for inpatient hospital stays when it wasn’t medically necessary

“Health care providers that improperly bill Medicare and Medicaid for medically unnecessary services to boost profits divert taxpayer funding meant to pay for services that enrollees actually need,” says Special Agent in Charge Steven J. Ryan of the U.S. Department of Heath and Human Services and the Office of Inspector General.

“When providers engage in improper financial arrangements, they undermine the integrity of medical decision-making.”

Oroville Hospital denies the allegations and is not liable for the false Medicare claims, according to the settlement agreement.

Healthcare Reform Update for December 6, 2024

5.3 million enroll in Marketplace plans since Nov. 1

Since Health Insurance Marketplace open enrollment began November 1, 2024, an estimated 5.3 million people have selected plans for coverage in 2025, according to the Centers for Medicare and Medicaid Services.

This includes:

• About 988,000 people who enrolled in a plan through the Health Insurance Marketplace for the first time
• About 4.4 million people who renewed an existing Marketplace plan or selected a new one
• About 945,000 people of the 5.3 million to enroll so far have enrolled in a health plan through a state-based marketplace

“These numbers reflect the strong and ongoing demand that individuals and families have for affordable, high-quality health care coverage and we expect this year will set another plan selection record,” says CMS Administrator Chiquita Brooks-LaSure.

According to CMS, 4 out of 5 people who meet eligibility requirements for coverage through the Health Insurance Marketplace can find plans for $10 or less per month with premium tax credits.

“Through the Marketplace millions of Americans seeking health coverage continue to find a high-quality plan at a low cost,” says Health and Human Services Secretary Xavier Becerra.

Open Enrollment deadline for coverage January 1, 2025 

Consumers who enroll in a health plan by midnight on December 15, 2024, can get full-year coverage beginning January 1, 2025. 

• The Open Enrollment period ends January 15, 2025, for states using the HealthCare.gov platform.
• For state-based Marketplace enrollment deadlines, see: When is Open Enrollment for 2024-2025?

Healthcare Reform Update for November 15, 2024

CMS releases 2025 rates for Medicare Part A & Part B

The Centers for Medicare & Medicaid recently announced 2025 rates for Medicare Parts A and B premiums and deductibles.

Beneficiaries eligible for Medicare can enroll during the open enrollment period through December 7, 2024. Beneficiaries can expect modest price increases in 2025.

New rates for Medicare in 2025 are:

Medicare Part A

Medicare Part A helps cover inpatient hospital stays, skilled nursing facility care, hospice care, and some home health services.

In 2025, Medicare beneficiaries will pay the following for Medicare Part A:

• Hospital deductible: $1,676

The Medicare Part A deductible covers the first 60 days of eligible hospital care. After 60 days, Medicare beneficiaries will pay:

• Days 61-90: $419 per day
• Beyond 90 days: $838 per lifetime reserve day

Medicare Part B

Medicare Part B covers outpatient services like doctor visits, preventive care, diagnostic tests, mental health care and some durable medical equipment. Medicare typically pays 80% of covered services.

In 2025, an individual with an annual income of less than or equal to $106,000 will pay the following for Medicare Part B:

• Monthly premium: $185
• Deductible: $257

Note: Income-monthly rate adjustments for Medicare Part B apply to beneficiaries earning more than $106,000 annually.

Healthcare Reform Update for November 7, 2024

Federal agencies crack down on illegal Medicare billing practices

Two federal agencies recently announced a partnership to help protect low-income Medicare beneficiaries from debt collectors and illegal billing practices. 

The Centers for Medicare & Medicaid Services and the Consumer Financial Protection Bureau are working together to prevent improper billing practices that affect an estimated 8.7 million qualified Medicare beneficiaries.

• Qualified Medicare beneficiaries are Medicare enrollees with limited income who qualify for protections against Medicare cost-sharing charges, such as deductibles, coinsurance, and copayments.

“Medical bills are a major contributor to bankruptcy and financial collapse for a family,” said Consumer Financial Protection Bureau Director Rohit Chopra. “We are working to ensure that Medicare beneficiaries are not subjected to illegal debt collection on improper medical bills.”

Here’s how the plan aims to help low-income Medicare beneficiaries:

• Enforce billing restrictions: Healthcare providers, including those in Medicare Advantage plans, are prohibited from billing qualified Medicare beneficiaries for Medicare cost-sharing.
• Stop debt collection: Debt collectors may not pursue collections on prohibited Medicare charges, according to the Fair Debt Collection Practices Act.
• Issue refunds: Insurance providers that collect money from low-income Medicare beneficiaries must issue refunds for any payments received for Medicare-covered services.
• Protect credit reports: Attempting to collect “debts not owed” can negatively impact credit reports, affecting beneficiaries’ access to housing, utilities, and other forms of insurance.

“Protecting low-income Medicare beneficiaries from illegal billing practices and debt collection is a priority,” said Centers for Medicare & Medicaid Services Administrator Chiquita Brooks-LaSure. “Qualified Medicare beneficiaries should never be charged for Medicare cost-sharing, period.”

Healthcare Reform Update for September 6, 2024

Hospice provider to pay $3.85 million for false Medicare claims

A nationwide hospice and home healthcare provider has agreed to pay $3.85 million for allegedly submitting false Medicare claims over a five-year period, according to the U.S. Department of Justice.

Intrepid, U.S.A., based in Dallas, Texas, with locations in 14 states, will pay to resolve allegations that the company violated the False Claims Act between 2016 and 2021 in two specific ways:

1. Submitting Medicare claims for patients who did not qualify for the Medicare home health benefit
2. Submitting Medicare claims for patients who did not qualify for the hospice benefit

“Businesses that engage in improper Medicare billing practices undercut the legitimate provision of healthcare services for patients in need,” says U.S. Attorney Andrew Luger.

“This settlement reinforces the importance of holding accountable health care providers who seek financial gain above quality patient care.”

According to the settlement, allegations against Intrepid also suggest the company:

• Provided home care and therapy services to Medicare beneficiaries that were not reasonable or medically necessary
• Provided services to Medicare beneficiaries by unlicensed or untrained staff
• Admitted patients to hospice care who were ineligible for the Medicare hospice benefit
• Submitted claims for services that were never provided

“Medicare’s hospice and home healthcare benefits provide critical services to vulnerable patient populations across the country,” says Principal Deputy Assistant Attorney General Brian M. Boynton, head of the Justice Department’s Civil Division.

“This settlement reflects our commitment to ensuring that these benefits are used to care for those who need them and not just to enrich those who seek to provide them.”

Healthcare Reform Update for August 16, 2024

Lower prices for 10 drugs to save Medicare $6 billion annually

Lower prices for 10 drugs widely used by Medicare beneficiaries will save an estimated $6 billion a year, beginning January 1, 2026, according to the Centers for Medicare & Medicaid Services.

• Last year 10 drugs were selected for pricing review as part of the Medicare Drug Price Negotiation Program. 
• The goal: Help lower the cost of some of the most expensive prescription drugs frequently used in the Medicare program to treat heart, disease, diabetes, and certain types of cancer.

“CMS negotiated in good faith on behalf of the millions of people who rely on these 10 drugs for their health and well-being,” says CMS Deputy Administrator and Director of the Center for Medicare Dr. Meena Seshamani. “The new negotiated prices will bring much needed financial relief, affordability, and access.”

CMS negotiated drug price discounts from 38 to 79 percent off retail prices for the following 10 drugs:

1. Eliquis (treats and prevent blood clots) 
2. Jardiance (controls blood sugar levels) 
3. Xarelto (lowers risk of stroke and blood clots) 
4. Januvia (controls blood sugar levels) 
5. Farxiga (controls blood sugar levels & lowers risk for heart disease) 
6. Entresto (treats heart failure) 
7. Enbrel (reduces symptoms of rheumatoid arthritis) 
8. Imbruvica (treats certain types of cancer) 
9. Stelara (treats plaque psoriasis, psoriatic arthritis, Crohn’s disease and ulcerative colitis)
10. Fiasp (controls blood sugar levels). This also includes: Fiasp FlexTouch; Fiasp PenFill; NovoLog; NovoLog FlexPen; NovoLog PenFill

CMS & out-of-pocket cost savings

The lower drug prices will save Medicare an estimated $100 billion over the next 10 years. 

In addition, people with Medicare prescription drug coverage will save an estimated $1.5 billion in out-of-pocket costs in 2026.

Negotiations continue to lower prescription drug costs

“Throughout the process, we remained true to our commitment to be thoughtful and transparent, meeting publicly with patients, providers, health plans, pharmacies, drug companies and others to help inform the process,” says Seshamani. “We will continue to do so for future cycles.”

• Next year, all Medicare Part D enrollees will also benefit from a $2,000 out-of-pocket cap on prescription drug costs.
• In addition, CMS will select up to 15 more drugs to review as part of the Medicare Drug Price Negotiation Program by February 1, 2025, with new pricing beginning in 2027.
•  

Healthcare Reform Update for June 25, 2024

HHS: Healthcare providers face penalties for blocking electronic health data

Healthcare providers that block access to electronic health records and information will face financial penalties, according to a new rule recently finalized by the U.S. Department of Health and Human Services.

“This final rule is designed to ensure we always have access to our own health information and that our care teams have the benefit of this information to guide their decisions,” says U.S. Department of Health and Human Services Secretary Xavier Becerra.

Penalties for blocking electronic health data:

• Fines: Fines of up to $1 million per violation
• Medicare participation: Reduced Medicare reimbursements or a one-year suspension from participating in the Medicare program
• Public disclosure: Publicly identified on websites managed by the U.S. Department of Health and Human Services
• Effective date: Beginning July 24, 2024, the U.S. Department of Health and Human Services will investigate reported violations of blocking electronic health data. Financial penalties for violations will begin Jan. 1, 2025.

“When health information can be appropriately accessed and exchanged, care is more coordinated and efficient, allowing the health care system to better serve patients,” says Becerra.

“But we must always take the necessary actions to ensure patient privacy and preferences are protected—and that’s exactly what this rule does.”

Healthcare Reform Update for June 20, 2024

Insurers may cut benefits based on 2025 Medicare Advantage rates

Some major insurance providers may cut Medicare benefits based on 2025 Medicare Advantage rates, recently announced by the Centers for Medicare and Medicaid Services.

• Payments from the government to Medicare Advantage plans are expected to increase on average by 3.70 percent, or over $16 billion, from 2024 to 2025.
• The federal government is projected to pay between $500 and $600 billion in Medicare Advantage payments to private health plans in 2025.

However, the rate change represents an estimated 0.2% drop in average payments for Medicare Advantage, which may lead to some insurers to:

• Cut or modify MA plan benefits
• Raise monthly premiums
• Reduce supplemental benefits like zero premiums, dental coverage, over-the-counter medical supplies, and other things

More than half of the 67.1 million seniors covered by Medicare, are enrolled in a Medicare Advantage plan, according to the Centers for Medicare and Medicaid Services.

“CMS continues to take steps to maintain the stability of the Medicare Advantage,” says Centers for Medicare and Medicaid Services Administrator Chiquita Brooks-LaSure.

“The finalized policies in the Rate Announcement will make improvements to keep Medicare Advantage payments up-to-date and accurate, and ensure that people with Medicare have access to robust and affordable health care options.”

Healthcare Reform Update for January 4, 2024

Marketplace enrollment up 33% from last year

An estimated 15.3 million people have enrolled in a plan through the Health Insurance Marketplace since November 1, 2023, according to the Centers for Disease Control and Prevention. This is a 33 percent increase in enrollments compared to this time last year.

By the time Open Enrollment ends on January 16, 2024, in most states, an estimated 19 million people will enroll in a health plan through the Marketplace or state-based marketplaces.

“Millions of Americans signing up for healthcare coverage under the Affordable Care Act is good news,” says U.S. Department of Health and Human Services Secretary Xavier Becerra.

“It means more Americans have the peace of mind of knowing that going to the doctor won’t empty their bank account.”

According to CMS:

• 9 out of 10 people using the Marketplace are eligible for savings
• 4 out of 5 people can find a plan through the Marketplace for $10 or less a month after subsidies
• 96 percent of consumers looking for health insurance through the Marketplace will be able to choose plans from at least three health insurers

Enrollment deadlines

• The Open Enrollment period ends January 16, 2024, for states using the HealthCare.gov platform.
• For state-based Marketplace enrollment deadlines, see: When is Open Enrollment for 2024?