Senior Healthcare Reform News Updates

Stay up-to-date on Healthcare Reform.

Below is a summary of recent events to help you stay current on the healthcare and Medicare news that impacts you. This page is updated frequently, so check back regularly to keep up with changes in the healthcare industry.

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:

Submitting Medicare claims for patients who did not qualify for the Medicare home health benefit
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:

Eliquis (treats and prevent blood clots)
Jardiance (controls blood sugar levels)
Xarelto (lowers risk of stroke and blood clots)
Januvia (controls blood sugar levels)
Farxiga (controls blood sugar levels & lowers risk for heart disease)
Entresto (treats heart failure)
Enbrel (reduces symptoms of rheumatoid arthritis)
Imbruvica (treats certain types of cancer)
Stelara (treats plaque psoriasis, psoriatic arthritis, Crohn’s disease and ulcerative colitis)
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?

Healthcare Reform Update for December 5, 2023

4.6 million enroll in Marketplace plans since Nov. 1

Since Health Insurance Marketplace open enrollment began Nov. 1, 2023, an estimated 4.6 million people have selected plans for coverage in 2024, according to the Centers for Medicare and Medicaid Services.

This includes:

920,000 people who enrolled in a plan through the Health Insurance Marketplace for the first time
7 million people who renewed an existing Marketplace plan or selected a new one

“In the first weeks of Open Enrollment, we have seen an increase in plan selections and a significant increase in the number of new enrollees year over year,” says CMS Administrator Chiquita Brooks-LaSure.

“Providing quality, affordable healthcare options is a top priority and the numbers prove that our focus is in the right place.”

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 from at least three health insurers.

Open Enrollment deadline for coverage January 1, 2024

Consumers who enroll in a health plan by midnight on December 15, 2023, can get full-year coverage beginning January 1, 2024.

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