Latest news with #healthplans
Yahoo
6 days ago
- Business
- Yahoo
Centene raises Wall Street optimism that Medicaid insurers can improve profits
By Amina Niasse NEW YORK (Reuters) -Wall Street regained confidence in Medicaid insurers after Centene said on Friday it expects to be able to raise rates charged to states for 2026 health plans for low-income Americans and strengthen profit margins. Insurer shares rose across the board. Centene shares were up 5% in early afternoon trading after falling 16% on the company's announcement of a second-quarter loss and forecast cut. Rivals UnitedHealth, CVS Health and Humana rose 1.61%, 2.69% and 3.45%, respectively. All three report earnings next week. Centene in an earnings call reassured investors it would work with states to ensure their payments for Medicaid plans match the company's increased medical costs for 2026. 'Our goal is to reprice 100%' of plans, said company CEO Sarah London. Insurers are paid a set amount by states for Medicaid plans, which are jointly funded with the federal government. Centene, UnitedHealth and Elevance have said this year that state reimbursements for these plans have lagged behind actual costs of care. Cautious investors have been looking for Medicaid health plan design changes and strategic geographic changes by the companies to reduce use of healthcare services. New work requirements for Medicaid recipients in President Donald Trump's signature tax-cut and spending bill have made some investors worry that healthy people could disenroll in coming years. The bill requires states to verify certain members are working or volunteering a minimum of 80 hours per month to qualify for Medicaid coverage starting in 2027. After a COVID-19 era requirement to keep people enrolled expired in 2023, Medicaid plans redetermined each person's eligibility. This pushed members off, changing the mix of sick and healthy participants, and some Medicaid insurers struggled. 'The Medicaid redeterminations have proven to be far more disruptive than anyone thought," said Jeff Jonas, a portfolio manager at Gabelli Funds. "The entire industry is focused on restoring margin over winning new contracts and membership." More detailed data could justify midyear price increases, said Kevin Gade, chief operating officer at Bahl & Gaynor, and correct mismatched rates set by states after the pandemic. More data over the next year will also enable insurers to improve cost management techniques and raise rates paid by states, Gade said. "With enough data you can take care of the problem.' Error in retrieving data Sign in to access your portfolio Error in retrieving data Error in retrieving data Error in retrieving data Error in retrieving data
Reuters
6 days ago
- Business
- Reuters
Centene raises Wall Street optimism that Medicaid insurers can improve profits
NEW YORK, July 25 (Reuters) - Wall Street regained confidence in Medicaid insurers after Centene (CNC.N), opens new tab said on Friday it expects to be able to raise rates charged to states for 2026 health plans for low-income Americans and strengthen profit margins. Insurer shares rose across the board. Centene shares were up 5% in early afternoon trading after falling 16% on the company's announcement of a second-quarter loss and forecast cut. Rivals UnitedHealth (UNH.N), opens new tab, CVS Health (CVS.N), opens new tab and Humana (HUM.N), opens new tab rose 1.61%, 2.69% and 3.45%, respectively. All three report earnings next week. Centene in an earnings call reassured investors it would work with states to ensure their payments for Medicaid plans match the company's increased medical costs for 2026. 'Our goal is to reprice 100%' of plans, said company CEO Sarah London. Insurers are paid a set amount by states for Medicaid plans, which are jointly funded with the federal government. Centene, UnitedHealth and Elevance have said this year that state reimbursements for these plans have lagged behind actual costs of care. Cautious investors have been looking for Medicaid health plan design changes and strategic geographic changes by the companies to reduce use of healthcare services. New work requirements for Medicaid recipients in President Donald Trump's signature tax-cut and spending bill have made some investors worry that healthy people could disenroll in coming years. The bill requires states to verify certain members are working or volunteering a minimum of 80 hours per month to qualify for Medicaid coverage starting in 2027. After a COVID-19 era requirement to keep people enrolled expired in 2023, Medicaid plans redetermined each person's eligibility. This pushed members off, changing the mix of sick and healthy participants, and some Medicaid insurers struggled. 'The Medicaid redeterminations have proven to be far more disruptive than anyone thought," said Jeff Jonas, a portfolio manager at Gabelli Funds. "The entire industry is focused on restoring margin over winning new contracts and membership." More detailed data could justify midyear price increases, said Kevin Gade, chief operating officer at Bahl & Gaynor, and correct mismatched rates set by states after the pandemic. More data over the next year will also enable insurers to improve cost management techniques and raise rates paid by states, Gade said. "With enough data you can take care of the problem.'
Yahoo
6 days ago
- Business
- Yahoo
Centene raises Wall Street optimism that Medicaid insurers can improve profits
By Amina Niasse NEW YORK (Reuters) -Wall Street regained confidence in Medicaid insurers after Centene said on Friday it expects to be able to raise rates charged to states for 2026 health plans for low-income Americans and strengthen profit margins. Insurer shares rose across the board. Centene shares were up 5% in early afternoon trading after falling 16% on the company's announcement of a second-quarter loss and forecast cut. Rivals UnitedHealth, CVS Health and Humana rose 1.61%, 2.69% and 3.45%, respectively. All three report earnings next week. Centene in an earnings call reassured investors it would work with states to ensure their payments for Medicaid plans match the company's increased medical costs for 2026. 'Our goal is to reprice 100%' of plans, said company CEO Sarah London. Insurers are paid a set amount by states for Medicaid plans, which are jointly funded with the federal government. Centene, UnitedHealth and Elevance have said this year that state reimbursements for these plans have lagged behind actual costs of care. Cautious investors have been looking for Medicaid health plan design changes and strategic geographic changes by the companies to reduce use of healthcare services. New work requirements for Medicaid recipients in President Donald Trump's signature tax-cut and spending bill have made some investors worry that healthy people could disenroll in coming years. The bill requires states to verify certain members are working or volunteering a minimum of 80 hours per month to qualify for Medicaid coverage starting in 2027. After a COVID-19 era requirement to keep people enrolled expired in 2023, Medicaid plans redetermined each person's eligibility. This pushed members off, changing the mix of sick and healthy participants, and some Medicaid insurers struggled. 'The Medicaid redeterminations have proven to be far more disruptive than anyone thought," said Jeff Jonas, a portfolio manager at Gabelli Funds. "The entire industry is focused on restoring margin over winning new contracts and membership." More detailed data could justify midyear price increases, said Kevin Gade, chief operating officer at Bahl & Gaynor, and correct mismatched rates set by states after the pandemic. More data over the next year will also enable insurers to improve cost management techniques and raise rates paid by states, Gade said. "With enough data you can take care of the problem.'
Geek Vibes Nation
22-07-2025
- Business
- Geek Vibes Nation
Navigate CMS-HCC Model V28 With AI, Accuracy & Clarity
CMS-HCC Model V28 demands precision. With expanded specificity, it reshapes how risk scores are calculated and forces organizations to realign clinical documentation with coding. Multi-vendor confusion, data integration issues, and coding inconsistencies are roadblocks. The good news? AI tools and Digital Health Platform integration offer a clear path forward. Businesses that embrace interoperability, organized planning, and more intelligent workflows will be most equipped to handle this change with assurance. Healthcare organizations are aligning with a sharp regulatory shift. With the CMS-HCC Model V28, clinical documentation needs to be more specific and coding more compliant than ever. Health plans and providers must now collaborate more closely and in more detail as a result of the push for specificity. Broad-stroke diagnoses will no longer qualify under the V28 Risk Adjustment framework, making precise clinical documentation a top priority. In this environment, risk models require coding that reflects real-world complexity rather than administrative simplification. The implications of the CMS-HCC Model V28 extend well beyond compliance. Delays in preparation put organizations at risk for workflow disruptions, audit risks, and revenue loss. It is no longer optional to have strategic alignment across platforms, people, and processes. The time has come to evaluate, modernize, and take charge of the information that determines financial performance. The Multi-Vendor Puzzle The operational load tied to risk adjustment is not just about codes and compliance. It's about navigating a fragmented ecosystem of tools, workflows, and vendors. As new models like CMS HCC V28 bring higher specificity, every disconnected system adds more friction. Discussions at the forum demonstrated how important it is for businesses to eliminate inefficiencies and create platform-wide end-to-end visibility. The challenge of fragmented systems Healthcare organizations face a jigsaw puzzle of disconnected technologies. Executives shared how managing 30+ vendor steps from clinical documentation to CMS submission introduces risk, delays, and confusion. Each vendor operates in silos, making it hard to align processes or ensure consistency. The solution Reduce complexity. By combining suppliers or implementing integrated technologies that unify everything under a single interface, organizations are simplifying their IT stacks. The outcome? Stronger compliance, improved accountability, and fewer manual interventions. Bridging Clinical Workflows and Coding Standards Aligning clinical workflows with coding expectations has emerged as a strategic priority due to the strain of new compliance requirements. With the added specificity in CMS HCC V28, the stakes are even higher. Organizations can no longer afford disjointed communication between clinical teams and coding professionals. Bridging this gap ensures not only regulatory compliance but also accurate risk capture and better care quality. Clinical accuracy drives compliance. One of the biggest pain points? The disconnect between what physicians document and what coders interpret. Misalignment here leads to missed HCCs or even inaccurate risk capture. Leading approaches include: Creating shared documentation protocols across clinical and coding teams Training on how V28 changes the diagnosis code requirements Embedding assistive tools into the physician workflow to guide documentation in real time The emphasis is on precision. Under CMS HCC V28, vague or broad documentation won't cut it. Advancing Interoperability Across Systems As organizations transition to more complex coding models like CMS HCC V28, interoperability becomes a strategic differentiator. A lack of clean data flow between systems can delay submissions, reduce the accuracy of risk scores, and limit the effectiveness of population health efforts. Aligning platforms, interfaces, and workflows to communicate without friction is central to operational success under evolving models. Making data move where it matters Timely and clean data exchange is mission-critical. Many organizations still struggle to get real-time data into the hands of decision-makers and coders. To solve this: Map all data flows between systems to identify gaps Regularly assess integration performance Set up rules for quickly resolving discrepancies Track data exchange metrics to measure progress When systems communicate effectively, risk scores improve, errors drop, and compliance strengthens. Strategic moves to stay ahead With implementation due in 2026, organizations have a tight window to prepare. The forum stressed practical steps being taken by leaders across the board. Key strategies include: Rolling out incentive-based programs to boost staff engagement Deploying dashboards to monitor V28-specific performance indicators Running test scenarios that simulate new V28 workflows Building cross-functional readiness task forces Structured preparation today translates to fewer surprises tomorrow. Role of AI and NLP in Smarter Risk Adjustment Modern risk adjustment depends on speed, accuracy, and data-driven insight. That's why the strategic use of AI and NLP is rapidly becoming a cornerstone of success under V28 Risk Adjustment. These technologies, particularly when combined with a scalable, user-friendly system architecture, simplify documentation procedures, identify lost coding opportunities, and comprehend difficult clinical terminology. When used properly, they complement human judgment rather than take its place. Technology fuels accuracy and speed. V28 Risk Adjustment demands more than manual chart reviews. AI and NLP are being used to process clinical notes, uncover overlooked diagnoses, and deliver coding suggestions rooted in clinical logic. These tools: Flag incomplete documentation instantly Suggest valid HCCs based on medical language Analyze patient history across multiple systems A strong Digital Health Platform ties these elements together, driving both speed and precision. Strengthening Trust Between Stakeholders As organizations move toward more accountable risk models like CMS HCC V28, fostering trust across stakeholders becomes non-negotiable. Providers need visibility into how their documentation translates into coding. Payers seek consistency and accuracy in submissions. Patients deserve clarity on how their care is categorized. Without mutual trust, even the best tools can falter. Strengthening these relationships begins with shared visibility and audit-ready transparency. Documentation done right supports everyone. Risk adjustment works best when there's transparency. Trust between payers, providers, and patients grows when everyone sees how diagnoses are captured and why they matter. Trusted strategies include: Giving clinicians control over accepted or rejected HCCs Showing clearly why AI flagged a certain condition Using audit-friendly interfaces to back every decision with data This is not just about compliance, it's about empowering the entire ecosystem. Integrating Instead of Layering Fragmented tools and disconnected workflows create noise, not clarity. Leaders at the forum stressed how layering new technologies on top of outdated systems only amplifies complexity. As expectations around risk adjustment grow sharper under CMS HCC V28, organizations must shift focus from stacking systems to integrating them. Unified platforms simplify operations, reduce rework, and promote data integrity across departments. Solving the multi-system chaos Risk adjustment shouldn't rely on patchwork systems. The forum echoed one truth loudly: integrated tools that span documentation, coding, and submission outperform cobbled-together vendor networks. With unified platforms, organizations: Avoid duplicate data entry Improve turnaround times Keep all departments aligned on coding priorities This approach supports real-time updates, especially vital when transitioning to CMS HCC V28. Sustaining Change Through Smart Execution Turning strategy into outcomes Execution matters. Tools alone won't move the needle unless they're tied to smart processes and metrics. Practical execution tips: Monitor workflow efficiency weekly Pilot innovations before system-wide rollout Get regular feedback from clinical and coding users Continuously adapt documentation protocols to match V28 standards This adaptive, measurement-driven approach ensures compliance is never a one-time event. Final Thoughts CMS-HCC Model V28 changes the game. Healthcare organizations that invest in interoperability, data accuracy, AI tools, and smarter workflows are best positioned to adapt. Documentation needs to be intentional, specific, and traceable. Experience Integrated Intelligence with Persivia Healthcare doesn't need more vendors, it needs better ones. Persivia offers Risk Adjustment Solution that empowers providers with transparent AI, NLP-backed insights, and full V24/V28 compatibility. With bidirectional EHR connectivity and a white-box AI engine, it enables clinicians to act on real opportunities without second-guessing algorithms. Learn more today.
CBS News
18-07-2025
- Business
- CBS News
Millions could face higher ACA premiums, lower subsidies: "There will be sticker shock"
Most of the 24 million people in Affordable Care Act health plans face a potential one-two punch next year — double-digit premium increases along with a sharp drop in the federal subsidies that most consumers depend on to buy the coverage, also known as Obamacare. Insurers want higher premiums to cover the usual culprits — rising medical and labor costs and usage — but are tacking on extra percentage point increases in their 2026 rate proposals to cover effects of policy changes advanced by the Trump administration and the Republican-controlled Congress. One key factor built into their filings with state insurance departments: uncertainty over whether Congress allows more generous, COVID-era ACA tax subsidies to expire at the end of December. "The out-of-pocket change for individuals will be immense, and many won't actually be able to make ends meet and pay premiums, so they will go uninsured," said JoAnn Volk, co-director of the Center on Health Insurance Reforms at Georgetown University. Especially if the higher subsidies expire, insurance premiums will be among the first financial pains felt by health care consumers after policy priorities put forward by President Trump and the GOP. Many other changes — such as additional paperwork requirements and spending cuts to Medicaid — won't occur for at least another year. But spiking ACA premiums, as the nation heads into key midterm elections, invites political pushback. Some on Capitol Hill are exploring ways to temper the subsidy reductions. "I am hearing on both sides — more from Republicans, but from both the House and Senate" — that they are looking for levers they can pull, said Pennsylvania-based insurance broker Joshua Brooker, who follows legislative actions as part of his job and sits on several insurance advisory groups. In initial filings, insurers nationally are seeking a median rate increase — meaning half of the proposed increases are lower and half higher — of 15%, according to an analysis for the Peterson-KFF Health System Tracker covering 19 states and the District of Columbia. KFF is a national health information nonprofit that includes KFF Health News. That's up sharply from the last few years. For the 2025 plan year, for example, KFF found that the median proposed increase was 7%. Health insurers "are doing everything in their power to shield consumers from the rising costs of care and the uncertainty in the market driven by recent policy changes," wrote Chris Bond, a spokesperson for AHIP, the industry's lobbying group. The emailed response also called on lawmakers "to take action to extend the health care tax credits to prevent skyrocketing cost increases for millions of Americans in 2026." Neither the White House nor the Department of Health and Human Services responded to requests for comment. These are initial numbers and insurance commissioners in some states may alter requests before approval. Still, "it's the biggest increase we've seen in over five years," said analysis co-author Cynthia Cox, a KFF vice president and director of its Program on the ACA. Premiums will vary based on where consumers live, the type of plan they choose, and their insurer. For example, Maryland insurers have requested increases ranging from 8.1% to 18.7% for the upcoming plan year, according to an analysis of a smaller set of insurers by Georgetown University researchers. A much larger swing is seen in New York, where one carrier is asking for less than a 1% increase, while another wants 66%. Maryland rate filings indicated the average statewide increase would shrink to 7.9% from 17.1% — if the ACA's enhanced tax credits are extended. Most insurers are asking for 10% to 20% increases, the KFF report says, with several factors driving those increases. For instance, insurers say underlying medical costs — including the use of expensive obesity drugs — will add about 8% to premiums for next year. And most insurers are also adding 4% above what they would have charged had the enhanced tax credits been renewed. But rising premiums are just part of the picture. A bigger potential change for consumers' pocketbooks hinges on whether Congress decides to extend more generous tax credits first put in place during President Joe Biden's term as part of the American Rescue Plan Act in 2021, then extended through the Inflation Reduction Act in 2022. Those laws raised the subsidy amounts people could receive based on their household income and local premium costs and removed a cap that had barred higher earners from even partial subsidy assistance. Higher earners could still qualify for some subsidy but first had to chip in 8.5% of their household income toward the premiums. Across the board, but especially among lower-income policyholders, bigger subsidies helped fuel record enrollment in ACA plans. But they're also costly. A permanent extension could cost $335 billion over the next decade, according to the Congressional Budget Office. Such an extension was left out of the policy law Mr. Trump signed on July 4 that he called the "One Big, Beautiful Bill." Without action, the extra subsidies will expire at the end of this year, after which the tax credits will revert to less generous pre-pandemic levels. That means two things: Most enrollees will be on the hook to pay a larger share of their premiums as assistance from federal tax credits declines. Secondly, people whose household income exceeds four times the federal poverty level — $84,600 for a couple or $128,600 for a family of four this year — won't get any subsidies at all. If the subsidies expire, policy experts estimate, the average amount people pay for coverage could rise by an average of more than 75%. In some states, ACA premiums could double. "There will be sticker shock," said Josh Schultz, strategic engagement manager at Softheon, a New York consulting firm that provides enrollment, billing, and other services to about 200 health insurers, many of which are bracing for enrollment losses. And enrollment could fall sharply. The Wakely Consulting Group estimates that the combination of expiring tax credits, the Trump law's new paperwork, and other requirements will result in ACA enrollment dropping by as much as 57%. According to KFF, insurers added premium increases of around 4% just to cover the expiration of the enhanced tax credits, which they fear will lead to lower enrollment. That would further raise costs, insurers say, because people who are less healthy are more likely to grit their teeth and reenroll, leaving insurers with a smaller, but sicker, pool of members. Less common in the filings submitted so far, but noticeable, are increases pegged to Trump administration tariffs, Cox said. "What they are assuming is tariffs will drive drug costs up significantly, with some saying that can have around a 3-percentage-point increase" in premiums as a result, she said. Consumers will learn their new premium prices only late in the fall, or when open enrollment for the ACA begins on Nov. 1 and they can start shopping around. Congress could still act, and discussions are ongoing, said insurance broker Brooker. Some lawmakers, he said, are consulting with the CBO about the fiscal and coverage effects of various scenarios that don't extend the subsidies as they currently exist but may offer a middle ground. One possibility involves allowing subsidies for families earning as much as five or six times the poverty level, he said. But any such effort will draw pushback. Some conservative think tanks, such as the Paragon Health Institute, say the more generous subsides led people to fudge their incomes to qualify and led to other types of fraud, such as brokers signing people up for ACA plans without authorization. But others note that many consumers — Democratic and Republican — have come to rely on the additional assistance. Not extending it could be risky politically. In 2024, 56% of ACA enrollees lived in Republican congressional districts, and 76% were in states won by Mr. Trump. Allowing the enhanced subsidies to expire could also reshape the market. Brooker said some people may drop coverage. Others will shift to plans with lower premiums but higher deductibles. One provision of Mr. Trump's new tax law allows people enrolled in either "bronze" or "catastrophic"-level ACA plans, which are usually the cheapest, to qualify for health savings accounts, which allow people to set aside money, tax-free, to cover health care costs. "Naturally, if rates do start going up the way we anticipate, there will be a migration to lower-cost options," Brooker said. KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.
