In this update:
- Federal Agencies
- CMS Releases 2025 Star Ratings for MA and Part D Plans
- CMS Releases 2026 Proposed Notice of Benefit and Payment Parameters
- CMS Issues RFI on Medicare $2 Drug List Model
- CDC Releases Youth Behavioral Risk Survey Data
- Other Updates
- CBO Publishes FY2024 Summary
- Supreme Court Rejects Biden Administration Appeal in Texas Abortion Case
- Biden Administration, AHA/AMA Oppose 5th Circuit Decision in No Surprises Act
- AHA Asks Biden Administration to Take Action on IV Solution Shortage
- KFF Releases 2024 Employer Health Benefits Survey
- New York State Updates
- OPWDD Adopts Final Rule to Update Specialty Hospital Regulations
- OMH to Host CFTSS Provider Forum
Federal Agencies
CMS Releases 2025 Star Ratings for MA and Part D Plans
On October 10th, the Centers for Medicare and Medicaid Services (CMS) released the 2025 Star Ratings for Medicare Advantage (MA), Medicare Advantage Prescription Drug (MA-PD), and Medicare Part D (PDP) plans. CMS publishes Star Ratings every year to measure the quality of health and prescription drug services received by consumers, and to empower consumers to make informed choices. For 2025, MA-PD plans were rated on up to 40 quality and performance measures, MA plans were rated on up to 30 measures, and PDP plans were rated on up to 12 measures. Overall:
- Approximately 40% of MA-PD plans offered in 2025 earned four stars or higher, compared to 42% of plans in 2024 and 68% of plans in 2022;
- Approximately 62% of MA-PD enrollees are currently enrolled in plans that will have four stars or more in 2025, compared to 74% of enrollees in 2024, and 90% in 2022;
- Approximately 27% of PDP plans offered in 2025 earned four stars or higher; and
- Approximately 5% of PDP enrollees are currently enrolled in plans that will have four stars or more in 2025.
Open enrollment begins on October 15th. More information is available here.
CMS Releases 2026 Proposed Notice of Benefit and Payment Parameters
On October 4th, CMS released the 2026 Notice of Benefit and Payment Parameters (Payment Notice). The Payment Notice proposes key changes to State-Based Marketplaces (SBMs), including:
- Certification Standards: CMS proposes to clarify current regulations to explicitly permit Exchanges to deny certification of any Qualified Health Plan (QHP) that does not meet qualification criteria;
- MLR Modifications: CMS proposes to adjust the medical loss ratio (MLR) calculation for qualifying issuers that focus on underserved communities that often have higher rates of serious health conditions;
- Public Reporting and Transparency: CMS proposes to publicly release the State-based Marketplace Annual Reporting Tool (SMART) and financial and programmatic audits as well as additional data for all Marketplaces and summary-level Quality Improvement Strategy (QIS) information publicly;
- Premium Payment Thresholds: CMS proposes to allow issuers to implement either a fixed-dollar or a percentage-based premium payment threshold to enable consumers to maintain their coverage even if they have not paid the full amount owed. CMS further proposes to allow issuers to select between two percentage-based thresholds: net premium threshold and gross premium threshold;
- Risk Adjustment Program: Funds in the risk adjustment program are subject to sequestration at a rate of 5.7 percent. For 2026, CMS proposes to recalibrate the risk adjustment models using new data. CMS proposes to set the risk adjustment user fee at $0.18 per member per month, the same rate used for the 2025 benefit year;
- Basic Health Program: CMS proposes to change the methodology used to recalculate the premium adjustment factor for Basic Health Program payment; and
- Application of Drug Manufacturer Coupons to Cost-Sharing Limits: Notably, the proposed rule does not address application of drugmaker coupons to deductibles and out-of-pocket (OOP) spending limits. The proposed rule indicates that HHS and the Departments of Labor and Treasury intend to issue a future notice of proposed rulemaking to address issues arising from a recent lawsuit.
The proposed rule is open for comment through November 12th. The proposed rule is available here, and the fact sheet is available here.
CMS Issues RFI on Medicare $2 Drug List Model
On October 8th, CMS released a Request for Information (RFI) and a sample list of products for the proposed Medicare $2 Drug List Model. Under this Model, Part D beneficiaries could access a month’s supply of certain generic medications for no more than $2. The Model will test whether access to reliably low-cost generic medications will improve medication adherence and health outcomes. The sample list includes generic drugs to treat high cholesterol and high blood pressure. Participation in the model would be voluntary for Part D sponsors and could start as early as January 2027.
The RFI is open for comment through December 9th. The announcement is available here, and more information on the program is available here.
CDC Releases Youth Behavioral Risk Survey Data
On October 10th, the Centers for Disease Control and Prevention (CDC) released the 2023 Youth Risk Behavior Surveillance report. Youth Risk Behavior Surveillance System (YRBSS) tracks a range of behaviors and conditions that lead to poor health among high school students. This year, based on trends among high school students, the survey added questions concerning social media use, racism at school, adverse childhood experiences, transgender identity, and unfair discipline in school, among others. Highlights from the report include:
- Roughly 40% of adolescents report persistently feeling sad or hopeless;
- Over 75% of students report frequent social media use, which was associated with higher prevalence of being bullied, feelings of sadness or hopelessness, and suicide risk;
- 20% of adolescents report seriously having considered suicide;
- Over 25% of trans youth and questioning students report having attempting suicide in the past year; and
- 32% of students report ever having experienced racism in school, which was associated with poor mental health, suicide risk, and substance use.
The announcement is available here, and the data is available here.
Other Updates
CBO Publishes FY2024 Summary
On October 8th, the Congressional Budget Office (CBO) released its fiscal year 2024 (FY2024) budget review. In FY2024, the federal budget deficit was $1.8 trillion, $139 billion over FY2023. Revenues in all major categories, especially income taxes, increased in FY2024. Expenditures increased by an estimated $617 billion (10%). The largest increase in expenditures for FY2024 was in education, while Medicare expenditures increased by $78 billion (9%) due to higher enrollment and rates.
The report is available here.
Supreme Court Rejects Biden Administration Appeal in Texas Abortion Case
On October 7th, the Supreme Court rejected an appeal from the Biden Administration to reconsider a decision of the Fifth Circuit which found that the Emergency Medical Treatment and Labor Act (EMTALA) does not apply to emergency abortions. EMTALA requires emergency rooms in hospitals with federal funding to provide stabilizing medical care, and the Administration’s challenge rested on their interpretation that Texas’s abortion law violated EMTALA.
The Texas Attorney General argues that there is no conflict between EMTALA and the Texas law, which permits abortion when a woman is at risk of “substantial impairment of a major bodily function.” The Administration disagrees that this standard sufficiently protects women, and urged the court to consider a circumstance where “terminating a pregnancy is required to stabilize an emergency medical condition that would otherwise threaten serious harm to the pregnant woman’s health…” This decision is consistent with two recent verdicts on related abortion cases, signaling potential disinterest by the Supreme Court in revisiting the issue.
Biden Administration, AHA/AMA Oppose 5th Circuit Decision in No Surprises Act
On October 4th, the Departments of Labor (DOL) and Justice (DOJ) filed an amicus brief disputing a recent Fifth Circuit court decision concerning the No Surprises Act. In August, the Fifth Circuit heard a case between Guardian Flight (an air ambulance provider) and Health Care Service Corporation (HCSC, under the Blue Cross Blue Shield Association umbrella). Guardian Flight argued that HCSC had not followed the independent dispute resolution (IDR) process under the No Surprises Act for 33 air transports, claiming they were owed nearly $1 million in payments. HCSC claimed they were not required to cover the services under the No Surprises Act or the Employee Retirement Income Security Act (ERISA), and the Fifth Circuit agreed.
In their amicus brief, the DOL and DOJ said that payments from the IDR process are “tantamount to mandatory plan benefits” and should be enforceable under ERISA, arguing that the decision undermines the intent of the law. The American Hospital Association (AHA), American Medical Association (AMA), Federation of American Hospitals, and the Texas Medical Association also expressed their support for Guardian in this case, noting that the precedent is an existential threat to providers.
AHA Asks Biden Administration to Take Action on IV Solution Shortage
On October 7th, the American Hospital Association (AHA) sent a letter to President Biden requesting federal assistance to remediate an impending shortage of IV solution. The Baxter manufacturing plant in Marion, NC, which supplies approximately 60% of IV solution used each day, was damaged during Hurricane Helene. The AHA is urging the Biden Administration to direct the Food and Drug Administration (FDA) to declare a shortage and allow additional flexibilities, declare a national emergency and/or national Public Health Emergency, and invoke the Defense Production Act.
The announcement is available here.
KFF Releases 2024 Employer Health Benefits Survey
On October 9th, the Kaiser Family Foundation (KFF) released its 26th annual Employer Health Benefits Survey. The survey included 2,142 interviews with non-federal public and private firms on topics including premiums, employee contributions, cost-sharing policies, wellness programs, and more. This year, the survey involved new questions concerning provider networks, abortion coverage, fertility benefits, and coverage for GLP-1 agonists. Key data from the 2024 report includes:
- Annual premiums for employer-sponsored family coverage grew by 7% to $25,572 in 2024 (compared to a 4.5% increase in worker wages and a 3.2% increase in inflation);
- Over the past five years, the average premium for family coverage has increased by 24% (compared to a 28% increase in worker wages and 23% increase in inflation);
- On average, employees contributed 16% of the premium for single coverage and 25% of the premium for family coverage, lower than percentages for 2023; and
- The average deductible for covered workers in a plan with a general annual deductible was $1,787 for single coverage.
The report is available here.
New York State Updates
OPWDD Adopts Final Rule to Update Specialty Hospital Regulations
On October 9th, the New York State (NYS) Office for People with Developmental Disabilities (OPWDD) adopted a final rule that amends Part 680 specialty hospital regulations to remove outdated language and ensure consistency with other regulations that have been updated or amended. The amended regulations:
- Update staffing and service requirements;
- Remove redundant regulatory requirements applicable to medical facilities;
- Change the responsibility for rate setting from OPWDD to the Department of Health (DOH); and
- Standardize language and include current terminology and nomenclature.
Specific changes include, but are not limited to:
- Clarifying that the specialty hospital may offer its other agency-licensed services to specialty hospital patients;
- Clarifying that if the approved capacity of a specialty hospital is fewer than 20 individuals, an on-staff psychiatrist is not required;
- Requiring the development of emergency preparedness plans, to be reviewed at least annually;
- Including the description and usage of supported decision-making agreements;
- Adding the requirement that a treating physician must recommend a patient’s admission to a specialty hospital and include a determination that no other less restrictive environment is sufficient;
- Adding behavior support services under psychology services, which must be provided by a behavior intervention specialist; and
- Clarifying that at least one full-time physician is required to be available 40 hours per week, who may be available on-call if a licensed nurse-practitioner is on duty.
The regulations are available here. OPWDD received no public comments, and no changes were made from the proposed regulations.
OMH to Host CFTSS Provider Forum
On November 7th from 1:30pm-3pm, the NYS Office of Mental Health (OMH) will host a provider forum for Children and Family Treatment and Support Services (CFTSS) programs. During the forum, the State will review recent changes and revisions to the CFTSS manual and will answer questions from participants. Participants will have an opportunity to connect with fellow CFTSS providers and state/county government partners.
Registration for the forum is available here. Program questions may be submitted in advance here. Questions regarding the forum may be sent to mctac.info@nyu.edu with the subject line “CFTSS Provider Forum.”