RISE summarizes recent regulatory-related headlines and reports.
Idaho issues stop order against insurers over limited access to MA products
The Idaho Department of Insurance this week issued cease and desist orders against UnitedHealthcare and Care Improvement Plus South-Central Insurance Companies for wrongfully limiting consumer and agents access to Medicare Advantage (MA) products in the state.
The order claims the insurers are intentionally limiting access to online and paper applications for MA plans and have discontinued agent and broker commissions even though the fees were included in the rates charged to Idaho residents eligible for Medicare. Agents have told the Idaho Department of Insurance that UnitedHealthcare representatives told them that the insurer did not want to sell any MA plans, despite planned marketing efforts. They were told the company discontinued offering agent commissions to discourage consumers from enrolling in the MA plans.
The elimination of commissions is not about saving money, the order said, rather it is about steering interest away from MA plans. The insurers are “deliberately manipulating the insurance market by disincentivizing agents from selling MA plans by making enrollment and applications unavailable and by refusing to pay commissions that are being paid by the agents' clients,” the order said.
UnitedHealth estimates enrollment in its MA plans will decrease by one million people in 2026, according to Becker’s Payer Issues. The company originally projected a 600,000 member decrease but the revised figure reflects the insurer’s “conservative path focused on margin growth.” Although the company still believes in the “long-term potential” of MA, the current move is due to the increasing cost of health care and funding cuts to the program, Becker’s reported.
OIG: Special Focus Facility Program for nursing homes needs improvement
A new Office of Inspector General (OIG) report reveals that Medicare’s Special Focus Facility program for the poorest-performing nursing homes is not working because facilities don’t keep up with the improvements they made over the long term.
The special focus program aims to address quality problems within the country’s nursing homes that have serious noncompliance issues. The OIG investigation said that between 2013 and 2022, nearly two-thirds of the nursing homes that were in the program improved enough to graduate but soon afterward showed the type of quality problems that put them in the program in the first place.
The program, the OIG said, relies too heavily on financial penalties that do not require changes in nursing home operations. OIG recommends that the Centers for Medicare & Medicaid Services (CMS) impose more nonfinancial enforcement remedies to encourage sustained complaints; assess the effectiveness of enforcement actions particularly for those nursing homes that received a staffing deficiency; and Incorporate nursing home ownership information into the program. CMS said it concurred with the assessment of the effectiveness of enforcement actions but not the other recommendations.
Cigna creates new pricing model that shares negotiated discounts with consumers
Cigna’s Evernorth division announced this week it will launch a new rebate-free pharmacy benefit model in 2027. The new model will offer members discounts that the insurer has negotiated with drug companies. This approach, the company said, will cut out the complex post-purchase rebate process by making the discounted price of the drug readily available and transparent from the start. Evernorth said the model will reduce members monthly cost for a brand-name prescription by an average of 30 percent.