Health Care Matters | August 28
Marketplace Fraud Crackdown Could Reshape Insurer Risk Pools
The Centers for Medicare & Medicaid Services (CMS) is intensifying efforts to identify and remove potentially improper Affordable Care Act Marketplace enrollments, including fully subsidized members who have not used their coverage. Insurers are now reviewing lists of potentially affected members and may be required to repay premium subsidies when eligibility cannot be verified. Oscar Health has reserved up to $1.1 billion for potential repayments and expects it could lose as many as 300,000 members, while Molina Healthcare and Centene have also warned that the program integrity efforts could affect costs and enrollment. CMS says it has removed approximately 1.5 million enrollees to date and identified another 1 million highly suspicious enrollments on HealthCare.gov. Read here.
Why It Matters
Removing improper enrollments may protect federal dollars, but disenrolling members who generate few or no claims could leave Marketplace plans with a smaller, higher-cost risk pool. Reduced risk-adjustment obligations may provide some relief, but insurers warn that the loss of premium revenue, added verification costs, and uncertainty about who will remain enrolled could contribute to higher premiums and market pullbacks in 2027. For insurers operating across multiple government programs, this pressure compounds existing challenges from elevated utilization, strained Medicaid margins, and Medicare Advantage star ratings and payment changes. Plans must now distinguish fraudulent or unauthorized enrollment from legitimate members who have not used their coverage, while helping eligible consumers verify their status before they lose coverage.
Look for the Helpers: A Second Act in Community Care
After retiring from cardiology, one physician found a new role volunteering at a nonprofit clinic serving uninsured and underinsured adults in Maryland. His experience highlights both the barriers many patients face in accessing routine care and the difference volunteer clinicians can make by bringing their time and expertise into community settings. It is a reminder that expanding access does not always require a new program or technology. Sometimes it starts with experienced people choosing to keep showing up. Read more here.
What We Are Reading
State-Level Impacts of OBBBA Provisions: A Data Dashboard
A Milbank Memorial Fund dashboard uses RAND estimates to show how Medicaid funding changes under the One Big Beautiful Bill Act could vary by state, including the effects of work requirements, provider tax limits, state directed payment changes, and Rural Health Transformation Program funding. Read here.
WebMD Ignite, Partners Launch New Rural Health Network Amid $50B Federal Investment
Fierce Healthcare reports on a new Collaborative Care Network designed to help rural communities connect existing clinical and community resources as states begin deploying Rural Health Transformation Program funding. Read here.
Chronic Care in Medicare: How Congress Can Strengthen the New APCM
A Primary Care Collaborative fact sheet examines challenges with Medicare’s Advanced Primary Care Management (APCM) services and highlights policy changes that could make the model easier for practices and patients to use. Readhere.
Tracking the $50 Billion Rural Health Transformation Program
KFF Health News examines how states are planning to use Rural Health Transformation Program funding and the challenges of tracking where the money ultimately goes as implementation moves forward. Read here.
Housing First and Health: What the Evidence Shows
A Health Affairs policy brief reviews the evidence on Housing First programs, including their effects on housing stability, health care use, and health outcomes for people experiencing homelessness. Read here.
Pop Health Podcast
What This Year's Proposed Physician Fee Schedule Means for ACOs
This year's proposed physician fee schedule includes a wide range of changes that could affect accountable care organizations, clinicians, and Medicare beneficiaries—from updates to financial methodology and quality measurement to new ideas for prospective payment and specialty care.
In this episode, Coral's Joy Chen and Maria Alexander speak with Jake Quinton, Chief Medical Officer for the Center for Medicare about which proposals matter most, what they signal about CMS’s longer-term vision for accountable care, and where CMS is seeking practical feedback from organizations working on the ground.