Health Care Matters | March 13
CMS Considers Allowing ACA Marketplace Plans Without Provider Networks
The Trump administration has proposed changes to Affordable Care Act marketplace rules that would allow insurers to offer health plans without traditional provider networks. Under the proposal, these plans would pay a set benchmark amount for medical services rather than relying on negotiated contracts with hospitals and physicians. Patients would be responsible for paying any difference between the benchmark payment and the provider’s actual charge. Supporters argue the approach could lower premiums and encourage price transparency, while critics warn it could increase financial risk for patients and shift administrative burdens to providers. The proposal is part of a broader rulemaking affecting ACA marketplaces and could take effect as early as the 2027 plan year. Read more here and here.
Why It Matters
Much of the impact of this proposal will depend on how CMS implements the details. The rule still requires issuers offering non-network plans to demonstrate that a sufficient number of providers are willing to accept the plan’s benchmark payment as payment in full. Without negotiated contracts, however, it is not clear how insurers would reliably document or verify that participation to CMS. The practical mechanics of demonstrating provider participation, and how strictly CMS enforces those standards, will likely determine whether these products remain niche offerings or become a meaningful part of the marketplace.
The proposal also raises broader beneficiary protection questions. ACA marketplaces today rely on negotiated networks that create relatively predictable payment relationships between plans and providers. Moving to a benchmark payment model shifts some of that predictability away from the insurer and toward the patient. Even with disclosure requirements, consumers comparing plans by premium, deductible, and metal level may not fully appreciate the potential for balance billing or additional price exposure until after care is delivered.
Risk pool dynamics may also shift if these products gain traction. Lower premium plans built around benchmark payments could attract healthier enrollees who are comfortable taking on more uncertainty about provider charges. Traditional network plans could then become increasingly concentrated with higher cost patients, placing upward pressure on their premiums over time. The proposal therefore represents not just a change in plan design but a broader test of how much variation in insurance structure the ACA marketplaces can accommodate while maintaining stable coverage and meaningful consumer protections
CMS Launches Effort to Unify Medicare Claims Processing Systems
CMS has released a solicitation for ClaimsCore, a major modernization initiative to replace several legacy Medicare fee-for-service claims processing systems with a single cloud-based platform. The new system is designed to adjudicate Part A, Part B, and DME claims in near real time while supporting more than 2 million users and processing over 100,000 claims daily. CMS plans to use a phased, challenge-based procurement in which up to four vendors will develop prototype solutions that run alongside existing systems before a final contractor is selected to build and implement the platform. If completed, ClaimsCore would consolidate multiple claims platforms that currently operate separately across Medicare into a unified environment. Read more here and here.
Why It Matters
This effort targets one of the most fundamental operational systems in Medicare: the infrastructure that receives, processes, and pays claims. Today, Medicare’s claims processing environment relies on multiple legacy systems developed decades ago and operated by different contractors. Consolidating these systems could improve interoperability, fraud detection, and the speed at which claims are adjudicated, while allowing CMS to update payment policies or model rules more quickly as the program evolves.
For providers and health systems, however, the transition could be operationally significant. Claims processing changes often require updates to billing systems, clearinghouse connections, and revenue cycle workflows, and even small differences in adjudication logic or error messaging can create temporary payment disruptions. Contractors, vendors, and provider organizations will likely need to adapt their systems to integrate with the new platform, test claim submissions, and train staff on updated processes. As CMS pilots and implements the system over the coming years, stakeholders will be watching closely for how the new platform affects claims timelines, payment accuracy, and administrative burden across the Medicare ecosystem.
Look for the Helpers: A Nurse’s Handmade Blankets Bring Comfort to Pediatric Patients
At SSM Health Monroe Hospital, registered nurse Beth Martz has found a simple way to make hospital stays a little less frightening for children. In her free time, Martz sews colorful handmade blankets and brings them to the hospital for pediatric patients receiving care. Staff say the blankets help reduce fear and anxiety and give kids something comforting to hold onto during treatment. The effort is entirely volunteer-driven and funded by Martz herself, showing how small acts of compassion can make a meaningful difference for patients and families. Read here.
What We Are Reading
Primary Care Physician Trends: Dissatisfaction, Stress, And Burnout In The US And 9 Comparator Countries, 2012–22
Health Affairs analyzes survey data from physicians across ten countries and finds that U.S. primary care physicians report some of the highest levels of dissatisfaction, stress, and burnout, raising concerns about workforce sustainability and the long-term stability of primary care delivery. Read here.
2025 Scorecard On State Health System Performance
The Commonwealth Fund evaluates health system performance across all 50 states and the District of Columbia using 50 measures of access, affordability, quality, outcomes, and equity, finding that while insurance coverage has improved nationally, significant geographic disparities in health outcomes and access to care persist. Read here.
Examining The Potential Impact Of Medicare’s New WISeR Model
KFF analyzes spending and utilization patterns for services targeted by the new WISeR model and finds the program’s impact on Medicare spending will likely be modest initially because the services subject to prior authorization account for a relatively small share of total Part B spending and are used by a limited number of beneficiaries. Read here.
Medicare’s Unrealized Opportunity: Using ACOs To Create Real Competition
Health Affairs Forefront examines how Medicare could strengthen traditional Medicare’s competitiveness with Medicare Advantage by expanding the role of ACOs and making accountable, coordinated care a more central structure for care delivery in the program. Read here.
2025 Medicare FFS Catheter Billing Anomalies And ACO Implications
Milliman analyzes recent Medicare fee-for-service claims data and identifies a sharp rise in spending for a urinary catheter billing code in 2025 driven largely by a small number of suppliers, highlighting potential financial implications for ACOs participating in value-based risk arrangements if the spending is not addressed through policy adjustments. Read here.
Pop Health Podcast
Primary Care Population-Based Payments and Value Based Payment State Lessons
In this episode of the Pop Health Podcast, Coral's Trevor Abeyta is joined by Araceli Santistevan, Payment Reform Unit Supervisor at the Colorado Department of Health Care Policy and Financing, and Andy Wilson, Managing Director for Analytics at Third Horizon Strategies. Together they discuss Colorado Medicaid’s APM 2 primary care capitation model, exploring what has worked, key challenges such as rate setting and post-COVID utilization changes, and lessons for states pursuing value-based payment.