Below is a roundup of payer-centric news headlines you may have missed during the month of March 2025.
Leading stories
Health plan CEO fired over scandal
The CEO of Superior HealthPlan, a Centene subsidiary in Texas, has been fired, reported The Dallas Morning News.
CEO Mark Sanders was appearing before a Texas House Committee hearing when he started facing questions over the practice. He said the company no longer employs private investigators.
“The conduct highlighted yesterday during the course of the Texas House Committee hearing is not reflective of our values nor is it a practice Centene’s current leadership condones,” said a Centene spokesperson in a statement to The Dallas Morning News.
"Following the hearing, Centene immediately launched an internal investigation to examine the conduct in question and to ensure our current practices are fully aligned with our core values and ethical standards.
The company said while background research is common, they reject the claim Sanders was spying through illegal means.
"Suggestions that these materials were used for leverage or blackmail are completely false," said Centene
This story has been updated with a statement of clarity by Centene.
Nevada awards Medicaid contracts
The state of Nevada released its notice of intent this month to divvy out its Medicaid awards to winning proposals from UnitedHealthcare, Anthem Blue Cross Blue Shield, Centene, CareSource and Molina Healthcare.
UnitedHealthcare will only serve one county, while Centene and CareSource received the highest scores.
New DOJ task force
The Department of Justice (DOJ) has launched an Anticompetitive Regulations Task Force to slash federal and state rules that “undermine free market competition and harm consumers, workers and businesses.”
The Antitrust Division will hold a public inquiry period to learn which laws and regulations are the “biggest barriers” to competition. Comments are due by May 26 and then the task force—comprised of attorneys, economists and others—will decide how to take action.
In healthcare, the DOJ said current regulations “encourage overbilling and consolidation.”
Blues plans’ financials
Blue Cross Blue Shield plans posted their financial performances for calendar year 2024 in March.
Blue Cross Blue Shield of Michigan recorded a loss of more than $1 billion on revenue, largely because the plan paid $3 billion more in medical and pharmacy services than the previous year. The insurer had an underwriting loss of $1.7 billion and an operating margin of -4.2%. GLP-1 drugs accounted for more than $1 billion in claims and a 29% increase over 2023. The company’s membership decreased by 64,000 members.
Regence BlueCross BlueShield of Oregon announced it paid $5,757 per member on healthcare in 2024. Medicare Advantage claims increased by 8.3%, and the insurer had an operating loss of 1.2%.
Regence BlueShield of Idaho grew its membership by more than 370,000 members but also had an operating loss of 1.2%. The insurer paid $637 million in healthcare to its members.
Regence BlueShield in Washington state also reported higher costs, with per member costs outpacing inflation. Its 1.5 million members led to “significant increases” in prescription drugs and medical care costs.
Regence BlueCross BlueShield of Utah disclosed a $6,054 per member cost but grew its membership by more than 730,000 people. The insurer had a net income of 1.8% and an operating loss of 0.4%.
Legal
What’s one more star ratings lawsuit?
Blue Cross Blue Shield of Massachusetts (BCBSMA) is suing (PDF) the Department of Health and Human Services over its 2025 star ratings results.
The insurer says application of a “case-mix adjustment” unfairly dropped its overall star rating from four stars to 3.5 stars, costing the health plan $35 million in damages.
BCBSMA wants the government to recalculate its Consumer Assessment of Healthcare Providers & Systems survey metric without applying the case-mix adjustment.
ERISA suits back to the drawing board
Recently, employees at large corporations have alleged in court their employer has mismanaged their benefits, leading to higher costs for prescription drugs and overcharges from pharmacy benefit managers.
The most recent example is a lawsuit against banking giant JPMorgan Chase, but the trend was kicked off against Wells Fargo and Johnson & Johnson.
The case against Johnson & Johnson was dismissed by a judge earlier this year, but the plaintiff filed (PDF) an amended complaint March 10. The new complaint is less likely to be dismissed by a judge, said Christopher Vanderwolk, an ERISA attorney, in a post on LinkedIn.
Wells Fargo successfully got the lawsuit (PDF) against them dismissed March 24, despite the judge agreeing the plaintiffs’ frustrations are “understandable.”
Industry
Caregiving platform enters Medicare Advantage market
Cleo, a family caregiving platform, has formed a partnership with Medicare Advantage company Sonder Health Plans, a business that recently grew its membership by 500% in the state.
Cleo focuses on chronic condition management and treatment of Alzheimer’s disease and dementia and helps plans improve their star ratings.
"As a member of the 'sandwich generation,' I am experiencing first-hand the growing complexity of watching my parents manage their health,” said CEO Madhavi Vemireddy, M.D., in a statement. “The application of Cleo's integrated care coordination and family caregiving support is perfectly suited for Medicare Advantage members and Sonder Health's population.
UnitedHealthcare cuts home health prior auth red tape
Beginning April 1, UnitedHealthcare won’t mandate prior authorization or other reviews for home health services under the unit formerly named naviHealth, as part of changes to reduce overall prior auth volume by 10%.
The change applies to Medicare Advantage and dual special needs plans in 37 states, a news release said.
Legislation
Dems push Trump to restore ACA navigators funding
A group of 22 Democratic lawmakers in Congress urged President Donald Trump to reverse $90 million in cuts to Affordable Care Act navigator program funding.
The cuts were one of the first actions taken by the Centers for Medicare & Medicaid Services under the Trump administration. These funds help individuals choose the health plan best for them, but Republicans have long said the program does not justify the cost.
“We are especially troubled by the imminent harm of these cuts at a time when navigators are more important than ever,” the lawmakers said. “As consumers are confronted with uncertainty around the future of the ACA’s enhanced premium tax credits and are worried about hundreds of billions of dollars of proposed cuts to the Medicaid program, navigators will be essential to helping individuals maintain access to affordable health care coverage.”
Studies
Long-term benefits of AOMs
Broad coverage of anti-obesity medications would raise life expectancy in the country, a new study by the USC Schaeffer Center found.
Life expectancy would increase by up to 1.8 years and Americans would not be plagued by chronic conditions like diabetes. Additionally, the researchers said access to these drugs would result in real returns of more than 13%, even after factoring in treatment costs.
“Although all patients accrue positive net social value from treatment, younger and healthier patients accrue the greatest social returns,” they wrote before adding, “In sum, expanded access to AOMs could generate $10 trillion in lifetime net social value to those who are currently treatment-eligible.”
Only one-third of private insurance plans and nearly all Affordable Care Act plans do not cover these drugs.
Medicare Advantage ‘trap’
There are two reasons beneficiaries are steered toward Medicare Advantage (MA) plans over traditional Medicare, a piece in JAMA Network by Weill Cornell Medicine professionals explains.
Insurers better incentivize agents and brokers to enroll members into MA plans, since these plans are normally more profitable for private insurers. It is also much more difficult to switch from MA to traditional Medicare than vice versa, they acknowledged.
The authors said brokers should not be rewarded with extra compensation for enrolling individuals into MA, enrollment target bonuses and health risk assessments by brokers should be prohibited and individuals should be better informed on the difficulty in switching from MA to traditional Medicare. Some states could also require plans accept all beneficiaries and mandate a set rate for premiums.
Two Paragon Health Institute reports
President Donald Trump-aligned health policy think tank Paragon Health Institute released several studies this month on Medicaid.
One paper focused on improper payments reported twice by the Centers for Medicare & Medicaid Services (CMS). The group argued the government’s reported figure of $543 billion in improper payments is much higher, because it ignored eligibility checks. They said the CMS more likely issued almost $1.1 trillion in improper payments and blamed the Affordable Care Act and Medicaid expansion as a source of trouble.
The other paper argues providers send money to states, and those funds are used to increase Medicaid spending through federal matching dollars, leading to outsized federal investment beyond the program’s initial intentions. It suggests Congress pursue block grants, eliminates provider taxes, slims back the provider tax safe harbor threshold and guts state-directed payments.
Quick hits
- Patients receiving continuous glucose monitor supplies through durable medical equipment providers had better adherence rates in Medicare Advantage and traditional Medicare, versus patients who received these supplies through pharmacies. Additionally, this led to a reduction in healthcare costs and ER visits, a study funded by CCS Medical published in Clinical Diabetes.
- Medicare Advantage insurer Zing Health expands its partnership with value-based kidney care company Strive Health to Ohio, Tennessee and Mississippi, a news release said.
- The Illinois Department Healthcare & Family Services awarded $3 billion each to Humana, Molina Healthcare, Aetna and a Centene subsidiary for a new dual-eligible special needs program Medicaid contract, reported Crain’s Chicago Business.
- Covered California, the state’s health insurance marketplace, will prioritize sending funds from underperforming health plans to enrollees through population health initiatives, as explained in a news release.
- Commonwealth Care Alliance, an insurer in Massachusetts, was blocked by the state’s Medicaid program from gaining new members due to financial struggles, reported The Boston Globe.
- The largest managed care organization in Maryland, Priority Partners, lost its accreditation for credentialing issues, the Associated Press reported.