Friday, April 3, 2026

CMS published the Contract Year 2027 MA and Part D Final Rule yesterday. Three billing-relevant changes: (1) 11 Star Rating measures removed — CMS is cutting administrative process measures where plans show little variation, refocusing on outcomes. (2) Supplemental benefits via debit cards get new transparency requirements — plans must publicly post SSBCI eligibility criteria. (3) A new Part C Depression Screening and Follow-Up measure starts with the 2027 measurement year (2029 Star Ratings). Separately, CMS proposed FY2027 payment updates for psychiatric facility and skilled nursing facility prospective payment systems.

Gov. Patrick Morrisey signed a prior authorization reform bill on March 31 — six months after Eric Tennant, a 58-year-old coal mining safety instructor from Bridgeport, died from stage 4 bile duct cancer. Tennant's insurer, the state's Public Employees Insurance Agency (PEIA), repeatedly denied a $50,000 noninvasive cancer treatment. PEIA reversed its decision only after KFF Health News and NBC News contacted the agency. By then, Tennant had been hospitalized and was no longer a candidate for the procedure. The new law, effective June 10, allows plan members approved for a course of treatment to pursue an alternative, medically appropriate treatment of equal or lesser value without a new prior auth.

The first public PA metrics went live March 31. Three days in, the data picture is sharpening. MA plans submitted 53 million PA requests in 2024 — 4.1 million denied (7.7%). Centene and CVS Health MA plans had the highest denial rates. 93.6% of Centene's appealed denials were overturned. On the ACA side, Oscar denies 25.3% of claims — nearly 20 percentage points higher than Kaiser Permanente (~6%). UnitedHealthcare's ACA denial rate dropped from 33% to 20% year-over-year, the largest single-insurer shift. Separately, SavingAdvice reports MA prior auth denials jumped 56% in recent years. KFF notes the data lacks service-level granularity — you can see that a plan denies 15% of requests, but not whether those are hip replacements or MRIs.

This is the same story as #2, framed for Track 2. Eric Tennant's insurer denied a $50,000 cancer treatment multiple times. The insurer reversed its decision only after journalists called. By then, Tennant was too sick for the procedure. He died at 58. His widow and three adult children watched the state sign a reform bill six months later. The insurer — a state employee health plan — never explained why it denied the treatment in the first place. Over 80% of MA prior auth denials are overturned on appeal. 0.2% of patients appeal.

On January 22, CEOs of UnitedHealth, CVS, Cigna, and Elevance sat for a marathon day of questioning before two House committees. Congress asked about care denials, vertical consolidation, and executive compensation. Rep. Nanette Barragan noted one CEO received a one-time equity award of $60 million. When asked whether overturned denials affect their pay, no executive raised a hand. ACA marketplace plans denied 19% of in-network claims in 2024. Less than 1% of patients appealed. National Nurses United found a correlation: the higher the denial rate, the higher the CEO pay.