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Medicare Advantage insurers face new curbs on overcharges in Trump plan
Dr. Mehmet Oz leads the Centers for Medicare & Medicaid Services. A CMS plan to keep payments to Medicare Advantage flat in 2027 roiled health insurance stocks this week.
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Anna Moneymaker/Getty Images
Medicare Advantage health plans are blasting a government proposal this week that would keep their reimbursement rates flat next year while making other payment changes.
But some health policy experts say the plan could help reduce billions of dollars in overcharges that have been common in the program for more than a decade.
On Jan. 26, Centers for Medicare & Medicaid Services officials announced they planned to raise rates paid to health plans by less than a tenth of a percent for 2027, far less than the industry expected. Some of the largest, publicly traded insurers, such as UnitedHealth Group and Humana, saw their stock prices plummet as a result, while industry groups threatened that people 65 and older could see service cuts if the government didn’t kick in more money.
In Medicare Advantage, the federal government pays private insurance companies to manage health care for people who are 65 and older or disabled.
“Chart reviews”
Less noticed in the brouhaha over rates: CMS also proposed restricting plans from conducting what are called “chart reviews” of their customers. These reviews can result in new medical diagnoses, sometimes including conditions patients haven’t even asked their doctors to treat, that increase government payments to Medicare Advantage plans.
The practice has been criticized for more than a decade by government auditors who say it has triggered billions of dollars in overpayments to the health plans. Earlier this month, the Justice Department announced a record $556 million settlement with the nonprofit health system Kaiser Permanente over allegations the company added about half a million diagnoses to its Advantage patients’ charts from 2009 to 2018, generating about $1 billion in improper payments.
KP did not admit any wrongdoing as part of the settlement.
“I do think the administration is serious about cracking down on overpayments,” said Spencer Perlman, a health care policy analyst in Bethesda, Maryland.
Perlman said that while the Trump administration strongly supports Medicare Advantage, officials are “troubled” by plans that rake in undue profits by using chart reviews to bill the government for medical conditions even when no treatment was provided.
In a news release, CMS Administrator Mehmet Oz said curbing this practice would ensure more accurate payments to the plans while “protecting taxpayers from unnecessary spending that is not oriented towards addressing real health needs.”
“These proposed payment policies are about making sure Medicare Advantage works better for the people it serves,” Oz said.
Richard Kronick, a former federal health policy researcher and a professor at the University of California-San Diego, called the proposal “at least a mildly encouraging sign,” though he said he suspected health plans might eventually find a way around it.
Kronick has argued that switching seniors to Medicare Advantage plans has cost taxpayers tens of billions of dollars more than keeping them in the government-run Medicare program, because of unbridled medical coding excesses. The insurance plans have grown dramatically in recent years and now enroll about 34 million members, or more than half of people eligible for Medicare.
David Meyers, an associate professor at the Brown University School of Public Health, called the proposed restriction on chart reviews “a step in the right direction.”
“I think the administration has been signaling pretty strongly they want to cut back on inefficiencies,” he said.
The outcry from industry, mostly directed at the proposal to essentially hold Medicare Advantage payment rates flat, was quick and sharp.
“If finalized, this proposal could result in benefit cuts and higher costs for 35 million seniors and people with disabilities when they renew their Medicare Advantage coverage in October 2026,” said Chris Bond, a spokesperson for AHIP, formerly known as America’s Health Insurance Plans.
CMS is accepting public comments on the proposal and says it will issue a final decision on the payment rates and other provisions by early April.
Meyers said health plans often claim they will be forced to slash benefits when they aren’t satisfied with CMS payments. But that rarely happens, he said.
“The plans can still make money,” he said. “They mostly are very profitable, just not as profitable as shareholders expected.”
The government pays Medicare Advantage plans higher rates to cover sicker patients. But over the past decade, dozens of whistleblower lawsuits, government audits, and other investigations have alleged that health plans exaggerate how sick their customers are to pocket payments they don’t deserve, a tactic known in the industry as “upcoding.”
Many Medicare Advantage health plans have hired medical coding and analytics consultants to review patients’ medical charts to find new diagnoses that they then bill to the government. Medicare rules require that health plans document — and treat — all medical conditions they bill.
Yet federal audits have shown for years that many health plans’ billing practices don’t hold up to scrutiny.
A December 2019 report by the Department of Health and Human Services inspector general found that the health plans “almost always” used chart reviews to add, rather than delete, diagnoses. “Over 99 percent of chart reviews in our review added diagnoses,” investigators said.
The report found that diagnoses reported only on chart reviews — and not on any service records — resulted in an estimated $6.7 billion in payments for 2017.
This week’s proposal is not the first time CMS has tried to crack down on chart reviews.
In January 2014, federal officials drafted a plan to restrict the practice, only to abruptly back off a few months later amid what one agency official described as an “uproar” from the industry.
The health insurance industry has for years relied on aggressive lobbying and public relations campaigns to fight efforts to rein in overpayments or otherwise reduce taxpayers’ costs for Medicare Advantage.
What happens this time will say a lot about the seriousness of the Trump administration in its crack down on controversial, long-standing payment practices in the program.
Perlman, the policy analyst, said it is “quite common” for CMS to partially backtrack when faced with opposition from the industry, such as by phasing in changes over several years to soften the blow on health plans.
David Lipschutz, an attorney with the Center for Medicare Advocacy, a nonprofit public interest law firm, said finalizing the chart review proposal “would be a meaningful step towards reining in overpayments to Medicare Advantage plans.
“But in the past, he said, even a minor change to Advantage payments has led the industry to protest that “the sky will fall as a result, and the proposal is usually dropped.”
“It’s hard to tell at this stage how this will play out,” Lipschutz said.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF.
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Map: 5.1-Magnitude Earthquake Strikes off the Coast of California
Note: Map shows the area with a shake intensity of 3 or greater, which U.S.G.S. defines as “weak,” though the earthquake may be felt outside the areas shown. The New York Times
A moderately strong, 5.1-magnitude earthquake struck in the North Pacific Ocean on Wednesday, according to the United States Geological Survey.
The temblor happened at 5:45 a.m. Pacific time about 40 miles west of Petrolia, Calif., data from the agency shows.
As seismologists review available data, they may revise the earthquake’s reported magnitude. Additional information collected about the earthquake may also prompt U.S.G.S. scientists to update the shake-severity map.
Subsequent quakes have been reported in the same area. Such temblors are typically aftershocks caused by minor adjustments along the portion of a fault that slipped at the time of the initial earthquake.
Aftershocks detected
Quakes and aftershocks within 100 miles
Aftershocks can occur days, weeks or even years after the first earthquake. These events can be of equal or larger magnitude to the initial earthquake, and they can continue to affect already damaged locations.
The New York Times
When quakes and aftershocks occurred
Sources: United States Geological Survey (epicenter, aftershocks, shake intensity); LandScan via Oak Ridge National Laboratory (population density) | Notes: Shaking categories are based on the Modified Mercalli Intensity scale. When aftershock data is available, the corresponding maps and charts include earthquakes within 100 miles and seven days of the initial quake. All times above are Pacific time. Shake data is as of Wednesday, June 3 at 6:03 a.m. Pacific time. Aftershocks data is as of Wednesday, June 3 at 8:01 a.m. Pacific time.
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California’s primary for governor is undecided as candidates vie to be in the top two
Xavier Becerra, Democratic gubernatorial candidate for California, and Steve Hilton, Republican gubernatorial candidate for California, shake hands while arriving for a gubernatorial debate at KRON Studios in San Francisco in April.
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Jason Henry/Getty Images North America
SAN FRANCISCO — The primary election for California governor is too close to call, with vote counting continuing Wednesday. Democrat Xavier Becerra and Republican business executive Steve Hilton lead the field with Democrat Tom Steyer in third place.
In California’s unusual primary system, all candidates, regardless of party, appear on a single ballot open to any registered voter. The top two candidates then move on to the general election, even if they’re from the same party. This year, voters had 60 names for governor to choose from.
The winner will lead the country’s most populous state, where leaders often take on national political prominence. Incumbent Gov. Gavin Newsom is at his two-term limit and could be a Democratic contender for president.
Becerra, former Health and Human Services secretary under President Joe Biden, pitched himself to voters as an experienced political leader who isn’t afraid of President Trump, but his lead caps one of the most surprising and dramatic comebacks in recent state political history. As recently as April, polls were showing Becerra — also a former member of Congress and California attorney general — languishing in single digits in a crowded field.
In his remarks at his watch party in Los Angeles, Becerra noted his underdog status.
“Here in Hollywood’s hometown, we love a good underdog success story,” he said, drawing parallels between his campaign and his immigrant parents’ success story in California. “Guess what? The underdog stayed in the fight. Like my parents, I never gave up. Never stopped putting one foot in front of the other. Never stopped believing in the beacon-like goodness of California. And thankfully, neither did you.”
Hilton is a former Fox News commentator who also served as a political adviser to former British Prime Minister David Cameron. He was endorsed by President Trump in April, helping him to pull ahead of Riverside County Sheriff Chad Bianco, the other major Republican in the race. Hilton has campaigned on the idea that California needs change after 16 years under total Democratic control.
The race is narrowing down after a tumultuous campaign
At his watch party in Huntington Beach, the British-born candidate — who became an American citizen five years ago — said it was the “honor of his lifetime” to receive over 1 million votes so far.
“Change is coming to California and it’s long overdue,” Hilton said. “We’re not there yet, but it’s looking good. It looks very much as if Californians really will have the chance to vote for change in November and take our state in a new direction.”
Democratic billionaire activist Steyer spent more than $213 million of his own money to boost his candidacy and push a progressive, populist message. While he was trailing Becerra and Hilton on Tuesday night, he said at his watch party in San Francisco that he remains confident he can close the gap in the days ahead.
“Together, we’ve scared the hell out of the corporate interests used to getting their way,” Steyer said. “It might take some time to figure out where this is going. We’re going to wait until every ballot is counted. We’re gonna give democracy a time to work. And we know we finished really strong.”
The early results are not certain to hold, in part because of unusual voting patterns in this primary election: Ballot-tracking data heading into Tuesday evening showed that Republicans were more likely to vote early by mail, while Democratic voters in this deep-blue state held onto their mail-in ballots or chose to vote in person. That’s the reverse of recent elections, which saw more Democrats voting by mail and Republicans tending to vote in person on Election Day.
The uncertainty on election night capped a race that remained crowded and unsettled to the end. To some extent, the race was defined by who wasn’t running.
Some of the state’s most high-profile Democrats — former Vice President Kamala Harris, U.S. Sen. Alex Padilla and California Attorney General Rob Bonta — all passed on a potential bid to succeed Newsom.
The race was disrupted in April when then-U.S. Rep. Eric Swalwell’s campaign for governor imploded amid allegations of sexual assault and harassment. Swalwell resigned from Congress shortly after the accusations surfaced and has denied assault allegations.
Swalwell had been gaining in polls and racking up high-profile endorsements, and his exit seemed to primarily benefit Becerra, who had been stuck in single digits in many polls. Ultimately, it quieted fears among Democrats who worried that the messy Democratic field could result in Bianco and Hilton winning the top spots in the June primary.
Marisa Lagos covers California politics at KQED and co-hosts the Political Breakdown show and podcast.
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Supreme Court reinstates Republican-favored Alabama congressional districts
The U.S. Supreme Court
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The Supreme Court on Tuesday cleared the way for Alabama to use a congressional district map favored by Republicans.
The court, in an unsigned order, overturned a three-judge district court panel that found that the map is “tainted by intentional race-based discrimination.” The court’s three liberals publicly dissented.
The ruling means that Alabama’s 2026 midterm elections will feature six Republican-leaning districts and one Democratic-leaning one, as opposed to a map with only five safe Republican seats. Democrat Shomari Figures, who represents Alabama’s Second District, will likely lose his seat as a result of the high court’s ruling.
The story of Alabama’s congressional map is long and tortured. It began in 2021, when the state implemented a new map to account for population changes in the census. The map featured only one majority-black district out of seven, even though the state is more than one-quarter Black.
Voters immediately sued, claiming the map illegally diluted minority votes in violation of the Voting Rights Act and the Constitution. Lower court judges agreed, ruling that the state must draw a map with two districts where Black voters have a realistic chance of electing their candidate of choice. The Supreme Court more than once has ordered Alabama to draw a compliant map.
But the state has refused and instead continued to litigate the case. On Tuesday, that tactic paid off.
What changed? In April, the Supreme Court’s conservative supermajority all but gutted what remains of the Voting Rights Act, ruling that states cannot purposefully draw districts that are majority-minority.
Alabama then asked the high court to reinstate the state’s old map, under the theory that this new ruling meant that it was permissible to use a map with only one majority-Black district. In an unsigned, unexplained order in May, the high court essentially reversed its previous opinions, and allowed Alabama to use the old map for the upcoming midterm elections.
This set off a flurry of activity in Alabama. By the time the Supreme Court issued its May order, absentee balloting had already begun, using the court-drawn map. So Republican Governor Kay Ivey cancelled elections and scheduled a special primary for August for the affected congressional races.
The case, however, was not over.
In its ruling, the Supreme Court had ordered a lower court panel to continue evaluating Alabama’s map in light of its recent Voting Rights Act decision. And just 15 days after that order, the panel, composed of three Republican judges—two of them Trump appointees—concluded unanimously that even under the Supreme Court’s new standards, the plan for a single black district was “intentionally discriminatory.”
So, once again, Alabama returned to the Supreme Court, arguing that the map was partisan, not racially discriminatory. In short, that the Republican legislature simply drew the map to elect more Republicans. And that under the Supreme Court’s new interpretation of the Voting Rights Act, the GOP map should be allowed to stand.
The court’s conservative agreed, writing that the lower court “did not heed the presumption of legislative good faith.”
The court’s three liberals publicly dissented, castigating the conservative majority for failing to abide by its 2006 decision in the case of Purcell v. Gonzalez. That decision declared that courts should not change election rules too close to an election.
Justice Sonia Sotomayor, in her dissent, said the court “debases the democratic process” and “corrodes the rule of law by rewarding Alabama’s gamesmanship and outright defiance of court orders.”
Tuesday’s decision is the latest in a series of Supreme Court rulings that could well reshape the 2026 midterm elections, making it much harder for Democrats to prevail.
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