Providence Health Plan shut down entirely after a sale to an unnamed national insurer collapsed, stranding 64,000 MA members without coverage.
Costco partners with SCAN to offer Medicare plans
Costco is partnering with nonprofit insurer SCAN to offer branded Medicare Advantage plans to its members.
Providence Health Plan shuts down after MA deal falls through
Providence Health Plan announced complete closure, leaving approximately 64,000 MA members without coverage after a sale to an unnamed national insurer collapsed.
⊕ +1 from PriorAuth
Epic launches real-time prior authorization at four health systems
Epic launched real-time prior authorization functionality at four health systems, automating the approval process at the point of care.
ACA insurers worst offenders on prior auth denials at 18%: KFF
KFF data show ACA insurers average an 18% prior authorization denial rate, the highest among insurance segments.
R1 RCM to acquire Humata Health for AI prior authorization
R1 RCM announced plans to acquire Humata Health to build out AI-driven prior authorization capabilities.
Senate Republicans block Dem bid to end AI prior auth in Medicare
Senate Republicans blocked a Democratic amendment that would have prohibited AI-driven prior authorization in Medicare.
CMS conducting six-year payment audits in 13-month window
CMS is completing six years of health plan payment audits within a 13-month period.
Health plans reassess coding vendor accuracy measurement
Health plans are reconsidering how they evaluate risk adjustment coding vendor accuracy as the compliance bar rises.
⊕ +1 from PriorAuth
Prior authorisation moves from payer discretion to regulated process.
Overturned by: twelve months with no federal rule advancing and penalties staying nominal and unnamed
Watching: Watch whether CMS finalizes its 2026 prior-auth interoperability rule enforcement timeline by Jan 2027; a delay would signal the regulatory track is also stalling. by Jan 2027
Last call: ● TESTING
Risk adjustment is a cost of participation, not a source of advantage.
Overturned by: any carrier attributing a margin beat to coding or risk-score improvement under V28, in two consecutive quarters
Watching: Watch whether any carrier discloses a reserve or restatement tied to the accelerated RADV cycle in Q3 2026 earnings (by Nov 2026); a reserve would confirm plans are pricing in clawback risk. by Nov 2026
Last call: ● TESTING
Penetration keeps rising. Who captures the growth is unresolved.
Watching: Watch whether another regional standalone plan announces exit or sale before 2027 AEP bid deadline (by Oct 2026); a second exit would confirm incumbents cannot compete without scale or novel distribution. by Oct 2026
Last call: ● TESTING
Margin discipline is structural and permanent, not a cycle to wait out.
Overturned by: realised MA enrolment growing at or above market for the carriers who announced contraction, through two consecutive AEPs
The cost of margin recovery is passed through. Where it lands is unresolved.
Overturned by: margin recovery achieved through genuine cost reduction rather than transfer
Star ratings will be restructured, not merely disputed.
Overturned by: a full cycle published, unchallenged, with stable cut points
The independent distribution channel consolidates under financial stress.
Overturned by: a new entrant scaling profitably, or commissions holding through an AEP