Weekly Roundup -
September 30, 2026
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2027 Maternity Care Coding Changes: How Providers, Health Plans, and States Can Prepare for Service-Level Reimbursement
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CMS Marketplace Anti-Fraud Actions: Financial and Strategic Implications for ACA Health Insurers
Program integrity has become an urgent, administration-wide healthcare priority, placing the Affordable Care Act (ACA) Marketplace under heightened scrutiny. On September 22, 2026, the Centers for Medicare & Medicaid Services (CMS) announced Federal Marketplace anti-fraud actions with immediate operational and financial implications for insurers.
This week, actuaries from Wakely Consulting Group, an HMA company, examine how Marketplace disenrollment actions could affect health insurers in 2026 and beyond across enrollment, morbidity, risk adjustment, financial reporting, operations, distribution strategy, and future pricing.
CMS Marketplace Anti-Fraud Actions and Unauthorized Enrollment Cancellations
CMS’s three-part program integrity strategy focuses on preventing fraudulent and improper enrollments, removing confirmed unauthorized enrollments, and enforcing Marketplace requirements for agents and brokers. The agency also established a Federal Marketplace anti-fraud coordination group comprising leaders from CMS and the US Department of Health and Human Services (HHS) to direct these efforts.
CMS reported canceling approximately 315,000 enrollments covering more than 760,000 individuals after determining that the coverage was unauthorized. The agency expects approximately $2.2 billion in advance payments of the premium tax credit (APTC) to be returned and will continue working with insurers to identify additional cases, prevent improper subsidy payments, and recoup prior payments.
This action follows a June 2026 report from the HHS Office of the Assistant Secretary for Planning and Evaluation, which identified approximately 1 million highly suspicious agent- and broker-assisted HealthCare.gov enrollments involving applications without a Social Security number and members paying no premium.
Although the absence of a Social Security number does not independently establish fraud, the September announcement sends a strong signal about CMS’s willingness to cancel enrollments confirmed as unauthorized.
Financial and Operational Implications for ACA Marketplace Insurers
Enrollment Losses and Morbidity Risk for ACA Marketplace Plans
In their August 2026 white paper, Implications for Potential Marketplace Unauthorized Enrollment Actions, actuaries from Wakely noted that while the overall enrollment reduction is known, its distribution across issuers and markets is not publicly available. If canceled members are disproportionately healthy or had limited healthcare utilization, their removal could increase average claims among the remaining population. For example, if non-utilizers represented 10 percent of an issuer’s enrollment, removing them would increase average claims per member per month by approximately 10 percent, assuming no other changes.
ACA Risk Adjustment Implications of Marketplace Disenrollments
Changes in enrollment and morbidity could materially affect ACA risk adjustment transfers, but the results will vary according to each issuer’s concentration of confirmed or potentially unauthorized enrollment. Issuers with greater exposure to canceled enrollment could see more favorable risk adjustment results even as average claim costs increase. Those transfers may not fully offset deterioration in the remaining risk pool, which underscores the need for plan- and state-specific analysis.
APTC Recoupment and Financial Reporting Considerations for Insurers
The timing and process to recoup approximately $2.2 billion in APTCs has near-term financial reporting considerations. Issuers should evaluate potential effects on:
- Premium and APTC accruals
- Risk adjustment transfer accruals
- Per member claims cost estimates
- Premium deficiency reserve considerations
According to CMS, the cancellations announced in September 2026 will be applied retroactively to original effective dates. The full effect of this heightened scrutiny, however, will depend on how CMS approaches recoupment and how quickly issuers process enrollment and financial adjustments.
Issuers may also incur near-term costs associated with identifying and investigating suspicious enrollments, reconciling records with CMS, processing cancellations, adjusting revenue accruals, supporting affected consumers, and updating broker oversight. Lower enrollment also leaves fewer premium dollars available to cover fixed administrative expenses.
How CMS Disenrollments Could Affect Future Marketplace Premiums
As 2027 premiums are finalized, issuers will need to consider enrollment and morbidity shifts for 2028 prices. Insurers with established monitoring and projection processes will be better positioned to assess new CMS information and adjust forecasts as policy and enforcement evolve for 2026 and 2027.
CMS Broker Enforcement and Marketplace Distribution Risks
In addition to strengthening oversight of enrollment data, CMS has intensified enforcement of agent and broker requirements. Since January 2026, the agency has sent termination notices to more than 200 noncompliant agents and brokers and issued 569 notices of intent to terminate Exchange Agreements associated with 2026 applications that lacked identifying applicant information. Issuers should assess concentration by broker, monitor enrollment quality, and consider how enforcement may affect acquisition channels, member mix, and future growth.
Market-Level Variation in Marketplace Disenrollment Risk
The effects of CMS’s actions are limited to Federally Facilitated Marketplace (FFM) states and state-based Marketplaces using the federal platform (SBE-FM) and do not extend to state-based Marketplaces operating their own eligibility and enrollment systems. Individual issuer effects could vary materially based on several factors, including state, county, issuer, product, broker channel, and member premium contribution.
Some issuers will be more exposed than others, particularly those with more enrollees paying low or $0 net premiums, greater broker reliance, substantial automatic reenrollment, or a strong presence among lower-cost plans. Understanding the financial impact will require analysis at the plan and market levels.
Key Actions for Health Insurers Following CMS Marketplace Disenrollments
Health insurers should assess a range of outcomes at the plan and state levels. This analysis should show how the concentration and health profile of canceled enrollment could affect claims, APTCs, risk adjustment, financial accruals, administrative expenses, distribution, and future rates.
The timing of CMS’s actions will shape those outcomes. Because the announced cancellations apply retroactively to original effective dates, insurers will need to account for APTC recoupment and related enrollment and financial adjustments. The ultimate impact will depend on the data CMS provides, the scope of additional reviews, processing timelines, and any appeals or corrections. Issuers should revisit their forecasts as these details emerge and federal actions continue ahead of the 2027 plan year.
Assessing Marketplace Disenrollment Risk: How HMA and Wakely Can Help
Health Management Associates (HMA) and Wakely Consulting Group combine policy, market, actuarial, and financial expertise to help health plans and state regulators assess the effects of Marketplace program-integrity actions. For insurers, our teams can develop plan-by-plan and state-by-state projections of enrollment, morbidity, claims, APTCs, risk adjustment, and premiums; test prospective and retrospective cancellation scenarios; and translate the findings into pricing, forecasting, distribution, and market strategy decisions.
State insurance regulators in affected FFM and SBE-FP states will need a market analysis of how the cancellations are distributed across issuers and whether changes in enrollment and morbidity could affect rates, risk adjustment, capital, or continued plan participation. Regulators should also evaluate whether approved 2027 rates and financial assumptions remain supportable and monitor solvency and consumer access as insurers adjust to this and CMS’s broader program integrity actions. HMA and Wakely can support this work through state-specific market assessments, issuer-level stress testing, rate and risk-pool analysis, and scenario projections that help regulators identify emerging concerns and act before they threaten market stability.
HMA and NALHE Partnership Advances Latino Leadership in Healthcare
Health Management Associates (HMA) is honored to be recognized as the National Association of Latino Healthcare Executives’ (NALHE) Partner of the Year. From the beginning, our goal was to be more than a sponsor. We wanted to be a true partner in advancing Latino healthcare leadership. Over the years, we have collaborated with healthcare organizations represented by NALHE members, shared ideas and expertise through thought leadership initiatives, supported chapter activities, and participated in programming that brings healthcare leaders together to learn from one another and build meaningful connections.
Being recognized as Partner of the Year reflects our shared work focused on developing leaders, supporting healthcare organizations, and improving the communities we serve. We look forward to building on this work together.
Federal Policy News
Fueled By Leavitt Partners Weekly Health Intelligence
Senate Wraps Pre-Recess Agenda as Funding Fight Looms
This week, the Senate is in session for the final few days before recess, which will see many members returning to their home states through the mid-term elections, while the House currently remains in recess until November. The full Senate is anticipated to consider several items this week, including legislation related to college sports, while committees are continuing to consider nominations and hold hearings before adjourning.
Nominations
Today, Wednesday, September 30, the Senate HELP Committee will vote on several Trump Administration nominees for key roles within HHS, specifically:
Dr. Nicole Saphier to be Medical Director in the Regular Corps of the Public Health Service and Surgeon General of the Public Health Service;
- Dr. Timothy Westlake to be Assistant Secretary for Mental Health and Substance Use; and
- Ms. Mary Lazare to be Assistant Secretary for Aging.
These nominations will likely be considered by the full Senate when they return after the mid-term elections, along with Mr. Chris Klomp to be HHS Deputy Secretary, which was recently advanced by the Senate Finance Committee. While Dr. Heidi Overton appeared before the Senate HELP Committee last Thursday to respond to members regarding her nomination for Commissioner of Food and Drugs, a committee vote on her nomination has not yet been announced.
Appropriations
Additionally, when Congress returns after the mid-term election, members will only have a few weeks to pass continued funding for fiscal year (FY) 2027 before the December 11 funding deadline. This effort could be complicated by the White House’s notice to Congress of a “pocket rescission” of $810 million. Last week, the Administration communicated to the Hill that it will not spend the entirety of funding approved by Congress for certain accounts and programs, and the rescissions include:
- $567 million appropriated in FY 2024 for HHS Office of Refugee Resettlement programs;
- $28 million appropriated in FY 2026 for the Agency for Healthcare Research and Quality; and
- $5 million appropriated in FY 2026 for the HHS Office of Minority Health.
Senate Appropriations Committee Chair Susan Collins (R-ME) opposed the move on social media, stating this is the most recent attempt by this Office of Management and Budget (OMB) to undermine Congress’s Constitutional power of the purse. She also wrote that the independent Government Accountability Office has concluded that pocket rescissions are unlawful and not permitted by the Impoundment Control Act.
Senate and House Appropriations Committee Ranking Members Patty Murray (D-WA) and Rosa DeLauro (D-CT) also issued statements criticizing the effort and stating that such a move is against the law.
Because appropriations bills generally require bipartisan support to pass, the Administration’s recent actions could increase pressure to include more detailed requirements in the legislation for how the Administration is to spend FY 2027 funding.
HHS Launches Medicaid Quality Initiative, Issues Community Engagement Guidance
On September 25, 2026, the Centers for Medicare & Medicaid Services (CMS) announced that it launched the Investing in Health Outcomes initiative with 37 states to shift Medicaid and Children’s Health Insurance Program (CHIP) quality measurement toward health outcomes rather than process measures. Participating states can sign a voluntary Medicaid Quality Pledge focused on prevention, chronic disease management, behavioral health, streamlined reporting, digital quality measurement, and greater alignment of financial accountability with outcomes. States will use these principles to develop health outcome targets and incorporate more outcomes-oriented measures into quality strategies and upcoming procurements. CMS plans additional workshops later this year on measure prioritization, value-based arrangements, reporting burden, and digital quality measurement.
Separately, on September 29, 2026, the US Department of Health and Human Services (HHS) Office for Civil Rights (OCR) released guidance clarifying certain confidentiality rules for state Medicaid programs regarding how protected patient records related to substance use disorder (SUD) can be used to verify medical frailty exemptions for the community engagement requirements approved by the 2025 budget reconciliation act (P.L 119-21, OBBBA). The guidance clarifies when Medicaid agencies can use an enrollee’s SUD records to verify a medical frailty exemption and aims to ensure that Medicaid agencies protect the privacy of these records.
MAHA Summit Highlights Federal Priorities in Chronic Disease, AI, and Healthcare Innovation
On September 29, the Make America Healthy Again (MAHA) Summit convened in Washington, D.C., to discuss health policy and care delivery. The agenda included discussions on chronic disease prevention, food and nutrition policy, health technology and artificial intelligence, value-based care, biotechnology innovation, and psychedelic medicine. Featured speakers included senior federal officials from HHS, CMS, NIH, and USDA, alongside leaders from industry, health systems, and digital health companies. Confirmed Administration participants included:
The event also included several private sector panelists from sponsoring organizations, including leaders from diagnostics companies, insurers, and restaurants, as well as athletes and actors. The event occurred in-person but included a virtual option.
CMS Opens Comment Period on 2027 Clinical Laboratory Fee Schedule
On September 21, CMS announced preliminary 2027 Medicare payment rates for clinical laboratory services that are intended to “align the 2027 clinical laboratory fee schedule rates with private sector payment rates.” The agency reports that Medicare is currently paying about 16 percent more than private payers for laboratory services and estimates that updating the Clinical Laboratory Fee Schedule (CLFS) could save taxpayers roughly $1 billion annually. The new rates are based on private payer data collected under the Protecting Access to Medicare Act (PAMA), which Congress recently amended through the Consolidated Appropriations Act of 2026.
For labs, including hospital labs, the proposal could mean significant reimbursement reductions for many tests, although CMS must phase in any decreases because federal law caps annual payment cuts at 15 percent per test through 2029. Laboratory industry groups have expressed concern that lower reimbursement rates could affect lab operations and patient access to testing, particularly in rural and underserved areas. CMS has opened a 30- day public comment period on the preliminary rates and plans to finalize the 2027 payment schedule in November 2026, with the new rates taking effect January 1, 2027.
Klomp Nomination Advances Following Committee Review
On September 24, the Senate Finance Committee voted 15–12 to advance the nomination of Mr. Chris Klomp to be HHS Deputy Secretary, sending it to the full Senate for a consideration. The vote followed his September 15 Senate Finance Committee hearing and a September 16 courtesy hearing before the HELP Committee. At both, lawmakers focused on the influence Mr. Klomp holds at HHS and how he might use it, with Democrats and Senate HELP Committee Chair Bill Cassidy (R-LA) urging him to push back if vaccine policy continues to be undermined. In the Senate Finance Committee vote, Senator Cassidy voted to advance Mr. Klomp’s nomination. Additionally, following positive commentary regarding his technical expertise during the Senate Finance Committee hearing, Senator Sheldon Whitehouse (D-RI) joined all Republicans in voting to advance the nomination. Following the vote, Finance Committee Chair Mike Crapo (R-ID) said Mr. Klomp emphasized effective leadership and operational excellence at HHS. Ranking Member Ron Wyden (D-OR) opposed the nomination, citing a lack of transparency in the White House’s drug pricing agreements and HHS’s handling of vaccine policy. If confirmed, Mr. Klomp would become the department’s second-highest official, a post that has been vacant since Jim O’Neill left in February. The Senate is unlikely to vote on Mr. Klomp’s nomination prior to leaving for an extended recess at the end of this week.
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State Policy News
CMS Approves Medicaid Reentry Waivers for Louisiana, Minnesota, Nevada, and DC
The Centers for Medicare & Medicaid Services (CMS) announced on September 23, 2026, that it has approved new Medicaid Section 1115 demonstrations for reentry services in Louisiana, Minnesota, and Nevada. The states are now authorized to provide pre-release Medicaid services to eligible incarcerated individuals for up to 60 days prior to release. CMS also approved the District of Columbia’s Whole-Person Care Transformation 1115 demonstration renewal request, which continues allowing the district to provide eligible beneficiaries with substance use disorder or serious mental illness Medicaid coverage while staying in an institution for mental diseases (IMDs), and adds reentry services for eligible incarcerated individuals prior to release. All four demonstrations are effective from October 1, 2026, through September 30, 2031. In addition, CMS issued a Frequently Asked Questions page regarding the goals, eligibility, and monitoring and evaluation requirements for the reentry demonstrations.
Idaho Plans Medicaid MCO Payment Penalties as Managed Care Launch Faces New Delays
The Idaho Capital Chronicle reported on September 25, 2026, that the Idaho Department of Health and Welfare intends to impose penalties against Medicaid managed care organizations (MCOs) for late payments once the state transitions to fully-capitated Medicaid managed care. The penalties would go to the provider seeking payment from a delayed claim, according to a private consultant working with DHW during a Medicaid Review Panel meeting. Idaho also plans to publicly post data about payment metrics, as well as prior authorization denial and approval rates and denial reasons. Idaho Medicaid Director Sasha O’Connell stated that the state may have to again delay implementation of managed care, which had already been delayed to 2030, over a lawsuit regarding a contract award for Idaho’s Medicaid management information system. The review panel will meet again in November to make a final decision on the implementation timeline. The state announced a blackout period for the comprehensive Medicaid managed care RFP will start on December 1, 2026.
CMS Approves Maine Medicaid 1115 Waiver Renewal and Reentry Services Expansion
The Centers for Medicare & Medicaid Services (CMS) approved on September 25, 2026, Maine’s section 1115(a) demonstration renewal, renamed the Maine Whole Person Care Waiver, from October 1, 2026, through September 30, 2031. The renewal continues existing substance use disorder services, extended MaineCare coverage for certain parents, home-based skill development, and parenting supports, while adding serious mental illness services in institutions for mental diseases, traditional health care practices, and pre-release Medicaid services for certain incarcerated individuals. Pre-release coverage is authorized for up to 60 days before release from jails and prisons and up to 90 days before release from youth correctional facilities, with services including case management, medication-assisted treatment, prescription medications, and physical and behavioral health services.
Minnesota Audit Identifies Medicaid Program Integrity Risks, Calls for Stronger Oversight
The Minnesota Office of the Legislative Auditor (OLA) released a report recommending increased oversight of the state’s Medicaid-funded services. OLA’s report was a review of a vulnerability assessment completed for the Minnesota Department of Human Services (DHS) by Optum State Government Solutions, a UnitedHealth Group company, which identified vulnerabilities in DHS’ eligibility requirements, billing and coding practices, provider oversight, and information technology controls, exposing them to risk of fraud. While DHS is working on a long-term strategy to strengthen payment integrity and reduce improper payments, it stated that Optum’s report flagged vulnerabilities that were later determined to be non-problematic.
Private Market News
Fueled By Wakely Consulting Group
CVS to Assume Full Ownership of Arizona Medicaid Plan Mercy Care Following Ascension Exit
Ascension and Dignity Health, part of CommonSpirit Health, have agreed to transfer full ownership of Arizona-based Mercy Care to CVS Pharmacy, pending regulatory approval. Mercy Care serves Medicaid beneficiaries through Arizona’s Medicaid program and operates a Medicare Dual Special Needs Plan, while Aetna has managed the organization’s administrative operations for more than two decades. The transaction aligns Mercy Care’s community presence with Aetna’s operational scale, technology capabilities, and capital resources, while Dignity Health will continue serving Arizona communities through its provider and hospital networks. Aetna has administered Mercy Care since 2002.
CMS Targets Medicare Advantage Program Integrity, Overpayments, and Plan Accountability
Centers for Medicare & Medicaid Services (CMS) Administrator Dr. Mehmet Oz signaled that the Trump Administration intends to maintain pressure on Medicare Advantage (MA) plan. Speaking at an industry event in September, Oz and other agency officials emphasized the need to strengthen oversight, improve accountability, and restore confidence in MA, even as CMS seeks to preserve MA’s appeal to beneficiaries.
Read the latest Wakely Wire for actuarial insights into the trends shaping payer strategy and financial performance.
Our Insights
Fueled By Experts Across Our HMA Companies
Health Management Associates
North Carolina, Illinois State of Reform Health Policy Conferences Slated for November
Managing constant change in healthcare takes more than just hard work. It takes a solid understanding of the legislative process and knowledge about intricacies of the healthcare system. That’s where State of Reform comes in. State of Reform pulls together practitioners, thought leaders, and policymakers – each working to improve the healthcare system in their own way – into a unified conversation in a single place.
- The 2026 North Carolina State of Reform Health Policy Conference will be taking place in-person on November 10th, 2026 at the Raleigh Marriott Crabtree Valley. Join the Conversation!
- The 2026 Illinois State of Reform Health Policy Conference will be taking place in-person on November 17th, 2026 at the Hyatt Centric Chicago Magnificent Mile. Join the Conversation!
Webinar: The Value of Home-Based Personal Care Services - October 22
This webinar, supported by TEAM Services Group, will provide an overview of home-based care, including the populations served, key service types, and delivery models. Experts will discuss findings from a review of the value of home-based care, highlighting its potential to stabilize health, improve the care experience, reduce unnecessary healthcare utilization, and enhance safety and satisfaction for both individuals receiving care and their family caregivers. The webinar will also examine opportunities to expand access to high-quality home-based care, including policy and system-level strategies that can strengthen the structural components needed to make these services more widely available to those who could benefit.
Wakely
2027 Medicare Advantage Second Plan Preview: Why Higher Cut Points Could Still Mean Lower 2028 Revenue
This white paper from actuaries at Wakely Consulting Group analyzes the 2027 Medicare Advantage Star Rating cut points and reward-factor thresholds released by the Centers for Medicare & Medicaid Services (CMS) in the September 8 Second Plan Preview. The analysis shows a challenging dynamic for Medicare Advantage organizations. Although more measure-level cut points increased than decreased, reward-factor thresholds fell at both the 65th and 85th percentiles. The lower contract-level reward-factor thresholds may indicate lower Overall Star Ratings and reduced Quality Bonus Payment revenue in 2028.
Leavitt Partners
New PICSA Playbook Offers a Roadmap for Advancing Pharmacists as Clinical Service Providers
As health care organizations look for practical ways to expand access, strengthen care coordination, and accelerate value-based care, pharmacists are emerging as a powerful—and often underused—clinical resource. To help organizations move from interest to implementation, the Pharmacy Interoperability and Clinical Services Alliance (PICSA), led by Leavitt Partners, has released a new playbook that gives pharmacies, has released a new playbook that gives pharmacies, pharmacists, health plans, and technology partners a clear path for putting pharmacist-provided clinical services into practice.
The Playbook for Onboarding Pharmacists as Service Providers Across Commercial and Medicaid Health Plans provides a practical, end-to-end framework for organizations ready to turn policy opportunity into sustainable implementation. It gives pharmacies, pharmacists, health plans, and technology partners a common roadmap for aligning credentialing, contracting, claims configuration, clinical workflows, documentation, reimbursement, and performance monitoring—so pharmacist-provided services can move from concept to consistent execution.
HMA Conference 2026 is Next Week!
Signals, Signs & Flashing Lights | October 5-7 | New Orleans
Learn More
RFP Calendar
RFP Calendar
| Date | State/Program | Event | Beneficiaries |
|---|---|---|---|
| Date: Summer 2026 | State/Program: Illinois Foster Care | Event: RFP Release | Beneficiaries: 33,000 |
| Date: July 28, 2026 (Delayed) | State/Program: Nevada Children's Specialty | Event: Awards | Beneficiaries: NA |
| Date: November 6, 2026 | State/Program: Indiana | Event: Proposals Due | Beneficiaries: 1,400,000 |
| Date: January 1, 2027 | State/Program: Illinois | Event: Implementation | Beneficiaries: 2,400,000 |
| Date: January 1, 2027 | State/Program: Nevada CO D-SNP | Event: Implementation | Beneficiaries: 88,000 |
| Date: January 1, 2027 | State/Program: Wisconsin LTC GSR 3 | Event: Implementation | Beneficiaries: 56,000 (all GSR) |
| Date: January 1, 2027 | State/Program: Illinois Tailored Care Management Program | Event: Implementation | Beneficiaries: 22,400 |
| Date: July 2027 | State/Program: Indiana | Event: Awards | Beneficiaries: 1,400,000 |
| Date: July 1, 2027 | State/Program: Nevada Children's Specialty | Event: Implementation | Beneficiaries: NA |
| Date: Fall 2027 | State/Program: Oregon | Event: RFP Release | Beneficiaries: 1,200,000 |
| Date: January 1, 2028 | State/Program: Wisconsin LTC GSR 4,6 | Event: Implementation | Beneficiaries: 56,000 (all GSR) |
| Date: 2028 | State/Program: North Carolina | Event: RFP Release | Beneficiaries: 2,200,000 |
| Date: 2029 | State/Program: California | Event: RFP Release | Beneficiaries: NA |
| Date: January 1, 2029 | State/Program: Indiana | Event: Implementation | Beneficiaries: 1,400,000 |