Insights

FAQs: What OPOs Need to Know About the Proposed Rule

On February 3, 2026, President Trump signed a $1.2 trillion spending deal that, among other points, introduced significant regulatory changes for Medicare Part D plans and PBMs providing services to PDP sponsors in the Medicare Advantage and Medicare Part D programs, and imposed significant new restrictions and transparency requirements on PBMs contracting with private group health plans.

On January 27, 2026, the Centers for Medicare and Medicaid Services (CMS) released a Health Plan Management System (HPMS) memo that provided a long-awaited update on how the agency plans to approach previously announced Risk Adjustment Data Validation (RADV) audits for Payment Years (PY) 2020-2024. The memo is the agency’s most comprehensive statement on the subject since September 25, 2025, when the Northern District of Texas vacated the 2023 RADV Final Rule. The memo makes clear that, while CMS has made certain operational adjustments in response to concerns expressed by Medicare Advantage Organizations (MAOs), the agency is largely pressing forward with the accelerated audit strategy announced in May 2025.

On January 26, 2026, the Centers for Medicare and Medicaid Services (CMS) circulated the Calendar Year (CY) 2027 Advance Notice to communicate proposed changes to Medicare Advantage (MA) capitation rates and Parts C and D payment policies.  The changes are expected to be finalized in April 2026 but may be delayed. The following is a summary of the most significant proposals, with further details below:

The U.S. Court of Appeals for the 6th Circuit may no longer be as favorable a venue for health plans engaged in legal disputes with members who allege that insufficiently detailed claim denials violate the Employee Retirement Income Security Act’s (ERISA) protections against “arbitrary and capricious” decision making.

Since the signing of Executive Order 14187 (“Protecting Children from Chemical & Surgical Mutilation”) in late January 2025, the Trump Administration has made its skeptical stance on gender-affirming care—especially regarding services provided to minors—clear.

On November 26, 2025, the Centers for Medicare & Medicaid Services (CMS) published its Proposed Rule for the Medicare Program; Contract Year 2027 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, and Medicare Cost Plan Program (the “CY 2027 NPRM” or “proposed rule”) for public comment. In addition to outlining prospective policy and technical changes to Medicare Advantage (Part C), the Medicare Prescription Drug Benefit (Part D), and Medicare Cost Plan regulations, the proposals showcase the government’s plans to make comprehensive updates in response to statutory changes—notably the Inflation Reduction Act of 2022 (IRA)—as well as feedback from interested parties, and current federal deregulatory priorities.

On Friday, November 21, the Centers for Medicare & Medicaid Services (CMS) noticed its appeal of the Northern District of Texas’ decision in Humana Inc. et al. v. Becerra et al.

On January 4, in its most recent effort to expand federal support for addressing health-related social needs (HRSNs), the Centers for Medicare & Medicaid Services (CMS) issued guidance to clarify an existing option for states to address HRSNs through the use of “in lieu of” services and settings policies in Medicaid managed care. This option is designed to help states offer alternative benefits that take aim at a range of unmet HRSNs, such as housing instability and food insecurity, and to help enrollees maintain their coverage and improve health outcomes. 

This summary of key lawsuits affecting managed care is provided by the Health Care Group of Crowell & Moring. If you have questions or need assistance on managed care law matters, please contact Chris Flynn, Peter Roan, or any member of the Health Care Group.

This summary of key lawsuits affecting managed care is provided by the Health Care Group of Crowell & Moring. If you have questions or need assistance on managed care law matters, please contact Chris Flynn, Peter Roan, or any member of the Health Care Group.

In Health Republic Insurance Co. v. U.S. (Jan. 10, 2017), the Court of Federal Claims (Court) rejected the Government’s motion to dismiss a lawsuit filed under the Tucker Act seeking to recover “risk corridors” payments pursuant to §1342 of the Affordable Care Act, holding that “HHS is required to make annual risk corridors payments to eligible qualified health plans” under the ACA, and that the “plaintiff’s claim for unpaid risk corridors payments is ripe for adjudication.” The Court’s decision was based on several factors, including the risk corridors program’s purpose of stabilizing insurance premiums in the ACA’s new and untested health insurance marketplace; notably, the Court held that even if the ACA were ambiguous and the court were to apply a Chevron deference analysis, HHS has interpreted the program to require annual payments, and the agency’s own actions (i.e., making partial annual payments) indicate it believes the program is annual in nature.

The Affordable Care Act (ACA) was enacted in 2010 and most of its provisions became effective by 2014. President Obama’s signature law ushered in nation-wide health insurance reforms and new pathways for coverage, but also created controversy over some of its key provisions—like the mandate to purchase insurance.

On Friday, October 14, 2016, the Centers for Medicare and Medicaid Services (CMS) released the pre-publication version of the final rule with comment period (Final Rule) that, beginning January 1, 2017, will implement the provisions of the Medicare Access and CHIP Reauthorization Act (MACRA) relating to the new Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). MIPS and APMs are collectively referred to as the “Quality Payment Program” or “QPP”. Physicians, physician assistants, nurse practitioners, clinical nurse specialists and certified registered nurse anesthetists (collectively, “MIPS-eligible clinicians”) are part of the QPP if they bill Medicare more than $30,000 a year or provide care for more than 100 Medicare patients a year (both higher thresholds than initially proposed by CMS in the notice of proposed rulemaking).

This summary of key lawsuits affecting managed care is provided by the Health Care Group of Crowell & Moring. If you have questions or need assistance on managed care law matters, please contact Chris Flynn, Peter Roan, or any member of the Health Care Group.

Under a recently proposed rule, the Centers for Medicare & Medicaid Services (CMS) would release on an annual basis data that Medicare Advantage (MA) organizations and Part D sponsors have typically considered to be proprietary and confidential.1 The proposed rule would also limit MA organizations to contracting with providers and suppliers that are enrolled in Medicare. This new network requirement could adversely affect some MA organizations’ ability to meet CMS network adequacy requirements. CMS solicits comments on several topics related to the proposed rule. Comments are due September 6, 2016.

The Medicare Access and CHIP Reauthorization Act (MACRA), enacted in April 2015, authorized the creation of the Medicare Quality Payment Program. Among other changes, MACRA provides for rewards for participation in Alternative Payment Models (APMs) to promote high-value rather than high-volume care. On May 9, 2016, the Centers for Medicare and Medicaid Services (CMS) published a notice of proposed rulemaking in the federal register to implement MACRA by creating the Quality Payment Program (MACRA Rule).

Yesterday, in U.S. House of Representatives v. Burwell, No. 14-1967 (RMC), D. D.C., May 12, 2016, the U.S. District Court for the District of Columbia held that the Affordable Care Act (ACA) does not authorize the administration to reimburse health plans operating on the ACA’s exchanges for cost-sharing reductions given to consumers as required by ACA Section 1402. As enacted, Section 1402 requires health plans on the ACA exchanges (so-called “Qualified Health Plans” or QHPs) to reduce the copayments and deductibles charged to consumers under certain income levels. The federal government, in turn, is required to reimburse QHPs for the amount of the reduction. Now, however, the district court has ruled that Section 1402 requires an annual appropriation to fund payments to health plans but Congress has never appropriated such funds, placing billions of dollars in government payments to health plans in jeopardy.

In a controversial move, HHS’ new rules for Medicaid Managed Care plans create a novel work-around for the prohibition on the use of Medicaid funds for mental hospital stays. One of the most venerable Medicaid rules—which was included in the original Act in 1965—is the exclusion of Medicaid assistance “for the care or services for any individual who has not attained 65 years of age and who is a patient in an institution for mental diseases” (IMD).1 An IMD is an institution “that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including medical attention, nursing care and related services.”2 The exclusion thus covers state and private mental hospitals, which have traditionally provided long-term care, often in locked wards, but not psychiatric wards in general med/surg hospitals.

Today the Centers for Medicare & Medicaid Services (CMS) published the Medicaid Managed Care final rule (the “Final Rule”) in the Federal Register. The Final Rule comes 14 years since the last Medicaid managed care rulemaking, when CMS promulgated the regulations implementing the Balanced Budget Act of 1997’s changes to the Medicaid program in 2002. The healthcare world has changed dramatically since then both through the enactment of the Affordable Care Act (ACA) and substantial growth in Medicaid managed care (the Final Rule notes that as of July 2013, 73.5 percent of Medicaid beneficiaries received at least some benefits through managed care).