New 2027 ACA draft rules could drive small firms toward individual market

By Allison Bell – The individual health insurance rules that federal regulators are developing for 2027 could help individual coverage crowd out more of the small-group market, according to Jeff Smedsrud. Smedsrud — a longtime supplemental health insurance benefits marketer who was the founder of HealthCare.com, and who now is the chief executive officer of Flex Benefits — predicted today in an email that the draft Affordable Care Act individual health insurance market rules will make individual major medical insurance more attractive and more affordable in many markets. Read Full Article...  ^{_{(Subscription required)}}

HVBA Article Summary

1. Potential Shift from Small-Group to Individual Market: The proposed 2027 ACA rules could incentivize small employers to move away from traditional group health coverage in favor of sending employees to the individual market. This shift may be driven by the increased affordability and attractiveness of individual major medical insurance under the new regulations. As a result, small group plans may become less common, especially among employers with fewer than 10 employees.

2. Key Features of the Draft Rules: The draft regulations introduce several changes, such as expanding access to catastrophic plans, allowing for higher out-of-pocket maximums, and enabling longer policy durations of up to 10 years. These features could make individual plans more appealing to both consumers and brokers, while also encouraging insurers to focus on long-term wellness strategies. The rules also propose measures to reduce state-mandated benefits and address subsidy application fraud.

3. Implications for Employer and Worker Coverage: If the draft rules are implemented, small employer plans could become increasingly expensive and may primarily serve lower-income or less healthy workers. This could lead to a scenario where comprehensive employer-sponsored health insurance is rare among very small businesses. The changes reflect a broader rethinking of the ACA system, potentially altering the landscape of health coverage options for both employers and employees.

UnitedHealthcare Tightens Specialist Access for Medicare Advantage Enrollees

By Wendell Potter – Theresa Schwartz, a 66-year-old Milwaukee plumber, says she’s one of those people who never went to a doctor before she was 40. That has changed in the second half of her life as she has dealt with major health issues, including lung cancer and rheumatoid arthritis. In recent years, her regular visits to the Milwaukee Rheumatology Center have been covered, without hassle, by her Medicare Advantage insurance provided through the nation’s largest health insurer, UnitedHealthcare. But Schwartz was surprised and became upset during her most recent visit there when she was told that — because of a new UnitedHealthcare policy — she will now need a referral from a primary care physician to be covered. Read Full Article...

HVBA Article Summary

1. New Referral Requirement for Specialist Visits: UnitedHealthcare has implemented a policy requiring Medicare Advantage HMO and HMO-POS enrollees to obtain referrals from a primary care physician before seeing certain specialists. This change is expected to impact a significant portion of the insurer’s 8.5 million Medicare Advantage members, particularly those who have long-standing relationships with specialists and have not previously needed referrals. The policy is currently in a trial period but will be fully enforced after April 30, potentially disrupting established care routines for many seniors.

2. Concerns Over Patient Access and Administrative Burdens: Patients and healthcare advocates worry that the new referral process will create bureaucratic delays and confusion, especially for elderly individuals and those with chronic conditions. Doctors’ offices are also facing challenges adapting to the electronic-only referral system and new requirements, such as specifying the number of specialist visits allowed within a set timeframe. These administrative hurdles could result in delayed or denied care, particularly if patients or providers are not fully informed about the new procedures.

3. Potential Impact on Healthcare Costs and Equity: While UnitedHealthcare states the referral policy aims to improve care coordination and reduce unnecessary specialist visits, critics argue it may primarily serve to lower costs for the insurer by reducing access to expensive treatments. The policy does not apply to higher-cost PPO plans or commercial insurance, raising concerns about discrimination against sicker and lower-income patients who rely on HMO plans. There is apprehension that such measures could lead to delayed or forgone care for vulnerable populations, as well as further narrowing of provider networks.

Facing Regulatory, Reimbursement Changes, Pharmacy Execs Also See Opportunities

By David Raths – A new report from pharmaceutical company Cencora is based on a survey of more than 100 health system pharmacy leaders. LeeAnn Miller, PharmD, vice president of business development and growth at Cencora’s Accelerate Pharmacy Solutions, spoke with Healthcare Innovation about some of the ways regulatory and reimbursement changes are reshaping pharmacy operations. Pharmacy is increasingly serving as a connector across departments, especially in specialty and ambulatory care, requiring new skill sets in business and clinical areas. Addressing payer and manufacturer access, capacity, and technology barriers is critical for the growth of specialty pharmacy programs and home infusion services. Read Full Article...

HVBA Article Summary

1. Pharmacy as a Connector Across Care Settings: Pharmacy leaders are increasingly acting as a bridge between clinical care, payer access, finance, and corporate partners, especially in specialty and ambulatory care. This role requires pharmacists to develop both clinical expertise and business acumen to effectively manage complex, expensive therapies and communicate their value to health system leadership. The shift of care to ambulatory settings further emphasizes the need for pharmacy to connect patients with specialty medications and support services.

2. Challenges in Specialty Pharmacy and Home Infusion Growth: Specialty pharmacy programs face significant barriers including payer restrictions that require patients to use external pharmacies, limited manufacturer access to drugs, and capacity constraints such as staffing and technology. Home infusion services are projected to grow substantially due to patient preference for convenient care locations and payer incentives for lower-cost care settings. However, many health systems have yet to fully implement these programs, indicating opportunities for expansion and partnerships to overcome administrative and operational challenges.

3. Emerging Therapies and Regulatory Complexities: The rise of cell and gene therapies presents both opportunities and challenges for health systems, with only a small percentage currently prepared to manage these complex treatments. Access to manufacturers, accreditation requirements, and reimbursement strategies are critical for successful adoption. Additionally, regulatory programs like 340B involve ongoing audits and administrative burdens, with recent changes such as the proposed rebate model creating financial and logistical concerns for health systems, though further regulatory evolution is expected.

UnitedHealth Group was the most profitable payer in a difficult 2025 for the industry

By Paige Minemyer – Ongoing headwinds caused by elevated utilization and medical costs continued to drag major health plans in the fourth quarter, completing the story of a complex 2025 for the industry. The most profitable company for the full-year was UnitedHealth Group, with $12.05 billion in earnings for 2025. The healthcare giant had a sizable lead on the next-highest payer in terms of profitability, which was Cigna at just below $6 billion. However, the company posted just $10 million in profit for Q4, the lowest tally among payers that turned a profit in the quarter. Read Full Article...

HVBA Article Summary

1. UnitedHealth Group's Financial Performance: UnitedHealth Group led the health insurance sector in profitability for 2025, significantly outpacing other major payers. Despite industry-wide challenges, the company also reported the highest annual revenue, demonstrating its dominant market position. However, its fourth-quarter profit was notably low compared to its annual results, indicating increased pressures at the end of the year.

2. Industry-Wide Struggles and Losses: Most large health insurers remained profitable in 2025, but Centene was a notable exception, posting substantial losses both for the year and in the fourth quarter. Centene faced particular difficulties in Medicaid and individual market segments, with rising costs and policy uncertainties contributing to its negative results. Other payers also contended with elevated medical costs and regulatory changes, impacting their financial outcomes.

3. Regulatory and Market Pressures: The Centers for Medicare & Medicaid Services' proposed flat rates for Medicare Advantage in 2027 have raised concerns among leading insurers, who argue that these rates do not reflect increasing medical costs. Companies like CVS and Humana are adjusting their strategies in response to these regulatory developments and shifting market dynamics. Insurers are also focusing on operational improvements and business model changes to navigate ongoing headwinds and position themselves for future stability.

Humana acquires MaxHealth, adding 82 clinics to CenterWell

By Alan Goforth – CenterWell, the health care services division of Humana, on Friday announced the acquisition of MaxHealth from Arsenal Capital Partners. MaxHealth, based in Tampa, currently owns a network of 54 primary care clinics, four specialty/ancillary clinics and 24 downstream affiliate clinics throughout western and southern Florida. These clinics provide care to more than 120,000 patients, including more than 80,000 patients in value-based care programs. MaxHealth now will be affiliated with and owned by CenterWell Senior Primary Care. Read Full Article...

HVBA Article Summary

1. Expansion of CenterWell's Network: The acquisition of MaxHealth significantly increases CenterWell's presence in Florida, adding a total of 82 clinics to its network. This move is part of Humana's broader strategy to expand its primary care footprint and enhance its service offerings for seniors. The integration of MaxHealth's clinics is expected to improve access to care for a larger patient population in the region.

2. Alignment of Organizational Values: Both CenterWell and MaxHealth emphasize patient-centered and results-driven care, aiming to simplify the healthcare experience and empower patients. Leadership from both organizations highlighted the cultural and operational synergies that are anticipated from the merger. This alignment is expected to facilitate a smoother transition and foster collaborative approaches to delivering high-quality care.

3. Market Growth and Strategic Acquisitions: The acquisition follows Humana's recent purchase of The Villages Health, reflecting a pattern of strategic growth through acquisitions in the Florida healthcare market. CenterWell Senior Primary Care experienced a 25 percent growth in 2025, serving over 100,600 additional patients. These moves indicate Humana's commitment to expanding its reach and influence in value-based care models for seniors.

Labcorp Rolls Out First FDA-Cleared Alzheimer’s Blood Test for Primary Care

By Daniel Beaird – Labcorp has launched nationwide access to the first FDA-cleared blood test for Alzheimer’s disease designed for use in primary care, expanding its Alzheimer’s testing portfolio across both primary and specialty care settings. The Elecsys® pTau-181 test helps clinicians assess symptomatic patients age 55 and older by identifying those who are unlikely to have amyloid pathology, the abnormal protein buildup in the brain associated with Alzheimer’s disease. Patients who receive negative results can be evaluated for other potential causes of cognitive decline, while those with positive results may be referred for additional diagnostic testing. Read Full Article...

HVBA Article Summary

1. Innovative Diagnostic Tool for Primary Care: The Elecsys pTau-181 test is the first FDA-cleared blood test for Alzheimer’s disease intended for use in primary care settings. This innovation allows primary care clinicians to assess amyloid pathology risk in symptomatic patients aged 55 and older without needing invasive procedures or specialist referrals. It represents a significant advancement in making Alzheimer’s diagnostics more accessible and less burdensome for patients.

2. Improved Patient Management and Referral Process: By identifying patients unlikely to have amyloid pathology, the test helps clinicians focus on other potential causes of cognitive decline, streamlining patient management. Those with positive results can be referred for further diagnostic testing, potentially leading to earlier and more accurate diagnosis. This approach may reduce unnecessary specialist visits and enable more timely interventions.

3. Collaboration and Development: Developed by Roche Diagnostics and cleared by the FDA in 2025, the test exemplifies collaboration between diagnostic companies and regulatory bodies to bring new technologies to market. Labcorp’s nationwide rollout expands access to this test, supporting primary care providers with a powerful tool to guide clinical decisions confidently. This development underscores the growing role of blood-based biomarkers in neurodegenerative disease diagnostics.

How Gen Z is changing health and life insurance

By Will Wood – The oldest members of Generation Z have just turned 28, the age at which people traditionally, have or are close to purchasing their first life insurance policy. Gen Z, however, is bucking the norm. Their life and career trajectories defy historic milestones, and their methods for researching and purchasing insurance are vastly different. For insurers in the typically slow-to-change life and health markets, these trends challenge longstanding assumptions, creating an immediate need for innovative products that can engage Gen Z on their terms. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Changing Priorities and Delayed Milestones: Generation Z is delaying traditional life milestones such as homeownership, marriage, and parenthood, which historically triggered the purchase of life insurance. Economic factors like the Great Financial Crisis and post-pandemic inflation have contributed to this shift. As a result, many Gen Z individuals are renting or living with parents, and birthrates are declining, altering the timing and nature of insurance needs.

2. Demand for Personalized and Digital Experiences: Gen Z expects a more personalized and digital-first customer experience when purchasing insurance. Surveys show that a significant portion of younger consumers would switch providers for unique, personalized experiences and better digital platforms. However, many life insurers struggle to meet these expectations due to legacy technology and limited digital capabilities, with only 31% offering the digital engagement that 59% of younger customers desire.

3. Need for Agile and Innovative Insurance Products: To remain relevant, life insurers must shift from traditional milestone-based policies to products focused on income protection that resonate with Gen Z's current financial realities. Insurers should adopt agile, AI-driven no-code platforms to quickly design and scale new products and enhance customer journeys. This approach allows insurers to meet Gen Z's needs now while maintaining flexibility for future changes as this generation's life circumstances evolve.