Regional health plans are navigating intense pressure right now — medical cost containment, CMS scrutiny, growth targets, member experience expectations, and operational resilience. And yet, many plans are operating under a quiet assumption: “Our call center partner is fine.” Maybe they are. But here’s the better question: If you were selecting your call center vendor today — knowing what you now know about performance, compliance risk, scalability, and cost — would you make

CMS has released portions of the February 2026 Medicare Advantage enrollment files. While membership by individual plan and plan/county has not yet been published, parent organization-level enrollment data (excluding PDP) provides early insight into market movement following a year of plan exits and regulatory pressure.

The 2026 HCCA Managed Care Compliance Conference made one thing clear: compliance in managed care is no longer a static, check-the-box function. It is rapidly evolving—shaped by advancing technology, heightened regulatory scrutiny and growing expectations that compliance teams operate as strategic risk partners across Medicare, Medicaid and commercial lines of business. Across sessions, speakers emphasized the need for compliance programs that are proactive, operationally emb

On Monday, the Centers for Medicare & Medicaid Services released the Calendar Year (CY) 2027 Advance Notice for the Medicare Advantage (MA) and Part D programs. At more than 160 pages, the document pairs a modest projected payment increase with some of the most consequential refinements to MA risk adjustment in recent years.

Medicare Advantage & Part D Advance Notice

CMS will begin issuing Program Audit notifications next month, and health plans should be actively preparing now—not waiting for the audit letter to arrive.

CMS is signaling a new era of audit scrutiny. With the introduction of its 2026 pilot audit approach, CMS is recalibrating how it evaluates Compliance Program Effectiveness (CPE)—placing heightened emphasis on real-time operational integration, governance, and issue resolution rather than static documentation alone.

The Office of Inspector General (OIG) has released another targeted Medicare Advantage (MA) compliance audit, this time reviewing diagnosis codes submitted by UCare Minnesota (H2459).

CMS has officially appealed the federal court ruling that struck down its 2023 RADV Final Rule, reaffirming the agency’s commitment to defend extrapolation as a central tool in Medicare Advantage oversight. On Nov. 21, the Department of Justice filed a notice of appeal in Humana Inc. v. Kennedy to the Fifth Circuit Court of Appeals. The lower court had vacated the RADV rule on procedural grounds, finding CMS violated the Administrative Procedure Act by shifting its legal jus

Review CMS’ 2026 CAHPS updates and learn what health plans should prioritize now. Key deadlines, survey changes, strategy focus areas, and how Rebellis can help

CMS just issued its 2026 Program Audit Annual Update , and there are several major shifts  that Medicare Advantage, Part D, and Cost Plans should begin preparing for now. Below are the key takeaways: 1. Audit Scoring Is Eliminated CMS is removing all audit scoring beginning in 2026. Conditions will no longer carry points , and CMS may consider alternative weighting methods in the future. 2. Condition Classifications Are Simplified CMS is retiring ICAR and ORCA categories.

The White House recently announced deals with Eli Lilly and Novo Nordisk to reduce pricing on GLP-1 medications. Medicare beneficiaries will pay no more than $50 per month  for approved treatments like Zepbound and Ozempic. In this announcement, the White House stated Ozempic, Wegovy, Mounjaro and Zepbound Medicare program costs will drop to $245, a significant reduction from current prices, without rebate considerations. Eli Lilly cites copay caps to start as early as Apri

The CY2026 CMS Readiness Checklist was released November 4.  Each year, the Centers for Medicare & Medicaid Services (CMS) releases its Annual Readiness Checklist, outlining the operational, regulatory and compliance requirements that Medicare Advantage (MA) and Part D plans must have in place for the upcoming year. While many elements are consistent year over year, CMS routinely adds new items and clarifies expectations based on evolving regulations and program priorities. T

As Medicare Part D oversight continues to intensify, formulary and benefit coding errors by Pharmacy Benefit Managers (PBMs) remain a top compliance risk for Plan Sponsors. Ensuring that claims adjudicate accurately to your CMS-approved formulary and benefit design is not just a best practice — it’s a compliance expectation. Annual benefit administration testing (BAT)  continues to be one of the most effective tools to validate the accuracy of your Part D benefit before the p

Cigna’s new pricing strategy raises important questions about the future of pharmacy benefit management. Beginning in 2026, the company plans to introduce a cost-plus reimbursement model for pharmacies, followed by a 2027 rollout of technology-driven price comparisons for Commercial customers—eliminating traditional rebates in the process. As specialty drug costs continue to rise, PBMs remain under increased scrutiny. Transparent pricing is no longer optional—it’s essential

What Was Vacated and Why It Matters   On September 25, 2025, a federal court in Texas vacated the Centers for Medicare & Medicaid...

NCQA just released its 2025 Health Plan Ratings, and the results send a clear message: success in today’s Medicare Advantage and...

CMS just announced a major change that will affect all Special Needs Plans ( SNP s) beginning with Contract Year (CY) 2027. Starting in...

As we enter the second half of the year, it’s time to prioritize one of CMS’ most important requirements for Medicare Advantage and Part...

As we approach 2026, the Centers for Medicare & Medicaid Services (CMS) has released critical updates to the Medicare Advantage (MA) and...