Star Ratings Chaos - The Clover Case

Star Ratings Chaos - The Clover Case

In this episode of Health Law Simplified, Sandy Durkin and Elizabeth Lippincott are joined by Melissa Newton Smith and Ana Handshuh for a deep dive into one of the most consequential recent developments in Medicare Advantage: the Clover Health star ratings decision. (*After recording, on June 17, 2026, CMS released an HPMS Memo stating that it was voluntarily recalculating 2027 Quality Bonus Payment (QBP) ratings, which are based on 2026 Star Ratings. We are in the process of recording an update to this episode to discuss this development.) The group begins with a high-level overview of the case, in which Clover challenged its 2026 star rating and the data CMS used to calculate it. The court’s ruling, which vacated the rating and required CMS to recalculate using a narrower set of data sources, raises fundamental questions about the structure of the entire Star Ratings program. The conversation explores why this case is different from prior star ratings challenges, including the court’s focus on statutory authority and whether certain measures should have gone through formal notice and comment rulemaking. The panel discusses the potential implications if that reasoning is applied more broadly, including impacts to Part D measures, quality bonus payments, and the stability of the program overall. Melissa and Ana share an operator’s perspective on what this means in practice. They explain how central the affected measures are to plan performance, why the ruling could disrupt current strategies, and what plan leaders should be thinking about now. The group also addresses the uncertainty facing Medicare Advantage plans, from financial planning to operational decision-making, as the litigation landscape continues to evolve. The episode closes with practical guidance for plans, including how to model potential impacts, align internal teams, and refocus on core drivers of quality such as access, outcomes, and member experience.

What the New Rules for 2027 Mean for Supplemental Benefits

Supplemental benefits have become a key feature of Medicare Advantage, shaping member experience, plan design, and regulatory oversight. In this episode of Health Law Simplified, we are joined by Regan Pennypacker, Senior Vice President, Compliance Solutions at ATTAC Consulting Group, to explore how these benefits have evolved and what recent CMS guidance means for plans. We walk through key regulatory changes to supplemental benefits, including special supplemental benefits for the chronically ill, and discuss how plans are approaching eligibility, documentation, and operational implementation. The conversation also highlights new eligibility criteria, transparency requirements, and increased scrutiny around debit card programs and over-the-counter benefits.  Drawing on Regan’s experience advising Medicare Advantage organizations, we focus on the practical challenges plans are facing and the steps they should be taking now to prepare. This episode offers a clear and actionable overview for anyone working in compliance, operations, or benefit design in Medicare Advantage.

Medicare Advantage at a Crossroads: Supplemental Benefits, Risk Adjustment, and What Comes Next

In this episode of Health Law Simplified, Sandy Durkin and Elizabeth Lippincott are joined by Brandon Solomon, Senior Vice President and General Manager at Pareto Intelligence, for an in depth discussion of where Medicare Advantage is headed and the operational, financial, and compliance pressures shaping its future. Brandon shares insights from two decades advising health plans and risk bearing providers across Medicare Advantage, Medicaid, and the ACA marketplace. The conversation explores how supplemental benefits are evolving in a more cost constrained environment, why plans are pulling back from “fringe” offerings, and which benefits truly improve health outcomes rather than just driving marketing differentiation. The discussion also takes a deep dive into risk adjustment, including the operational burden of increasing RADV audits, the implications of CMS’s decision to exclude unlinked chart reviews, and the practical, nuanced, realities of linking diagnoses to claims. Brandon breaks down the differences between prospective, concurrent, and retrospective chart reviews, and explains why plans are being advised to act as if extrapolation is back, even amid ongoing litigation. Finally, the episode examines changes to Star Ratings, the elimination of administrative measures, CMS’s tightening of quality thresholds, and how plans must rethink strategy in an era of fewer measures, tighter margins, and heightened scrutiny. The conversation closes with reflections on Medicaid and ACA eligibility trends, disenrollment risks, and what healthcare lawyers should understand about risk adjustment work in an increasingly regulated landscape.

Medicare Supplement (Medigap) 101: What It Covers, Who Regulates It, and Who Chooses It

In this episode of Health Law Simplified, Sandy Durkin and Elizabeth Lippincott shift gears from Medicare Advantage to take a practical look at Medicare Supplement insurance, also known as Medigap, and why it remains an important part of the Medicare coverage landscape. They walk through how Medigap plans became standardized, why the product is state regulated but shaped by federal minimum standards, and what that structure means for rate oversight, marketing review, and regulatory enforcement. A major focus of the discussion is guaranteed issue rights, including when people can purchase certain Medigap plans without medical underwriting and why those rules matter for Medicare Advantage enrollees who want to return to Original Medicare. Finally, Sandy and Elizabeth compare Medigap and Medicare Advantage from a consumer perspective, including the flexibility of a non-network model, the need to purchase standalone Part D coverage when pairing Original Medicare with Medigap, and the premium and cost considerations that drive many coverage decisions. They close with a forward looking discussion of why Medicare Supplement may continue to play a meaningful role in the Medicare market going forward, especially with higher income retirees.

PBM Reform + OIG Guidance + 2026 Medicare Advantage Enrollment = What You Need to Know

In this episode, Sandy Durkin and Elizabeth Lippincott break down several significant developments shaping the Medicare Advantage and Part D landscape. They begin with a close look at newly enacted federal legislation affecting pharmacy benefit managers (PBMs), including major reforms to Part D contracting that eliminate spread pricing and compensation tied to drug prices or rebates, replacing it with a flat, fair market value administrative fee. The discussion explores why this change is so consequential, how it may alter PBM incentives, and what plans should be thinking about as implementation approaches. The conversation then turns to the Office of Inspector General’s newly issued Medicare Advantage compliance program guidance, the first major update in more than 25 years. Sandy and Elizabeth discuss why this guidance matters, how it fits alongside updated CMS audit protocols, and what it signals about expectations for “operationalized” compliance programs. Finally, they examine early Medicare Advantage enrollment trends for 2026, including slowing overall growth and the continued expansion of Special Needs Plans, and consider what these patterns may mean for plan strategy going forward.