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

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.

Inside CMS: Advance Notice, RADV Audits, Special Needs Plans, Dual-Eligible Integration

In this episode, Sandy and Elizabeth break down the latest CMS updates shaping the Medicare Advantage landscape, diving into the Advance Notice, RADV audit enforcement, emerging enrollment trends, and sweeping Special Needs Plan (SNP) regulatory changes. We unpack CMS’s recent memo outlining its refined RADV audit strategy, including expanded audit cadence, updated sampling methodologies, extended medical record submission timelines, and the agency’s approach to balancing accelerated oversight with operational realities for plans and providers. The conversation then turns to Medicare Advantage enrollment trends, including signs of market flattening, the expansion of SNPs, and potential shifts toward Medigap coverage. Finally, we explore major policy developments affecting D-SNPs, C-SNPs, and I-SNPs, with a focus on CMS’s push toward deeper Medicare–Medicaid integration for dually eligible beneficiaries. Whether you’re a health plan executive, legal or compliance professional, policy analyst, or advisor, this episode provides timely insights into where CMS is headed—and what these changes mean for strategy, operations, and risk in the year ahead.

2025 Medicare Advantage Year in Review (It’s been a lot!)

In our Year in Review episode, hosts Elizabeth Lippincott and Sandy Durkin distill a turbulent 2025 into the developments that mattered most for Medicare Plans. You’ll hear a clear breakdown of the year’s biggest compliance and enforcement stories—from DOJ’s kickback allegations against major MA players to CMS’s aggressive expansion of RADV audits, followed by a late‑year court decision that vacated CMS’s extrapolation rule on procedural grounds. We also cover regulatory highlights and the operational realities behind plan exits and non‑renewals, including run‑out obligations and audit exposure that linger long after a contract ends. The episode closes with what leaders should do now: tighten documentation and vendor oversight, align risk adjustment with care management, and prepare for continued regulatory scrutiny—because stability comes from readiness, not predictability.