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Insurance articles
Washington Drops the Frequency Test From Its Insurance Claim Rules
Two orders fining USAA and Allstate a combined $230,000 arrived weeks before new Washington rules take effect that delete the requirement that claim-handling violations be a general business practice before regulators can call them unfair.
Utah Lets the Algorithm Work and Regulates Who Signs the Denial
Senate Bill 319 takes effect January 1 and requires Utah insurers to disclose AI use and to base adverse determinations on independent medical judgment rather than a recommendation from any other source.
CMS Gave Itself a Standing Power to Cut Brokers Out of the Exchanges
The new rule codifies a permanent authority to suspend agent and broker registration, then uses it for the first time on the brokers who joined last year while 315,000 enrollments covering 760,000 people come off the books.
Five Hospitals Contracted With Blue Cross Texas and Were Paid by Pennsylvania Rules
Five HCA-affiliated hospitals are suing Independence Blue Cross over denied claims made under the BlueCard program, where the plan that decides payment is not the plan the hospital signed with.
Molina Is Ending the Medicare Drug Plans 80,000 Members Still Hold
Molina told investors in February it would exit its traditional Medicare Advantage drug plans and members learn from a letter in October, because investor disclosure and member notice run on separate clocks.
State Farm's Return to California Starts With Five Feet of Clear Ground
The insurer filed to write new homeowners policies again after three years, but only for homes hardened against wildfire, and the regulator says a filing is a starting point.
A $14 Million Bet That Employers Can Rebuild Health Plans With AI
Nara Health, an AI-native third-party administrator for self-insured employers, raised $14 million led by Khosla Ventures to replace legacy claims infrastructure with direct contracting and reference-based pricing.
Senate Asks State Regulators to Explain Private Equity's Life Insurance Bet
Sen. Elizabeth Warren is pressing the NAIC on how state regulators oversee private equity owned life insurers after the Walter probe revealed a related party restatement from $1.4 billion to more than $17 billion.
The $500 Obamacare Refund Is Smaller and Stranger Than It Sounds
The administration says nearly a million unsubsidized marketplace enrollees in 30 states will get $500 checks in October, drawn from a surplus of HealthCare.gov user fees whose spending authority is unresolved.
A Comparison Site Compared Two Insurers and Called It the Market
An Australian Federal Court has found comparison site Choosi misled customers by claiming to survey a range of insurers while overwhelmingly comparing policies from one. The ruling draws a legal line around the word range.
North Carolina Covers GLP-1s in Medicaid but Not for Teachers
Two state programs reached opposite answers on weight-loss drug coverage, and the difference traces to who writes the check: the General Fund for Medicaid, the health plan's own budget for teachers and state employees.
A Populist Health Movement and the Insurance Industry Have Landed on the Same Device
RFK Jr.'s push for wearables and insurers' wellness programs want the same continuous body data for opposite reasons. What happens next depends on insurance rating law, not the hardware.
The Surprise-Billing Fight Now Turns on a Number One Side Gets to Calculate
A federal appeals court just handed doctors another win in the fight over the No Surprises Act's payment benchmark, the QPA. The law pulled patients out of surprise-billing disputes, but the underlying cost didn't disappear, it moved into a formula insurers calculate and providers keep suing over.
A Popular Law Capped What Seniors Pay for Drugs. The Cost Didn't Vanish. Ending This Subsidy Shows Where It Went.
CMS is ending a subsidy that masked a cost the 2022 out-of-pocket cap created. Ending it doesn't remove the cost, it moves it back onto premiums.
A Bank Lost $600,000 to Fraud. Its Insurer Paid $100,000. The Policy Covered All of It.
The insurer agreed the loss was covered, then characterized it into the smaller sublimit. That fight, not a denial, is where most cyber claims get decided.
Iowa Banned Spread Pricing. An Audit Suggests PBMs Just Moved It to a Different Timescale.
A state auditor found one PBM collected about $100 million in back-end value from Iowa Medicaid over three years, through a mechanism the ban didn't anticipate.
Insurers Promised to Fix Prior Authorization. The Fine Print Excludes the Drugs People Depend On.
Insurers pledged 90 days of continuity when patients switch plans. Humana says that pledge doesn't cover drugs, and a patient was hospitalized because of it.
You Can Lose Your ACA Subsidy Without Your Income Changing at All
A verification rule can suspend tax credits over a database mismatch, while the full premium comes due, and it has nothing to do with affordability.
Should Medicaid Pay Your Rent? California Says Yes, and the Waiver Expires This Year
California has spent nearly $12 billion routing Medicaid money into housing and food. Republicans call it waste. The real question is what Medicaid is for.
Medicaid's New Work Rule Doesn't Require Anything of Employers. It Will Still Land on Their HR Desks.
There's no employer mandate in the rule, but the proof enrollees need has to come from payroll, on a 30-day clock.
Medicare Just Proposed Killing an Entire Health-Tech Business Model
CMS's 2027 rule would bar reimbursement for remote patient monitoring by third-party vendors. The fraud was real, but the remedy targets a structure, not a behavior.
Medicare Advantage Denied Their Rehab Care, Then Reversed Almost Every Appeal. That's the Business Model.
Insurers overturned 95% of appealed skilled nursing denials, and 97% of the ones a UnitedHealth AI contractor issued.
U.S. Health Care Spending Will Hit $6 Trillion in 2026. Here's What the Number Hides.
The number that matters is buried in an assumption the government's own actuaries had to make about the recent coverage cuts.
The AMA Owns the Codes Medicare Requires. Two Investigations Want to Know Why.
A doctors' lobby owns the code set Medicare requires and licenses it back to the industry for hundreds of millions a year.
The Spiral Is Not a Prediction. It Is in the Filings.
2027 ACA rate filings show insurers pricing in roughly four points of premium increase purely because the risk pool is getting sicker.
Two Hours a Year, a Thousand Dollars a Month
AI scribes save physicians about two hours a year and generate about $1,004 more revenue per provider per month.
The Subsidy Fight Is an Argument About the Invoice, Not the Bill
Enhanced ACA subsidies lapsed and premiums for subsidized enrollees more than doubled. Congress is fighting over who pays the bill, not why it's so large.
Two Levers, One Direction
UnitedHealth just audited the program regulators are investigating and gave it a 97%. Meanwhile, insurers keep suing their way to better quality scores.