Weekly Roundup -
February 11, 2026
Smart. Strategic. Essential.
Unmatched Healthcare Insights from 量子资源网,
Leavitt Partners & Wakely.
Featured:
Webinar Replay – 2027 ACA Considerations: Proposed NBPP and Other Key Changes and Trends
ACCESS WEBINARTrending: In Focus
Tending the Embers: Staying Ready for Medicare Advantage RADV Audits
The听Centers for Medicare & Medicaid Services (CMS)鈥痠ssued听a听memo听January 27, 2026,听with updates听on听the agency鈥檚听approach听to听checking whether Medicare Advantage (MA) plans are being paid correctly. These reviews are听conducted听through听which听help CMS confirm that the diagnoses MA plans听report听are听supported听by medical records.听
The January 2026 memo signals that听CMS听intends to honor听its听commitment to strengthen oversight of MA payments,听including听accelerating听and expanding听the use of RADV audits听and using听AI (artificial intelligence)听to streamline human coding reviews.听MA organizations听must now听prepare to respond to the RADV audit notice within the required five-month window, while balancing听their听other risk-adjustment programs.听
In this article, we explain the听rapidly evolving landscape听affecting听RADV听audits.听Wakely, an 量子资源网 company, addresses what these changes mean for MA organizations and听key considerations to ensure they are prepared for the upcoming听enhancements to federal program integrity initiatives.听
Overview听of CMS鈥 RADV Refresh听
CMS听听a major shift听in May 2025:听All MA plans will听undergo听RADV audits鈥攏ot听just a small sample as before.听These audits听look for cases听in which听diagnosis听information听submitted听by a plan does not match听the听documentation听in the patient鈥檚 medical record.听When this happens,听CMS听may听decide听the plan听was overpaid听and require repayment. Historically, CMS听audits听have听identified听widespread diagnosis-code documentation errors, resulting in听significant revenue recoupment from MA听plans.听
The听2025 announcement听creates听a听framework for听additional听risk for听MA听plans, which could shift to risk-bearing provider groups.听As听we听explained in an听, key components of that听announcement include:听
- All MA plans will be audited starting听with听Payment Year听(PY)听2018.听
- CMS committed to accelerating audits by听adding more staff and using听new听technology.听
- CMS听planned to听use 鈥渆xtrapolation鈥濃攎eaning听if errors were found in a small sample of records, the error rate could be applied to the full population, which could lead to much larger repayment amounts.听
- CMS also planned to听eliminate听the fee-for-service听(FFS)听adjuster鈥攁听policy that previously helped reduce the amount a plan would have to repay. This听proposal听would increase financial risk for plans.听
Both the use of extrapolation and the removal of the FFS adjuster were later challenged in court.听
Legal Challenge听
In听September听2023, Humana听听CMS in听federal court, arguing that the 2023 RADV final rule,听which allowed extrapolation and removed the FFS adjuster,听was put into place without following proper federal rulemaking procedures.听On听September 25,听2025,听the court听agreed with Humana and听vacated听certain parts听of听this听final听rule, meaning certain parts of the rule are no longer in effect.听
CMS appealed the ruling on November 1, 2025,听which has听created听uncertainty听about how听RADV听audits听will work听in future years.听
Navigating the听Legal and Regulatory Changes听in Early 2026听
The听court did听not听say听that extrapolation or elimination of the听FFS听adjuster is听illegal鈥攐nly that听CMS did not follow the required process for changing the rules.听Hence,听the 2023听RADV听final rule听cannot听take effect unless CMS听wins its听appeal听or听reissues听the policy using the proper steps.听
In its January听2026听Health Plan Management System (HPMS)听memo,听CMS听stated听that听it will听comply with听the order while it is in effect.听
The听pending听litigation听does not diminish CMS鈥檚 broader commitment to increased audit activity and heightened scrutiny of MA risk-adjustment practices.听
Effect of听the Ruling.听During RADV audits, CMS selects a sample of enrollees and requests corresponding medical records from the MA plan. These records are reviewed to confirm that the documented diagnoses meet CMS requirements. If unsupported diagnoses are found, CMS may recalculate payments and recover overpayments from the health plan. This audit process听maintains听program integrity and ensures听accurate听payments.听
Plans that听submit听incomplete records could owe听significant听repayments to CMS.听
CMS鈥檚听January 2026听memo听clarifies听how the听agency听plans听to roll out听additional听RADV听audits听starting听with听PY 2020. CMS also听addresses听the agency鈥檚听plans听to:听听
- Reduce burden on plans and providers,听for example by extending the submission window听听
- Balance the volume of medical record submissions needing review听by using smaller sample sizes听where appropriate听
- Use AI听to further accelerate the review process听
Preparing for听What鈥檚 Next听
Given CMS鈥檚 stated direction and the still unsettled litigation environment, MA plans should remain vigilant and audit ready.
Key steps include:听
- Prioritizing听timely听and complete chart submission processes听
- Strengthening internal criteria to听identify听and听prioritize听charts most likely to support diagnoses听
- Improving documentation and coding accuracy through provider engagement听
- Conducting proactive self鈥audits to听identify听potential vulnerabilities听
- Partnering with expert RADV consultants to navigate audit strategy, documentation, and submission readiness听
Connect with Us听
Wakely听assists听plans with their RADV initiatives and development of听robust RADV playbooks.听For more information about Wakely鈥檚 RADV playbooks, contact听.听
Federal Policy News
Fueled By Weekly Health Intelligence
HHS Funding Secured for FY 2026 as Attention Turns to FY 2027
On February 3, President Trump鈥鈥, the Consolidated Appropriations Act, 2026 (Public Law 119-75) into law, enacting听fiscal year (FY)听2026 appropriations for the Department of Health and Humans Services (HHS), as well as extenders for key Medicare, Medicaid, and public health programs and several reforms focused on pharmacy benefit managers (PBMs). The PBM changes, which had been under consideration by Congress for several years, will institute certain oversight and reporting measures for PBMs in Medicare Part D and the commercial health insurance market.听
Except for funding for the Department of Homeland Security, which was extended through February 13, Congress has completed the FY 2026 appropriations process, and will now look to begin work on FY 2027 appropriations. Congressional appropriations leaders have indicated that they are听working to schedule听key hearings with agency leadership, tentatively slated to begin as soon as this month with markups听anticipated听in the House in May. Additionally, in the coming weeks, President Trump is expected to听submit听the FY 2027 budget request to Congress. As hearing and markup schedules develop, stakeholders should听anticipate听that there will be deadlines announced for submission of FY 2027 funding and policy priorities to听appropriations听committees in the coming weeks.听
FDA Expands Flexibility for 鈥淣o Artificial Colors鈥 Labels
On February 5,听US Food and Drug Administration (FDA)听听a shift in approach to relax how it enforces manufacturers鈥 use of 鈥渘o artificial colors鈥 labeling on food products. In a听 sent to industry, FDA provided notice of its intent to exercise enforcement discretion in voluntary labeling claims. This will allow food and beverage companies to have the flexibility to label products with 鈥渘o artificial colors鈥 as long as petroleum-based colors are not present. Previously, companies were only able to make this claim if their products did not include any added colors, including those derived from natural sources. According to FDA, this decision will 鈥渕ake it easier for companies to move away from petroleumbased synthetic colors and adopt safer, naturally derived alternatives.鈥 The agency also noted that it approved two petitions: 听was added, expanding the palette of allowable natural colors, and the food categories where听听can be used听was听expanded.听
This work builds on听听actions听by the听Department of Health and Human Services听and FDA听encouraging听companies to phase out petroleum-based colors, as articulated in the听administration鈥檚听. FDA is also tracking voluntary commitments from food manufacturers that have agreed to limit the use of petroleum-based dyes.听
White House Launches TrumpRx.gov Drug Pricing Platform
On February 5, the White House officially launched听, a website听听by the administration as 鈥済iv[ing] Americans direct access to dramatically lower prices on dozens of common, high-cost brand-name prescription drugs.鈥 According to a听听accompanying the launch, the initial rollout of the platform featured 鈥40 of the most popular and expensive branded medicines in the nation,鈥 developed by the 鈥渇irst five manufacturers to reach [most-favored-nation (MFN)] pricing deals,鈥 although the document indicated that the website would add additional products 鈥渋n the coming months.鈥澨听
As听听by听The Wall Street Journal,听rather than serve as a marketplace for direct sales in and of itself, the platform 鈥渁llows customers to search for specific medicines and purchase them through a manufacturer鈥檚 direct-to-consumer site, or in some cases gives users coupons that they can present at certain pharmacies.鈥 The site鈥檚 launch received praise from some Republican policymakers, such as听, although recent听听indicates听that President Trump鈥檚 broader MFN initiative has 鈥渂[een] met with a skeptical eye from Republicans.鈥 Congressional Democrats have broadly criticized the platform, which Senate Finance Committee Ranking Member Ron Wyden (D-OR)听听as a 鈥済lorified coupon book.鈥 At听a high level, while the website鈥檚 supporters have framed it as a source of savings and simplified access for uninsured and underinsured Americans, the platform鈥檚 skeptics have criticized its narrow scope, its potential incompatibility with insurance benefit designs, and its promotion of certain drugs with low-cost generic competitors.听
HHS Names Diana Diaz-Harrison National Autism Coordinator
On February 3, HHS听听the appointment of Diana Diaz-Harrison as National Autism Coordinator in a series of posts on X. The National Autism Coordinator leads the coordination of autism-related research, services, and supports across the HHS agencies and other federal partners. Ms.听Diaz Harrison most recently worked as Principal Deputy Commissioner in the Administration on Disabilities, an agency under the Administration for Community Living (ACL), and previously served as Deputy Assistant Secretary in the Department of Education鈥檚 Office of Special Education and Rehabilitative Services. Prior to her federal service, Ms. Diaz-Harrison founded a network of autism-focused charter schools in Arizona, as well as an organization seeking听to expand such charter schools for听autistic children nationally. In听听to local Arizona press, Ms. Diaz-Harrison emphasized the sharp rise in autism prevalence over recent decades and听stated听the necessity of听identifying听the disorder鈥檚 causes鈥generally aligning听with Secretary Kennedy鈥檚听 for autism policy and among several newly 听members of the reconstituted Interagency Autism Coordinating Committee (IACC).听
MACPAC Releases 2026 MACStats Medicaid, CHIP Data Book
This month the Medicaid and CHIP Payment and Access Commission (MACPAC)鈥鈥痶he听2026听MACStats: Medicaid and CHIP Data Book, which includes Medicaid and Children鈥檚 Health Insurance Program (CHIP) data on eligibility and enrollment, benefits, service use, access to care, and state and federal spending. Total Medicaid spending grew 6.3 percent in fiscal 2024 to听$957.4 billion. Total CHIP spending was听$28.2 billion.听
Ready to talk about your organization's challenges?
Schedule a ConsultationState Policy News
Arizona
Arizona Lawsuit Challenges AHCCCS Over Autism Therapy Contract Changes. The Arizona Capital Times 鈥痮n February 9, 2026, that parents filed a new class action lawsuit against the Arizona Health Care Cost Containment System (AHCCCS), alleging it improperly approved provider network changes by Mercy Care and Centene/Arizona Complete Health that disrupted autism therapy services. The lawsuit follows an earlier case filed in December 2025 over the same contract terminations involving听Centria听Autism and Action Behavior Centers. Both cases stem from insurers ending contracts with these providers, forcing families to change applied behavioral analysis听(ABA)听services. In both lawsuits, plaintiffs are asking the court to pause the March contract terminations while the cases听proceed.
Minnesota
Minnesota听Announces Automated Medicaid Pre-Payment Review System. On February 6, the听Minnesota Department of Human Services鈥听that it is advancing an automated Medicaid pre-payment review system in partnership with Optum to strengthen fraud prevention. The state expects to have the system fully implemented听by the end of 2026. Optum reviewed听nearly four听years of claims across 14 high-risk service areas, with early testing identifying data and policy gaps, particularly in Early Intensive Developmental Behavioral Intervention services, though no fraud was confirmed. In its first听90 days, Optum established analytics processes, conducted 192 targeted reviews, and implemented quality control protocols. State officials say continued refinement over the next nine months will improve oversight, reduce fraud risk, and rebuild public trust.听
South Dakota
South听Dakota Governor Signs $402 Million RHTP Bill. As听听in听Government Market News,鈥疭outh Dakota Governor Larry Rhoden has signed a $402 million bill (House Bill 1044) that will begin the process of implementing the federal Rural Health听Transformation Program (RHTP), with approximately $189.4 million of the funds coming from the federal government. The state will work on modernizing healthcare delivery, developing a Data Atlas to act as a hub for electronic health records, and implementing an alternative payment model, among other priorities.听
Virginia
Virginia Appoints Steve Ford as Medicaid Director. The Richmond-Times Dispatch鈥鈥痮n February 6, 2026, that Steve Ford has been appointed by Governor Abigail Spanberger to lead Virginia鈥檚 $24 billion听Medicaid program, which serves听nearly 2听million low-income, elderly, and disabled residents. Ford will serve as the听director of the Department of Medical Assistance Services.听
Washington
Washington Receives Federal Approval for Revised RHTP Budget. The Washington Health Care Authority (HCA)鈥鈥痮n February 10, 2026, that the U.S. Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS) have approved Washington鈥檚 revised budget for the federal Rural Health Transformation Program (RHTP). HCA worked in collaboration with the state Department of Health, Department of Social and Health Services, and the Governor鈥檚 Office to reduce the RHTP budget down from $200 million to $181 million, which was what HHS and CMS had allocated to Washington in the December 2025 Notice of Award, without eliminating any of the activities planned for the funds.听
Private Market News
Fueled By
CMS Releases 2027 Proposed Notice of Benefit, Payment Parameters
On February 9, 2026, the Centers for Medicare & Medicaid Services (CMS)听听the proposed听 for 2027, which includes several significant changes to federal and state-based Affordable Care Act (ACA) health insurance Marketplaces. The changes in the NBPP focus on addressing fraud, tightening broker and agent practices, increasing accountability, and removing federal barriers on plans. Key components of the proposal include:听听
- Allowing issuers to offer catastrophic plans with terms of up to 10 years 听
- Repealing standardized plan options and related requirement limits听
- Permitting听low-deductible plans with high听maximum听out-of-pocket limits, aligning affordability and coverage incentives听
- Expanding hardship exemptions听
- Permitting听certain non-network plans to receive Qualified Health Plan certification听
- Strengthening听eligibility and income verification with enhanced enforcement policies听
- Ensuring federal subsidies for Essential Health Benefits do not finance state-mandated benefits听
- Modernizing network adequacy and provider access reviews听听
CMS will accept public comments on the proposed rule through March 11, 2026.
Aledade Expands Value-Based Care Network With 700 New Practices
Aledade听听more than 700 primary care practices to its network for 2026, expanding to more than 3,000 organizations serving over听3 million patients听in value-based care programs. The company鈥檚 growth aligns with continued federal support for accountable care models through the Centers for Medicare & Medicaid Services and the听.
Our Insights
Fueled By Experts Across Our 量子资源网 Companies
量子资源网
Webinar Replay: Meeting the Healthcare Needs of Unhoused People Part 1: Service and Care Responses
In听January 2026, 量子资源网 held the first in its two-part听webinar听series听exploring how current events are听impacting听people experiencing homelessness and their access to care. This听webinar听highlighted the model of care for healthcare for听the homeless听clinics and medical respite care providers and how these services interact with broader systems of care. Additionally, we explored how the current environment is听impacting听delivery and financing of care for some of our most vulnerable neighbors.听
Webinar Replay 鈥 Meeting the Healthcare Needs of Unhoused People Part 2: State Policy Responses
In the second of our two-part series听exploring how current events are听impacting听people experiencing homelessness and their access to care, we focused on听state responses to recent federal policy changes, such as the 2025 Budget Reconciliation Act (P.L. 119-21,听OBBBA). These changes bring听new听considerations for听retaining听Medicaid coverage gains and听section听1115听demonstration听services that have been determined听effective听in the last decade. States will听need to听meet new requirements鈥攂ut they also have options to reduce the negative impact on vulnerable populations and the healthcare providers that serve them. This听webinar听discussed state-level policy options, shared resources, and considered how to move forward in the current environment.
Wakely
Wakely Summary: Advance Notice of Methodological Changes for CY 2027 MA Capitation Rates and Part C and Part D Payment Policies
The Centers for Medicare & Medicaid Services (CMS) recently released the 2027 Advance Notice of Methodological Changes for Medicare Advantage Capitation Rates and Part C/D Payment Policies, which proposes听important changes听in plan payments, risk听adjustment听and other financial and regulatory requirements for 2027.听Wakely summarizes key changes that will affect Medicare Advantage pricing for CY2027. This Advance Notice is more consequential than others in recent history, as the effective payment rate falls听substantially below听the averages seen in years past.听听
This paper has been written in partnership with Jonathan Blum, Co-Founder & Managing Partner at Health Transformation Strategies, LLC.
Webinar: Summary & Impacts of the 2027 Medicare Advantage Advance Notice
On鈥疐ebruary 12,鈥 2026, join鈥痗onsultants鈥痜rom鈥疻akely, an 量子资源网 company, for鈥痑n overview of the proposed changes听in听the 2027 Advance Notice of Methodological Changes for Medicare Advantage Capitation Rates and Part C/D Payment Policies.听Speakers will focus on the听likely impact鈥痶hat the new rates and policies will have on Medicare Advantage bids, membership growth,鈥quality鈥痑nd strategy. Speakers will also touch on the important items from the CY2027 Proposed Rule, released听on November 25, 2025.听
Webinar: CY2026 Trends in Medicare Advantage Part D Plan Benefits
On February 25, 2026, join the experts from Wakely, an 量子资源网 Company, for a data-driven discussion of the key Part D benefit trends shaping Medicare Advantage Part D plans in CY2026. The Inflation Reduction Act鈥檚 Part D benefit redesign听commenced听January 1, 2025, with Maximum Fair Price drugs introduced January 1, 2026. As benefit design becomes more uniform across Part D plans, this听webinar explores how sponsors adjusted the Part D benefits of their plans to meet the requirements of the legislation, while still听remaining competitive. We will review the CY2025->CY2026 movements of Part D benefits and formulary placement, in addition to exploring benefit & formulary differences between MAPD & PDP plans for CY2026. 听
Check Your ACA Risk Adjustment Data Validation (RADV) Engine Lights
Risk Adjustment Data Validation (RADV) audits are a critical听component听of the Affordable Care Act (ACA) Marketplace, ensuring accuracy of risk adjustment data听submitted听by health plans. These audits help verify validity and reliability of data used to calculate risk adjustment transfers. Operationalizing a RADV audit involves careful planning, resource allocation, and adherence to regulatory requirements.听Through the Wakely National Risk Adjustment Reporting (WNRAR) project, we analyze RADV performance for about 80% of the Health Insurance Oversight System (HIOS) IDs in the market.听We are sharing some of the key questions for health plans to ponder as听they听reflect on听their听recent听initial听RADV results.鈥听
RFP Calendar
RFP Calendar
| Date | State/Program | Event | Beneficiaries |
|---|---|---|---|
| Date: February 2026 | State/Program: Illinois | Event: Awards | Beneficiaries: 2,400,000 |
| Date: February 17, 2026 | State/Program: Nevada CO D-SNP | Event: Proposals Due | Beneficiaries: 88,000 |
| Date: February 19, 2026 | State/Program: Nevada Children's Specialty | Event: Awards | Beneficiaries: NA |
| Date: May 12, 2026 | State/Program: Nevada CO D-SNP | Event: Awards | Beneficiaries: 88,000 |
| Date: June 24, 2026 | State/Program: Wisconsin LTC GSR 3 | Event: Awards | Beneficiaries: 56,000 (all GSR) |
| Date: August 2026 | State/Program: Indiana | Event: RFP Release | Beneficiaries: 1,400,000 |
| Date: January 1, 2027 | State/Program: Illinois | Event: Implementation | Beneficiaries: 2,400,000 |
| Date: January 1, 2027 | State/Program: Nevada Children's Specialty | Event: Implementation | Beneficiaries: NA |
| Date: January 1, 2027 | State/Program: Nevada CO D-SNP | Event: Implementation | Beneficiaries: 88,000 |
| Date: January 1, 2027 | State/Program: Wisconsin LTC GSR 3 | Event: Implementation | Beneficiaries: 56,000 (all GSR) |
| Date: January 1, 2027 | State/Program: Illinois Tailored Care Management Program | Event: Implementation | Beneficiaries: 22,400 |
| Date: January 1, 2028 | State/Program: Wisconsin LTC GSR 4,6 | Event: Implementation | Beneficiaries: 56,000 (all GSR) |
| Date: Fall 2027 | State/Program: Oregon | Event: RFP Release | Beneficiaries: 1,200,000 |
| Date: 2028 | State/Program: North Carolina | Event: RFP Release | Beneficiaries: 2,200,000 |