Month: June 2025

Posted on in CMS Data Highlights, Medicare

Less Rural Areas See Sharpest Fall in Share of Medicare PDP Enrollment Since 2015

Less rural areas saw the largest decline in the share of Medicare Part D enrollees choosing stand-alone prescription drug plans (PDPs) over the past decade, according to an analysis of the Centers for Medicare & Medicaid Services Part D enrollment data from 2025 and 2015. 

Nationwide, rural residents continue to enroll in stand-alone PDPs at higher rates than those in urban or less rural areas. As of May 2025, nearly six in 10 rural Medicare Part D enrollees are in PDPs, down from more than eight in 10 in 2015. 

Meanwhile, less rural areas — defined as those adjacent to metro regions — saw the largest drop in share over the past decade. In 2015, approximately 76.4% of Part D enrollees in these areas chose stand-alone PDPs; by 2025, that share had fallen to 46.3%, a 30.1 percentage-point decrease.

In 2025, about four in 10 urban enrollees are in PDPs, compared with six in 10 in 2015. Greater availability of Medicare Advantage provider networks in urban settings may have accelerated the shift to Medicare Advantage Prescription Drug (MA-PD) plans.

Despite these declines, 19 states still have at least 60% of rural Part D enrollees in stand-alone PDPs in 2025. Nine states have 75% or more of Part D enrollees in PDPs: Nevada, Alaska, Massachusetts, California, Kansas, Nebraska, Wyoming, South Dakota and North Dakota.

Among less rural areas, PDPs cover over 60% of Medicare Part D enrollees in 13 states in 2025. While compared with a decade ago, the share of enrollees choosing PDPs dropped in all states with rural adjacent areas, eighteen states experienced a decline of more than 30 percentage points. 

In urban areas, only eight states have 60% or more of Part D enrollees choosing PDPs in 2025. Alabama, Maine and Michigan saw more than a 30 percentage-point drop in the percentage of enrollees choosing PDPs across all geographic areas over the past decade.

Stand-alone PDPs availability has declined in recent years, with the average number of PDPs available hitting a record low in 2025. The Medicare Payment Advisory Commission (MedPAC) highlighted this trend in its April meeting and June 2025 Report to Congress, calling for market stabilization in the coming years. The shift from PDPs to MA-PD plans is consistent with the move from traditional Medicare fee-for-service to Medicare Advantage in the broader Medicare program, as shown in Medicare Monthly Enrollment.

Methodology: 

This analysis uses Medicare Part D enrollment data from May 2015 and May 2025 to examine shifts in the share of beneficiaries enrolled in stand-alone prescription drug plans (PDPs) versus other Medicare Part D coverage options. The data sources include the Centers for Medicare & Medicaid Services’ Monthly Enrollment by CPSC and Monthly PDP Enrollment by SCC files. The analysis is conducted at the county level, allowing for geographic comparisons over time.

To assess changes by geographic area, the analysis incorporates the Urban Influence Codes (UICs) released by the U.S. Department of Agriculture in 2013 and 2024. 

For 2025, counties with UICs 1 and 4 are categorized as “urban” areas. Counties with UICs 7, 8, and 9 are designated as “rural,” while those with UICs 2, 3, 5, and 6 are classified as “rural adjacent to urban” areas. For 2015, the categorization differs slightly based on the 2013 codes: UICs 1 and 2 are labeled as “urban,” UICs 8, 11, and 12 as “rural,” and UICs 3 through 7, 9, and 10 as “rural adjacent to urban.”

Because Connecticut transitioned from county-based geography to planning regions in 2022, this analysis approximates its geographic classification using historical county data. Specifically, Litchfield County and Windham County are assigned UIC 2, placing them in the “rural adjacent to urban” category. The remaining counties are assigned UICs 1 and 4, consistent with “urban” classification.

Posted on in CMS Data Highlights

Major Health Insurers Boost Lobbying Spending Amid Policy Shifts

Major health plans and industry organizations increased their lobbying expenditures by 23% in the first quarter of 2025 compared to the same period in 2024, according to data compiled by OpenSecrets. Leading the spending surge were Blue Cross Blue Shield plans, AHIP, The Cigna Group, and UnitedHealth Group.

The spike in lobbying comes as President Donald Trump, now in his second term, focuses his health care agenda on reversing several Biden-era policies — particularly those involving the Affordable Care Act and Medicaid. Since January, lobbyists representing health insurers and insurance agents have invested millions in influencing federal policy.

Blues plans reported record-high quarterly lobbying expenditures, spending over $9.1 million in the first quarter of 2025 and collectively ranking as the top individual lobbying spender among the major health plans. Among all BCBS affiliates, Elevance Health, Inc. and Health Care Service Corp. led in lobbying investment.

Blues plans lobbied heavily for key legislations, including the Lower Costs, More Transparency Act (H.R.5378), SITE Act (S.1869), and FAIR Act (H.R.3417). These bills aim to promote site-neutral Medicare reimbursement and expand price and billing transparency for payers. Collectively, BCBS entities hired 114 lobbyists in the first quarter, with 65.8% of whom previously held positions in the federal government.

AHIP, the trade group representing health insurance companies, spent more than $4.8 million in the first quarter. Kaiser Permanente invested nearly $3.1 million, more than doubling its total lobbying expenditures for all of 2024. The group spent $3 million on Health Care Affordability Act of 2025 (H.R.247 and S.46). In addition to health coverage-related issues, Kaiser spent $60,000 on lobbying efforts related to value-based care and the appropriate use of artificial intelligence in health care, according to its public filing.

Lobbying expenditures in the health services/health maintenance organizations (HMO) sector have risen steadily over the past decade, though the industry saw an 8.8% year-over-year decline in 2024. OpenSecrets includes a variety of non-residential health care programs and health maintenance organizations in the sector. Several major health insurers are categorized separately, as part of the insurance industry, on OpenSecrets, and BCBS was listed in both industries. This analysis combined the lobbying spending by BCBS from both industries.

 

Posted on in ACA Marketplace, CMS Data Highlights

Analysis Tallies Impact of Enhanced Premium Tax Credits Expiration on 2026 ACA Premiums

An analysis of preliminary premium filings from ACA-regulated health plans across five states indicates an additional 5.58 percentage-point increase in premiums due to the projected expiration of enhanced subsidies under the Affordable Care Act. Insurers in Massachusetts highlighted their discontinuation of coverage for popular but costly anti-obesity GLP-1 drugs in their filings.

In May, House Republicans passed the “One Big Beautiful Bill Act,” which notably did not include an extension of the enhanced ACA subsidies. These enhanced subsidies increased the level of advance premium tax credits (APTCs) available to lower-income individuals (making $0-premium plans widely available to that group) and extended APTC eligibility to people with incomes at or above 400% of the federal poverty level. Without a permanent extension of the enhanced subsidies, subsidized ACA enrollees would see their premium payments rise sharply starting Jan. 1, 2026. 

Over half of the insurers included in this analysis indicated that the expiration of enhanced APTCs would lead to premium increases. Among the insurers who quantified the impact, the projected increases, in addition to annual rate changes, ranged from 1.0% to 13.7%, with an average projected premium impact of about 5.58%. The analysis is based on 36 early insurer premium filings from Oregon, New York, Maryland, Vermont and Massachusetts. 

Oregon

Six insurers have submitted rate change requests for 2026, ranging from an average increase of 3.9% to 12.9%, resulting in a weighted average increase of 9.7%, according to the Oregon Division of Financial Regulation. This average increase is slightly higher than last year’s requested weighted average increase of 9.3%. Four of the six insurers attributed part of the increases to the expiration of enhanced subsidies, which could raise premiums by 1.0% to 4.5%.

In 2025, the monthly average premium for all enrollees is $696 per person per month in the exchange. With the enhanced subsidies, the monthly average premium among those with allocated APTC amounts greater than $0 is $199. For the year 2025, about 80% of ACA enrollees received APTCs in Oregon, according to CMS. 

New York

Fourteen insurers have submitted rate change requests for 2026, ranging from an average increase of 0.9% to 66.4%, according to the New York Department of Financial Services. Only five insurers specified how much of their premium increases were driven by the expiration of enhanced subsidies. The largest insurer in the state, Fidelis Care, attributed 3.90% of its requested rate hike to the policy change. 

In 2025, the monthly average premium for all enrollees is $791 per person per month in New York’s state-based marketplace. With the enhanced subsidies, the monthly average premium among those with allocated APTC amounts greater than $0 is $340. For the year 2025, about 63% of ACA enrollees received APTCs in New York, according to CMS. 

Maryland

Six insurers have requested an overall average rate increase of 17.1% for 2026, with individual insurer requests ranging from 8.1% to 18.7%, according to the Maryland Insurance Administration. In the news release, the agency noted that the rate increases “are the highest since the implementation of Maryland’s reinsurance program in 2019 and reflect the anticipated loss of enhanced federal tax credits.” If the enhanced tax credits were to continue, the projected average rate increase would drop to 7.9%. 

The two largest insurers in the state, CareFirst BlueChoice and Optimum Choice, attributed 13.7% and 5.8% of their requested rate hikes to the anticipated policy change, respectively. In addition, CVS Health’s Aetna has announced plans to exit Maryland’s individual market in 2026, a move that will affect 4,939 enrollees.

In 2025, the monthly average premium for all enrollees is $492 per person per month in Maryland’s state-based marketplace. With the enhanced subsidies, the monthly average premium among those with allocated APTC amounts greater than $0 is $108. For the year 2025, about 76% of ACA enrollees received APTCs in Maryland, according to CMS. 

Vermont 

BlueCross and BlueShield of Vermont proposed a 23.3% average premium hike for 2026, while MVP Health Plan requested a 6.2% increase, according to Vermont’s Green Mountain Care Board. BCBSVT attributed 6.6% of its requested rate increase to the anticipated expiration of enhanced subsidies. MVP Health Plan noted that “a disproportionate share of healthy members are expected to leave the market,” resulting in an increased morbidity impact of 7.1%.

In 2025, the monthly average premium for all enrollees is $1,067 per person per month in Vermont’s state-based marketplace. With the enhanced subsidies, the monthly average premium among those with allocated APTC amounts greater than $0 is $192. For the year 2025, about 93% of ACA enrollees received APTCs in Vermont, according to CMS. 

Massachusetts

Eight insurers have submitted rate change requests for 2026, with proposed average increases ranging from 9.90% to 16.20%, according to the Massachusetts Division of Insurance. Of these, only Fallon Community Health Plan Inc. — which accounted for 5.6% of individual market membership statewide — specified that 3.5% of its requested rate increase was due to the anticipated expiration of enhanced federal subsidies. 

Unlike many other states, Massachusetts insurers also cited the rising costs of covering popular anti-obesity medications, specifically GLP-1 drugs, as a contributing factor to premium pressures. Five insurers — Tufts Health Plan, WellSense Health Plan (Boston Medical Center), Mass General Brigham Health Plan, Harvard Pilgrim Health Care and Blue Cross Blue Shield of Massachusetts HMO Blue, Inc. — announced they will no longer cover GLP-1 drugs for weight loss indications in 2026. Combined, these five insurers covered 92.2% of the state’s individual market. 

In 2025, the monthly average premium for all enrollees is $535 per person per month in Massachusetts’ state-based marketplace. With the enhanced subsidies, the monthly average premium among those with allocated APTC amounts greater than $0 is $126. For the year 2025, about 83% of ACA enrollees received APTCs in Massachusetts, according to CMS. 

Posted on in Data Stories

A Look at the Medicaid MCO Market Ahead of Potential Policy Changes

With Donald Trump now sworn in as the 47th president and Republicans controlling both chambers of Congress, the future of Medicaid is uncertain.  

During his campaign, Trump promised to slash federal spending. And according to a document now circulating on Capitol Hill, House Republicans are considering several Medicaid policy changes that could reduce federal spending by $2.3 trillion, including imposing a per capita cap on federal Medicaid funding, reducing the funding match rate for the Medicaid expansion population, and lowering the federal medical assistance percentage (FMAP) floor from the current 50% level. 

As of January, more than 66.1 million people are enrolled in a managed Medicaid health plan, according to AIS’s Directory of Health Plans. The top 10 Medicaid MCO insurers by membership held about 60.9% of the national market. Centene Corp. alone accounted for 18.6% of the national market and covered Medicaid enrollees in 28 states across the nation. Elevance Health, Inc. and UnitedHealthcare ranked the second and the third largest, holding about 11.0% and 8.8% market share, respectively.

In 26 states, Centene is among the top three insurers by membership within the state’s Medicaid market. Molina Healthcare, Inc., the fourth-largest Medicaid MCO insurer, held 6.0% of the national market and ranked among the top three insurers in eight states. The company has more than 3.9 million Medicaid beneficiaries, accounting for almost 85.5% of its total membership. For more specific market share data, hover over the graphics below.

The Affordable Care Act expanded Medicaid coverage to people with incomes of up to 138% of the federal poverty level. The federal government covers 90% of the cost for ACA expansion enrollees and states pay 10% of the costs. As of 2025, 40 states and Washington, D.C., have adopted Medicaid expansion, as a Supreme Court decision made expansion optional. The FMAP for the non-expansion Medicaid population is based on states’ and U.S. territories’ per capita income and ranges from 50% to 83% for fiscal year 2025, according to KFF. 

The Paragon Health Institute, a right-leaning health care research firm, has proposed reducing the FMAP for Medicaid enrollees to the standard Medicaid match rate by 2034, which could shift a significant amount of Medicaid spending from the federal government to the states and lead to millions of people losing coverage. 

As of March 2024, more than 21 million people — 24% of total Medicaid enrollment — had coverage thanks to the ACA’s expansion provision, according to a KFF analysis. About 4.3 million expansion enrollees reside in 12 states that have “trigger laws” that would end expansion or require other changes if the match rate is below 90%. 

Of the 12 states with the trigger laws, eight voted for Trump as president and four voted for Kamala Harris. In Arkansas, Indiana, Iowa, Montana, New Hampshire, New Mexico and Virginia, more than 30% of Medicaid beneficiaries obtain their coverage through Medicaid expansion. 

This infographic was reprinted from AIS Health’s weekly publication Health Plan Weekly.