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The Michigan Department of Health and Human Services this week awarded contracts to nine health plans to launch the MI Coordinated Health program on January 1, 2026. Selected payers include Centene Corp., Molina Healthcare, Humana Inc., UnitedHealthcare and CareSource’s partnership with Health Alliance Plan (HAP). The new plans will serve individuals dually eligible for both Medicare and Medicaid, beginning in select counties before expanding statewide in 2027. MI Coordinated Health aims to provide comprehensive care coordination, including home- and community-based services and nursing-facility care. It will replace the MI Health Link program, which ends on December 31, 2025, ensuring a seamless transition for current enrollees. MI Health Link currently serves 34,413 duals via managed care plans.

CMS on Oct. 10 released its 2025 Medicare Advantage and Part D Star Ratings, revealing a continued decline in the number of plans achieving high ratings. Only 40% of Medicare Advantage prescription drug (MA-PD) contracts earned four stars or higher for the 2025 plan year, though 62% of all MA-PD members are enrolled in these highly rated contracts (those earning four or more Stars). Among major MA insurers, Humana Inc. saw the biggest ratings drop, as its largest MA contract earned just 3.5 Stars for 2025. Its percentage of members enrolled in highly rated plans plummeted from 94% to 25%, representing 1.55 million members out of 6.07 million.

Pfizer has secured its second FDA approval for a hemophilia treatment within six months. The latest approval is for Hympavzi, a subcutaneous injection designed for patients aged 12 and older with hemophilia A or B who have not developed antibodies to previous treatments. This new therapy aims to reduce bleeding episodes and offers a more convenient alternative to traditional intravenous infusions. With its $795,600 wholesale acquisition cost (WAC), Hympavzi is positioned as a cost-effective option compared to other treatments on the market. Pfizer’s Beqvez, a gene therapy that treats hemophilia B, was approved in April. So far, the drug holds covered status for 32% of all insured lives under the medical benefit, often with utilization management restrictions applied.

The U.S. Securities and Exchange Commission (SEC) does not intend to recommend an enforcement action related to its multiyear investigation of Clover Health Investments Corp. The SEC launched its probe shortly after a 2021 report from the activist short-seller Hindenburg Research criticized multiple Clover business practices and accused its leaders of failing to disclose when the firm went public that it was under investigation by the Dept. of Justice. The Medicare Advantage-focused startup earlier this year settled a series of shareholder-led class action lawsuits that related to the DOJ probe. According to Sept. 30 SEC filing by the company, the agency on Sept. 26 informed Clover that it had concluded its investigation and, “based on the information that the SEC had as of the date of the notice,” it would not seek an enforcement penalty. Clover Health currently serves 79,660 MA members.

A Texas judge has issued a temporary injunction halting a $116 billion Medicaid proposal that would have required 1.8 million low-income Texans to switch their health plan, the Dallas Morning News reported Oct. 4. The decision comes after concerns were raised about the fairness of the state’s procurement process, which excluded several nonprofit health plans, including Cook Children’s Health Plan, Texas Children’s Health Plan, and Driscoll Health Plan, which have served the program for more than a decade. The ruling aims to prevent significant disruption and confusion among Medicaid beneficiaries, particularly children enrolled in CHIP. Blue Cross Blue Shield of Texas, Molina Healthcare, CVS Health Corp.’s Aetna and UnitedHealthcare were awarded the new contracts. Texas’ managed Medicaid plans currently serve 3,891,152 people.

Starting on Jan. 1, 2025, most Blue Shield of California commercial plan enrollees will have access to a Humira (adalimumab) biosimilar with a $0 copay as part of the insurer’s Pharmacy Care Reimagined model. Blue Shield announced the initiative on Oct. 1 and said it would partner with Fresenius Kabi, which manufactures a Humira biosimilar, and Evio Pharmacy Solutions, a company that Blue Shield and other Blues plans founded in 2021. As part of the agreement, Blue Shield will purchase the Humira biosimilar for a monthly price of $525, significantly below the net price of $2,100 per month for branded Humira. Blue Shield revealed the Pharmacy Care Reimagined model in August 2023 and noted it would shift from a traditional PBM contract with CVS Health Corp.’s Caremark to a pharmacy benefits arrangement with five different vendors. The insurer currently serves 2,318,709 members via commercial risk-based plans, with an additional 828,971 enrolled in self-funded products.

CVS Health Corp.'s board of directors is reportedly considering breaking up its diversified health care enterprise due to the poor performance of its Aetna health benefits division, which has struggled to contain Medicare Advantage costs. CVS Health reportedly met with hedge fund investor Glenview Capital to discuss ideas about turning the company around; Glenview Capital has denied that it was pushing for a breakup of CVS. “Given what has happened over the last year, we don’t find it surprising that CVS’s board is taking a hard look at different options,” wrote Evercore ISI analyst Elizabeth Anderson in a Sept. 30 research note. Anderson added that CVS is “probably likelier to stay together vs. be broken up, but this decision will likely depend on the 2025 Medicare Advantage outlook and new pharmacy reimbursement model success.” Aetna currently serves 25,126,507 members, with 17.2% enrolled in MA.

Virginia-based integrated system Sentara Health last month launched Virtual Express Care, an on-demand service providing video visits with minimal wait times (generally less than 30 minutes) to address simple health concerns. This new service allows patients to see providers without needing an appointment, and is accessible from 7:00 a.m. to 7:00 p.m. Monday through Friday. Sentara aims to enhance access to care and plans to expand this service to 24/7 availability in the future. “We are seeing more and more people seek the virtual option organically and be comfortable using this to bridge refills, to get access for an acute illness, a referral, or a note for work,” Dr. Mark Haggerty, director of medical operations for Sentara Telehealth Services and Digital Solutions, said in a statement. Sentara is the third-largest insurer in its home state, serving 847,663 members.

Premera Blue Cross on Oct. 1 said that it will exit the Medicare Advantage market starting January 1, 2025, citing to changing market conditions and financial pressures. The company says this strategic shift will allow it to focus on its growing lines of business, such as employer-sponsored health plans, Medicare supplement plans and exchange plans. “This was an incredibly difficult decision, particularly given our position as the only local commercial health plan in Washington and our commitment to serving our community,” CEO Jeffrey Roe said in a statement. “Despite our best efforts, the challenging market and financial constraints have made the long-term success of our Medicare Advantage program unsustainable.” Premera currently serves 31,852 MA members in Washington. The insurer will continue to offer Medicare supplement plans.

Startup Medicare Advantage insurer Zing Health has successfully raised $140 million in a recent funding round to expand its integrated, Chronic Special Needs Plans (C-SNPs). The investment will enable Zing Health to reach more beneficiaries and enhance its member experience by integrating high-quality care providers. The funds will also support the company’s mission to serve underserved communities with specialized healthcare needs. “The industry today does not do enough to tailor plans and member experience to individuals’ needs,” Zing Health CEO Andrew Clifton said in a statement. “Through the delivery of C-SNP plans to underserved seniors, we are providing the appropriate benefits to improve health outcomes and leveraging technology to ensure members receive high quality, value-based care through a seamless member experience.” Zing Health currently serves 12,890 MA and dual eligible members, with 62% enrolled in C-SNPs.