Weekly Roundup -
February 11, 2026
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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
TheCenters for Medicare & Medicaid Services (CMS) issuedamemoJanuary 27, 2026,with updatesonthe agency’sapproachtochecking whether Medicare Advantage (MA) plans are being paid correctly. These reviews areconductedthroughwhichhelp CMS confirm that the diagnoses MA plansreportaresupportedby medical records.
The January 2026 memo signals thatCMSintends to honoritscommitment to strengthen oversight of MA payments,includingacceleratingand expandingthe use of RADV auditsand usingAI (artificial intelligence)to streamline human coding reviews.MA organizationsmust nowprepare to respond to the RADV audit notice within the required five-month window, while balancingtheirother risk-adjustment programs.
In this article, we explain therapidly evolving landscapeaffectingRADVaudits.Wakely, an ϱ company, addresses what these changes mean for MA organizations andkey considerations to ensure they are prepared for the upcomingenhancements to federal program integrity initiatives.
Overviewof CMS’ RADV Refresh
CMSa major shiftin May 2025:All MA plans willundergoRADV audits—notjust a small sample as before.These auditslook for casesin whichdiagnosisinformationsubmittedby a plan does not matchthedocumentationin the patient’s medical record.When this happens,CMSmaydecidethe planwas overpaidand require repayment. Historically, CMSauditshaveidentifiedwidespread diagnosis-code documentation errors, resulting insignificant revenue recoupment from MAplans.
The2025 announcementcreatesaframework foradditionalrisk forMAplans, which could shift to risk-bearing provider groups.Asweexplained in an, key components of thatannouncement include:
- All MA plans will be audited startingwithPayment Year(PY)2018.
- CMS committed to accelerating audits byadding more staff and usingnewtechnology.
- CMSplanned touse “extrapolation”—meaningif 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.
- CMS also planned toeliminatethe fee-for-service(FFS)adjuster—apolicy that previously helped reduce the amount a plan would have to repay. Thisproposalwould increase financial risk for plans.
Both the use of extrapolation and the removal of the FFS adjuster were later challenged in court.
Legal Challenge
InSeptember2023, HumanaCMS infederal court, arguing that the 2023 RADV final rule,which allowed extrapolation and removed the FFS adjuster,was put into place without following proper federal rulemaking procedures.OnSeptember 25,2025,the courtagreed with Humana andvacatedcertain partsofthisfinalrule, meaning certain parts of the rule are no longer in effect.
CMS appealed the ruling on November 1, 2025,which hascreateduncertaintyabout howRADVauditswill workin future years.
Navigating theLegal and Regulatory Changesin Early 2026
Thecourt didnotsaythat extrapolation or elimination of theFFSadjuster isillegal—only thatCMS did not follow the required process for changing the rules.Hence,the 2023RADVfinal rulecannottake effect unless CMSwins itsappealorreissuesthe policy using the proper steps.
In its January2026Health Plan Management System (HPMS)memo,CMSstatedthatit willcomply withthe order while it is in effect.
Thependinglitigationdoes not diminish CMS’s broader commitment to increased audit activity and heightened scrutiny of MA risk-adjustment practices.
Effect ofthe Ruling.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 processmaintainsprogram integrity and ensuresaccuratepayments.
Plans thatsubmitincomplete records could owesignificantrepayments to CMS.
CMS’sJanuary 2026memoclarifieshow theagencyplansto roll outadditionalRADVauditsstartingwithPY 2020. CMS alsoaddressesthe agency’splansto:
- Reduce burden on plans and providers,for example by extending the submission window
- Balance the volume of medical record submissions needing reviewby using smaller sample sizeswhere appropriate
- Use AIto further accelerate the review process
Preparing forWhat’s Next
Given CMS’s stated direction and the still unsettled litigation environment, MA plans should remain vigilant and audit ready.
Key steps include:
- Prioritizingtimelyand complete chart submission processes
- Strengthening internal criteria toidentifyandprioritizecharts most likely to support diagnoses
- Improving documentation and coding accuracy through provider engagement
- Conducting proactive self‑audits toidentifypotential vulnerabilities
- Partnering with expert RADV consultants to navigate audit strategy, documentation, and submission readiness
Connect with Us
Wakelyassistsplans with their RADV initiatives and development ofrobust RADV playbooks.For more information about Wakely’s RADV playbooks, contact.
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 , the Consolidated Appropriations Act, 2026 (Public Law 119-75) into law, enactingfiscal year (FY)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.
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 areworking to schedulekey hearings with agency leadership, tentatively slated to begin as soon as this month with markupsanticipatedin the House in May. Additionally, in the coming weeks, President Trump is expected tosubmitthe FY 2027 budget request to Congress. As hearing and markup schedules develop, stakeholders shouldanticipatethat there will be deadlines announced for submission of FY 2027 funding and policy priorities toappropriationscommittees in the coming weeks.
FDA Expands Flexibility for “No Artificial Colors” Labels
On February 5,US Food and Drug Administration (FDA)a shift in approach to relax how it enforces manufacturers’ use of “no artificial colors” labeling on food products. In a 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 “no artificial colors” 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 “make it easier for companies to move away from petroleumbased synthetic colors and adopt safer, naturally derived alternatives.” The agency also noted that it approved two petitions: was added, expanding the palette of allowable natural colors, and the food categories wherecan be usedwasexpanded.
This work builds onactionsby theDepartment of Health and Human Servicesand FDAencouragingcompanies to phase out petroleum-based colors, as articulated in theadministration’s. FDA is also tracking voluntary commitments from food manufacturers that have agreed to limit the use of petroleum-based dyes.
White House Launches TrumpRx.gov Drug Pricing Platform
On February 5, the White House officially launched, a websiteby the administration as “giv[ing] Americans direct access to dramatically lower prices on dozens of common, high-cost brand-name prescription drugs.” According to aaccompanying the launch, the initial rollout of the platform featured “40 of the most popular and expensive branded medicines in the nation,” developed by the “first five manufacturers to reach [most-favored-nation (MFN)] pricing deals,” although the document indicated that the website would add additional products “in the coming months.”
AsbyThe Wall Street Journal,rather than serve as a marketplace for direct sales in and of itself, the platform “allows customers to search for specific medicines and purchase them through a manufacturer’s direct-to-consumer site, or in some cases gives users coupons that they can present at certain pharmacies.” The site’s launch received praise from some Republican policymakers, such as, although recentindicatesthat President Trump’s broader MFN initiative has “b[een] met with a skeptical eye from Republicans.” Congressional Democrats have broadly criticized the platform, which Senate Finance Committee Ranking Member Ron Wyden (D-OR)as a “glorified coupon book.” Ata high level, while the website’s supporters have framed it as a source of savings and simplified access for uninsured and underinsured Americans, the platform’s skeptics have criticized its narrow scope, its potential incompatibility with insurance benefit designs, and its promotion of certain drugs with low-cost generic competitors.
HHS Names Diana Diaz-Harrison National Autism Coordinator
On February 3, HHSthe 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.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’s 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 seekingto expand such charter schools forautistic children nationally. Into local Arizona press, Ms. Diaz-Harrison emphasized the sharp rise in autism prevalence over recent decades andstatedthe necessity ofidentifyingthe disorder’s causes—generally aligningwith Secretary Kennedy’s for autism policy and among several newly members of the reconstituted Interagency Autism Coordinating Committee (IACC).
MACPAC Releases 2026 MACStats Medicaid, CHIP Data Book
This month the Medicaid and CHIP Payment and Access Commission (MACPAC) the2026MACStats: Medicaid and CHIP Data Book, which includes Medicaid and Children’s 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$957.4 billion. Total CHIP spending was$28.2 billion.
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Arizona
Arizona Lawsuit Challenges AHCCCS Over Autism Therapy Contract Changes. The Arizona Capital Times on 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 involvingCentriaAutism and Action Behavior Centers. Both cases stem from insurers ending contracts with these providers, forcing families to change applied behavioral analysis(ABA)services. In both lawsuits, plaintiffs are asking the court to pause the March contract terminations while the casesproceed.
Minnesota
MinnesotaAnnounces Automated Medicaid Pre-Payment Review System. On February 6, theMinnesota Department of Human Services 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 implementedby the end of 2026. Optum reviewednearly fouryears 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 first90 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.
South Dakota
SouthDakota Governor Signs $402 Million RHTP Bill. AsinGovernment Market News, South Dakota Governor Larry Rhoden has signed a $402 million bill (House Bill 1044) that will begin the process of implementing the federal Rural HealthTransformation 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.
Virginia
Virginia Appoints Steve Ford as Medicaid Director. The Richmond-Times Dispatch on February 6, 2026, that Steve Ford has been appointed by Governor Abigail Spanberger to lead Virginia’s $24 billionMedicaid program, which servesnearly 2million low-income, elderly, and disabled residents. Ford will serve as thedirector of the Department of Medical Assistance Services.
Washington
Washington Receives Federal Approval for Revised RHTP Budget. The Washington Health Care Authority (HCA) on 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’s 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’s 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.
Private Market News
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CMS Releases 2027 Proposed Notice of Benefit, Payment Parameters
On February 9, 2026, the Centers for Medicare & Medicaid Services (CMS)the proposed 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:
- Allowing issuers to offer catastrophic plans with terms of up to 10 years
- Repealing standardized plan options and related requirement limits
- Permittinglow-deductible plans with highmaximumout-of-pocket limits, aligning affordability and coverage incentives
- Expanding hardship exemptions
- Permittingcertain non-network plans to receive Qualified Health Plan certification
- Strengtheningeligibility and income verification with enhanced enforcement policies
- Ensuring federal subsidies for Essential Health Benefits do not finance state-mandated benefits
- Modernizing network adequacy and provider access reviews
CMS will accept public comments on the proposed rule through March 11, 2026.
Aledade Expands Value-Based Care Network With 700 New Practices
Aledademore than 700 primary care practices to its network for 2026, expanding to more than 3,000 organizations serving over3 million patientsin value-based care programs. The company’s growth aligns with continued federal support for accountable care models through the Centers for Medicare & Medicaid Services and the.
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Webinar Replay: Meeting the Healthcare Needs of Unhoused People Part 1: Service and Care Responses
InJanuary 2026, ϱ held the first in its two-partwebinarseriesexploring how current events areimpactingpeople experiencing homelessness and their access to care. Thiswebinarhighlighted the model of care for healthcare forthe homelessclinics and medical respite care providers and how these services interact with broader systems of care. Additionally, we explored how the current environment isimpactingdelivery and financing of care for some of our most vulnerable neighbors.
Webinar Replay – Meeting the Healthcare Needs of Unhoused People Part 2: State Policy Responses
In the second of our two-part seriesexploring how current events areimpactingpeople experiencing homelessness and their access to care, we focused onstate responses to recent federal policy changes, such as the 2025 Budget Reconciliation Act (P.L. 119-21,OBBBA). These changes bringnewconsiderations forretainingMedicaid coverage gains andsection1115demonstrationservices that have been determinedeffectivein the last decade. States willneed tomeet new requirements—but they also have options to reduce the negative impact on vulnerable populations and the healthcare providers that serve them. Thiswebinardiscussed 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 proposesimportant changesin plan payments, riskadjustmentand other financial and regulatory requirements for 2027.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 fallssubstantially belowthe averages seen in years past.
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 February 12, 2026, join consultants from Wakely, an ϱ company, for an overview of the proposed changesinthe 2027 Advance Notice of Methodological Changes for Medicare Advantage Capitation Rates and Part C/D Payment Policies.Speakers will focus on thelikely impact that the new rates and policies will have on Medicare Advantage bids, membership growth, quality and strategy. Speakers will also touch on the important items from the CY2027 Proposed Rule, releasedon November 25, 2025.
Webinar: CY2026 Trends in Medicare Advantage Part D Plan Benefits
On February 25, 2026, join the experts from Wakely, an ϱ 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’s Part D benefit redesigncommencedJanuary 1, 2025, with Maximum Fair Price drugs introduced January 1, 2026. As benefit design becomes more uniform across Part D plans, thiswebinar explores how sponsors adjusted the Part D benefits of their plans to meet the requirements of the legislation, while stillremaining 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.
Check Your ACA Risk Adjustment Data Validation (RADV) Engine Lights
Risk Adjustment Data Validation (RADV) audits are a criticalcomponentof the Affordable Care Act (ACA) Marketplace, ensuring accuracy of risk adjustment datasubmittedby 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.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.We are sharing some of the key questions for health plans to ponder astheyreflect ontheirrecentinitialRADV results.
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 |