Below is a roundup of payer-centric news headlines you may have missed during the month of July 2025.
Leading stories
AOC, Dems voice concerns with CMMI model adding prior auth requirements in Medicare
A group of 42 Democratic lawmakers, led by Rep. Alexandria Ocasio-Cortez and Rep. Lloyd Doggett, wrote to the Centers for Medicare & Medicaid Services (CMS) to pause implementation of a new Innovation Center model.
In June, the agency rolled out a pilot model—Wasteful and Inappropriate Service Reduction (WISeR)—to test prior authorization requirements in traditional Medicare. The Medicare Advantage program, meanwhile, is routinely scrutinized for the role prior authorization plays in delaying or denying care.
Democrats say the model incentivizes higher rates of prior authorization because private insurers are paid “based on a share of averted expenditures” and encourages health plans to use artificial intelligence to make haphazard determinations.
“We understand that CMMI has intentionally selected healthcare services that are reported to have limited clinical value and may be vulnerable to abuse in the Medicare program, and we support efforts to ensure Medicare remains a good steward of taxpayer dollars,” the lawmakers said (PDF). “However, the expansion of AI-fueled prior authorization will not improve program integrity in traditional Medicare.”
Clover Health creates NJ pharmacy program
Medicare Advantage insurer Clover Health has launched a community-based pharmacy pilot program in New Jersey in partnership with a digital health division of Independent Pharmacy Cooperative, a group purchasing organization for independent pharmacies.
Participating pharmacies to “monitor prescription fills, identify adherence gaps and collaborate with local doctors,” a press release explains.
In a LinkedIn post, Clover CEO Andrew Toy said the initiative is a key step in furthering value-based care by involving local pharmacists.
Regulatory
Colorado premiums to rise by 28% in exchange market
Premiums will increase by 28% to 38% in Colorado because of the recently passed Trump budget bill and pending the expiration of enhanced subsidies this year.
Statewide increases did not exceed 11% for the last four years. More than 300,000 people will pay more for healthcare, the Colorado Division of Insurance said this month.
“The sad reality is that many of those folks will be forced to gamble with their health because they simply cannot afford these rate increases caused by the federal government,” said Michael Conway, the state’s insurance commissioner.
Industry
Vitable announces primary care-backed ICHRA
Health benefits platform Vitable Health is launching primary-care-backed individual coverage health reimbursement arrangement (ICHRA) services in Ohio.
The state recently passed a law giving a $400 per-employee tax credit to small businesses offering ICHRAs. Vitable’s services will offer virtual primary care, mental health coaching, covered prescriptions and preventive tests.
“This is a moment of alignment,” said CEO Joseph Kitonga in a news release. “Ohio’s policy leadership, the rising adoption of ICHRAs, and Vitable Health’s primary care-first model are all converging toward a system where small businesses can finally afford to offer real healthcare.”
Humana enters Medicaid scene in Virginia
Medicaid enrollees in Virginia can now enroll in a Humana plan, along with plans offered by four other carriers.
The insurer said it would commit $2 million to the Virginia Health Care Foundation.
“We have the privilege of serving Medicare Advantage and TRICARE members throughout Virginia, and we are honored to expand our human-centered care to Virginians covered by Cardinal Care,” said Humana Healthy Horizons President John Barger in a news release.
Imagine360’s new product leverages transparent PBM
Complete Care, a new platform by alternative health plan Imagine360, gives employers access to new services.
Those offerings include contracts with health systems, reference-based pricing, third-party administrative services and stop-loss insurance. It's powered by alternative pharmacy benefit manager Liviniti. Both Liviniti and Imagine360 share Water Street Healthcare Partners as an investor.
“Imagine paying for groceries every day but not seeing itemized prices or receipts until after the fact,” said Imagine360 President and CEO Jeff Bak. “This is how most employers have to manage two of their biggest benefits-related expenses: medical claims and pharmacy costs. Complete Care sets a new industry standard, providing businesses with a comprehensive view of their healthcare spending.”
Quick hits
- Paid sick leave work benefits increased the odds of an enrollee receiving various types of care, a study in The Lancet finds.
- Health plans are more likely to follow clinical guidelines when utilization management is recommended, a study in Health Affairs using Tufts Medicine specialty drug and coverage statistics shows.
- A new report uncovers the scope of nearly 2,700 UnitedHealth Group acquisitions.
- One Medicaid claims process employs at least 1,800 engineers and analysts in India, despite state contracts requiring U.S.-based work, reported Bloomberg Law.
- A union health plan has sued Optum for allegedly paying more than $4 million for GLP-1 drugs, even though the health plan did not allow coverage for popular drugs like Wegovy, reported the Minnesota Star Tribune.
- Immigration and Customs Enforcement agents now have access to 1.8 billion insurance claims and 58 million medical bills, reported 404 Media.