Health Law Simplified

In this episode, Sandy Durkin and Elizabeth Lippincott break down several significant developments shaping the Medicare Advantage and Part D landscape. They begin with a close look at newly enacted federal legislation affecting pharmacy benefit managers (PBMs), including major reforms to Part D contracting that eliminate spread pricing and compensation tied to drug prices or rebates, replacing it with a flat, fair market value administrative fee. The discussion explores why this change is so consequential, how it may alter PBM incentives, and what plans should be thinking about as implementation approaches.
The conversation then turns to the Office of Inspector General’s newly issued Medicare Advantage compliance program guidance, the first major update in more than 25 years. Sandy and Elizabeth discuss why this guidance matters, how it fits alongside updated CMS audit protocols, and what it signals about expectations for “operationalized” compliance programs.
Finally, they examine early Medicare Advantage enrollment trends for 2026, including slowing overall growth and the continued expansion of Special Needs Plans, and consider what these patterns may mean for plan strategy going forward.

In this episode, Sandy and Elizabeth break down the latest CMS updates shaping the Medicare Advantage landscape, diving into the Advance Notice, RADV audit enforcement, emerging enrollment trends, and sweeping Special Needs Plan (SNP) regulatory changes.
We unpack CMS’s recent memo outlining its refined RADV audit strategy, including expanded audit cadence, updated sampling methodologies, extended medical record submission timelines, and the agency’s approach to balancing accelerated oversight with operational realities for plans and providers.
The conversation then turns to Medicare Advantage enrollment trends, including signs of market flattening, the expansion of SNPs, and potential shifts toward Medigap coverage.
Finally, we explore major policy developments affecting D-SNPs, C-SNPs, and I-SNPs, with a focus on CMS’s push toward deeper Medicare–Medicaid integration for dually eligible beneficiaries.
Whether you’re a health plan executive, legal or compliance professional, policy analyst, or advisor, this episode provides timely insights into where CMS is headed—and what these changes mean for strategy, operations, and risk in the year ahead.

In our Year in Review episode, hosts Elizabeth Lippincott and Sandy Durkin distill a turbulent 2025 into the developments that mattered most for Medicare Plans.
You’ll hear a clear breakdown of the year’s biggest compliance and enforcement stories—from DOJ’s kickback allegations against major MA players to CMS’s aggressive expansion of RADV audits, followed by a late‑year court decision that vacated CMS’s extrapolation rule on procedural grounds. We also cover regulatory highlights and the operational realities behind plan exits and non‑renewals, including run‑out obligations and audit exposure that linger long after a contract ends.
The episode closes with what leaders should do now: tighten documentation and vendor oversight, align risk adjustment with care management, and prepare for continued regulatory scrutiny—because stability comes from readiness, not predictability.

In this episode of Health Law Simplified, hosts Sandy and Elizabeth unpack a pivotal federal court ruling that vacates a key CMS rule governing RADV audits in Medicare Advantage. Learn why the court struck down CMS’s extrapolation methodology and elimination of the Fee-for-Service Adjuster, and what this means for MA plans, compliance teams, and future rulemaking. We explore the procedural missteps that led to the ruling, its alignment with broader judicial scrutiny of CMS, and the potential ripple effects across the industry. Plus, hear practical insights on how MA organizations can respond and prepare for what’s next.

This episode of Health Law Simplified explores the recent wave of insurer exits from the Medicare Advantage market, examining why major carriers are leaving and the financial, regulatory, and operational challenges involved. Sandy and Elizabeth discuss the strategic consequences of non-renewal, including CMS contracting bars, notification requirements, run-out responsibilities, audits, and legal risks, while offering practical advice for organizations considering an exit and highlighting the impact on employees, members, and the broader healthcare landscape.