Health Law Simplified

In this episode of Health Law Simplified, Sandy Durkin and Elizabeth Lippincott shift gears from Medicare Advantage to take a practical look at Medicare Supplement insurance, also known as Medigap, and why it remains an important part of the Medicare coverage landscape.They walk through how Medigap plans became standardized, why the product is state regulated but shaped by federal minimum standards, and what that structure means for rate oversight, marketing review, and regulatory enforcement.A major focus of the discussion is guaranteed issue rights, including when people can purchase certain Medigap plans without medical underwriting and why those rules matter for Medicare Advantage enrollees who want to return to Original Medicare.Finally, Sandy and Elizabeth compare Medigap and Medicare Advantage from a consumer perspective, including the flexibility of a non-network model, the need to purchase standalone Part D coverage when pairing Original Medicare with Medigap, and the premium and cost considerations that drive many coverage decisions. They close with a forward looking discussion of why Medicare Supplement may continue to play a meaningful role in the Medicare market going forward, especially with higher income retirees.

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.

In this episode of Health Law Simplified, hosts Sandy Durkin and Elizabeth Lippincott welcome Charles Baker, Vice President of Compliance Solutions at ATTAC Consulting, for a deep dive into the evolving landscape of Medicare Advantage compliance. From the operational impact of RADV audits and the philosophical roots of risk adjustment to the implications of the No UPCODE Act and the future of in-home HRA assessments, Charles shares his unique perspective shaped by years in social work, academia, and health plan leadership. Tune in for a candid conversation on how managed care organizations can align regulatory demands with meaningful patient care.

In this episode of Health Law Simplified, we unpack a major shift in Medicare Advantage oversight: CMS’s sweeping expansion of its Risk Adjustment Data Validation (RADV) audit program. Beginning immediately, CMS will significantly expand its oversight by auditing all 550 eligible Medicare Advantage contracts each year – an ambitious leap from the previous annual review of just 60 plans. Hosts Sandy Durkin and Elizabeth Lippincott explore why CMS is cracking down, how it's scaling up with new technology and a 50-fold increase in medical coders, and what this means for health plans and providers. They break down the legal and financial implications of extrapolated audit findings, including the risk of large recoupments, and talk about their expectations for the extrapolation methodology for targeted audits.  This episode offers critical insights and practical steps to prepare for one of the most consequential oversight changes Medicare Advantage plans have seen.

This episode of Health Law Simplified unpacks the U.S. Department of Justice’s False Claims Act lawsuit against major Medicare Advantage insurers and brokerages. The DOJ alleges illegal kickbacks and discriminatory practices targeting disabled beneficiaries. The episode also explores CMS’s 2025 Final Rule on broker compensation, its legal challenges, and the broader implications for compliance, marketing ethics, and regulatory enforcement in the Medicare Advantage space.

In this episode, Elizabeth and Sandy delve into the latest updates in the Medicare Advantage and Part D landscape. Our word of the year, "stability," sets the tone as we explore the implications of the CMS final rule for 2026, which finalizes several Biden-era proposals. We discuss the key changes in the rule, including new guardrails for supplemental benefits and the Medicare Prescription Payment Plan, and highlight what was notably left out of the rule. Additionally, we cover the CMS rate announcement and the rebranding of the health equity incentive program to "Excellent Health Outcomes for All (EHO4all)," set to be implemented for the 2027 Star Ratings. Lastly, we examine the recent developments in the risk adjustment litigation against UnitedHealth Group, focusing on the special master's report and its potential impact on MA plans.

We talk with Molly Turco, who served as Senior Policy Advisor on Medicare Advantage (MA) and Medicare Part D at the Center for Medicare at the Centers for Medicare & Medicaid Services until leaving the agency in January. Molly unpacks updates in MA policy and reimbursement, including the v28 risk adjustment model and prior authorization. 

Join us as we walk through the 2022 Inflation Reduction Act’s changes to Medicare Part D and Medicare Advantage. Learn about how those changes are impacting the senior health plan market today.

We talk about how health care leaders can make peace with uncertainty as we move into 2025 and a new administration. What are the hot button issues for health plans and others in this dynamic time? What can we anticipate in the market for Medicare plans in particular?

Health Law Simplified℠ breaks down the latest legal developments, challenges, and regulatory impacts in managed care—giving business leaders the insights they need to stay ahead. Join attorneys Elizabeth Lippincott, Sandra Durkin, and Katarina Weessies each month for practical, engaging conversations about the ever-evolving world of health law.