The Regulator

The federal government is canceling coverage for more than 760,000 Affordable Care Act marketplace enrollees this week and says the move will return $2.2 billion in taxpayer-funded subsidies, the government’s largest marketplace fraud action to date. The Centers for Medicare and Medicaid Services (CMS) announced September 22, 2026 that it canceled roughly 315,000 enrollments confirmed as unauthorized, recovering an estimated $2.2 billion in advance payments of the premium tax credit that had been flowing to insurers on those enrollees’ behalf. The agency paired the cancellations with a new Interim Final Rule imposing a temporary moratorium on new agent and broker registrations for the 2027 plan year for anyone without an active 2026 Exchange Agreement, on top of more than 200 broker terminations since January and 569 notices of intent to terminate issued this summer to agents who submitted applications missing Social Security numbers. Existing brokers must now verify their identity through Login.gov or ID.me, and consumers must give electronic authorization before a broker can act on their marketplace application. Confidence: High. This run reviewed CMS’s own press release and fact sheet directly. Sources: CMS Cracks Down on Fraud, Waste, and Abuse in the Federal Health Insurance Marketplace, Centers for Medicare and Medicaid Services, Federal Marketplace (FFE and SBE-FP) Anti-Fraud Actions, Centers for Medicare and Medicaid Services.

Medicare will start paying laboratories what private insurers pay for the same blood and diagnostic tests starting next year, a change CMS says will save taxpayers roughly $1 billion annually. CMS announced preliminary Calendar Year 2027 Clinical Laboratory Fee Schedule rates September 21, 2026, after finding Medicare currently pays about 16 percent more than private insurers for identical lab tests; the new methodology, authorized by the Consolidated Appropriations Act, 2026, requires CMS to collect updated private-payor rate data every three years instead of roughly once since 2014. Rate reductions are capped at 15 percent per test per year through 2029 to phase in the change gradually, and CMS opened a 30-day public comment period September 21 with final 2027 rates expected in November and the new rates taking effect January 1, 2027. Confidence: High. This run reviewed CMS’s own press release and fact sheet directly. Sources: CMS Announces New Preliminary Medicare Payment Rates for Laboratory Services, Saving Taxpayers an Estimated $1 Billion Annually, Centers for Medicare and Medicaid Services, Preliminary Calendar Year (CY) 2027 Medicare Clinical Laboratory Fee Schedule Payment Rates, Centers for Medicare and Medicaid Services.

A durable medical equipment supplier agreed to pay $825,000 this week after a whistleblower said it billed Medicare for knee and back braces patients never properly qualified for. The Department of Justice (DOJ) announced September 21, 2026 that Crown Medical Solutions LLC and its owners, Michelle and Philanzo King, settled False Claims Act allegations that the company billed Medicare for durable medical equipment, including knee braces, heel stabilizers and back braces, that was not medically necessary or lacked a valid physician prescription, between November 1, 2017 and April 30, 2019. The settlement resolves a qui tam lawsuit filed by former employee Karen Martinelli, who will receive roughly $123,750 of the recovery for bringing the alleged fraud to the government’s attention. Confidence: High. This run reviewed DOJ’s own press release directly. Sources: Crown Medical Solutions and Its Owners to Pay $825,000 For Fraudulent Billing Scheme, U.S. Department of Justice.

A federal judge hears arguments today on whether the government can strip HIV treatment funding from clinics that refuse to drop gender-affirming care from their programs, a fight over money that reaches more than half of the roughly 1.2 million Americans living with HIV. The American Academy of HIV Medicine, the HIV Medicine Association and other provider groups, represented by Lambda Legal, sued the Health Resources and Services Administration (HRSA) and the Department of Health and Human Services (HHS) in June 2026 over new Ryan White HIV/AIDS Program funding conditions, issued in March and June, that bar grantees from spending program dollars on gender-affirming medical care and restrict how clinics may acknowledge patients’ gender identity. The government’s motion to dismiss the case is scheduled for a hearing today, September 23, 2026, before Judge William G. Young in the U.S. District Court for the District of Massachusetts. Confidence: Medium-High. This run reviewed the case’s docket activity via the Georgetown Health Care Litigation Tracker and the plaintiffs’ own case page directly; the arguments made at today’s hearing itself were not independently observed this run. Sources: American Academy of HIV Medicine et al. v. Health Resources and Services Administration et al., Georgetown Health Care Litigation Tracker, The American Academy of HIV Medicine et al. v. U.S. Department of Health and Human Services et al., Lambda Legal.

Oregon’s Medicaid program made up to $4.1 million in erroneous payments because the state never caught nearly 650 duplicate enrollee ID numbers, according to a state audit that lands as the program faces a $421 million budget shortfall. The Oregon Secretary of State’s Office found the state’s benefit eligibility system contained roughly 650 duplicate identification codes among more than 2 million enrollee IDs reviewed, each duplicate capable of triggering a second monthly payment to a coordinated care organization for the same Medicaid recipient; auditors tested 56 of those pairs directly and confirmed $230,252 in overpayments, then projected the total could reach $4.1 million across the full set. The Oregon Health Authority, which is separately grappling with a projected $421 million Medicaid budget deficit tied to federal funding limits, accepted all of the audit’s recommendations, including returning the erroneous payments to the federal government and building a quality-control process, with a two-year implementation timeline. Confidence: Medium-High. This run relied on Oregon Public Broadcasting and KOIN reporting that reviewed the Secretary of State’s audit directly; the audit document itself could not be independently retrieved this run. Sources: Oregon Medicaid program erroneously paid up to $4.1M due to system errors, audit says, Oregon Public Broadcasting, State audit finds Oregon Medicaid overpayments could reach $4.1 million, KOIN.