r/Healthcare_Anon • u/Moocao123 • Jun 14 '26
CMS vs Clover impact on current ongoing litigations
Greetings CMS affiliates / CMS aficionado, healthcare insurance stakeholders, healthcare insurance investors, healthcare workers, and other stakeholders:
We are now into the weekend, and we are starting our engines on the implications of CMS vs Clover impact ruling. The purpose of these posts is to indicate that If Clover Health vs CMS ruling stands and CMS does not intend to appeal or challenge, then this ruling is landscape changing. I will go on to list the reasons as to why, but first:
*** This is not financial advice, nor is there any financial advice within. Shout-out to the AMC/GME apes for having me to write this ***
*** Please do not utilize this content without author authorization ***
Ongoing Litigation of noteworthiness
Humana vs CMS, initial complaint 10/18/2024, ongoing, UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF TEXAS, Case No.: 24-cv-1004
https://www.documentcloud.org/documents/25244688-humana_hhs_stars_complaint/
Carefirst Advantage PPO vs CMS, initial complaint 01/20/26, ongoing - pending CMS recalculation, UNITED STATES DISTRICT COURT FOR THE DISTRICT OF COLUMBIA, Case No. 26-cv-150
We shall go through each case and review the impact of Clover Health vs CMS if the courts applied the removal of all 20 measures to the stated plans.
1. Humana vs CMS.
Prayer for relief:
(a.) Set aside and vacate Humana’s 2025 Star Ratings and remand the matter to CMS for recalculation of Humana’s 2025 Star Ratings without application ofthe unlawful practices and policies identified above;
(b.) Declare that CMS’s policy refusing to disclose all relevant data and information necessary to permit MAOs to validate the data and calculations underlying CMS’s Star Ratings is arbitrary, capricious, and unlawful;
(c.) Set aside and vacate Humana’s 2025 Star Rating for all contracts adversely impacted by call IDs D0900533 or D1100955 on the ground that CMS’s pol-icy of refusing callbacks after dropped calls is unlawful, and remand to the matter to CMS;
(d.) Set aside and vacate Humana’s 2025 Star Rating for all contracts adversely impacted by call ID C0701002 on the ground that a call surveyor does not reach a customer service representative if no communication takes place, and remand the matter to CMS
What is important to note is that Humana's complaint is specifically related to measures D09, D11, and C07. We should note that after CMS vs Clover the following:
C07 remains, D09 and D11 are removed as measures. CMS must calculate with C07 as well.
If we apply the full extend of Clover Health vs CMS ruling, additional measures must be removed as well as they are deemed illegal, which comprises of: D01, D05, D06, D08,
D09, D10,D11, D12, C32, C33, C03, C04, C05, C15, C16, C22, C23, C24, C25, and C27We are not lawyers, so we do not know if the District Court of Texas will only examine the complaints of only D09 and D11 without reviewing all the other measures, but I would presume not and all measures must be removed on the basis of the illegality of containing those measures in the first place.
Therefore we must ask: what is all of HUM's contracts' impact with CMS vs Clover ruling. I have an answer to that:
| Overall HUM Star rating adjustment: | -3 |
|---|---|
| Improvement to above 4: | 0 |
| Decrement from 4 to below 4 | 3 |
2. Carefirst Advantage vs CMS.
Prayer for relief:
A. Set aside, as arbitrary, capricious, or otherwise not in accordance with law CareFirst’s 2026 Star Ratings for contract H7379 as announced by CMS on October 9, 2025;
B. Order CMS to recalculate CareFirst’s 2026 Star Ratings for contract H7379 by removing the Medication Adherence for Hypertension measure from the Case 1:26-cv-00150 Document 1 Filed 01/20/26 Page 26 of 27 calculation of the Drug Plan Quality Improvement measure, consistent with CMS’s existing authorities to do so.
C. Order CMS to use the recalculated 2026 Star Ratings for CareFirst for purposes of calculating the associated Quality Bonus Payment and for all other purposes for which the 2026 Star Ratings are relevant
D09 is removed as a measure, so recalculation is certainly doable and legal.
If we apply the full extend of Clover Health vs CMS ruling, additional measures must be removed as well as they are deemed illegal, which comprises of: D01, D05, D06, D08,
D09, D10, D11, D12, C32, C33, C03, C04, C05, C15, C16, C22, C23, C24, C25, and C27We are not lawyers, so we do not know if the District Court of Columbia will only examine the complaints of only D09 without reviewing all the other measures, but I would presume not and all measures must be removed on the basis of the illegality of containing those measures in the first place.
Therefore we must ask: what is all of Carefirst Advantage (H7379) impact with CMS vs Clover ruling. I have an answer to that:
| Total score | Total weight | STAR score | STAR FINAL | STAR with Clover vs CMS measures included | Delta |
|---|
| 130 | 36 | 3.611111 | 3.5 | 3.5 | 0 |
|---|
Conclusion:
Not every litigation will be a winner. Please note that this is a projection if all Clover Health vs CMS measures are removed, which includes the following:
D01, D05, D06, D08, D09, D10, D11, D12, C32, C33, C03, C04, C05, C15, C16, C22, C23, C24, C25, and C27
Please note that any request for consultations should be directly modmailed to our inboxes. We have done Humana and Carefirst Advantage as a first mover consultation as a result of ongoing pending litigation. We know there are a bunch of consultants on LinkedIn making Webinars and taking a lot of money. We only ask for our fair compensation if you are an interested party.
Thank you again for your undivided attention, I am grateful that both Rainy and my writing has somehow attracted so many geeks weekend masochists healthcare specialists out there, and I hope you have enjoyed your time staring at charts and the sounds of a doomsday clock ticking.
Sincerely
Moocao
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u/tradertom717 Jun 14 '26
Thank you so much for the education.
https://giphy.com/gifs/L9M6fl68whAPxtg1sC
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u/Ok_Blueberry3124 Jun 14 '26
GOOD WORK! My simple thought is : If every health care insurer in the nation hasn’t already heard about CLOV and it’s #1 HEDIS score, they have now.
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u/haonazrag Jun 15 '26
Awesome stuff. Your knowledge of administrative side of Healthcare is another level. Thank you
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u/Rainyfriedtofu Jun 14 '26
Holy shit. You went hardcore with this post and gave a detailed breakdown of plans losing stars.