• California: Earlier this month, California Attorney General Rob Bonta (D) announced that state officials have charged 21 people as part of a multimillion-dollar scheme to use stolen identities to charge a government insurance program for hospital services. After being notified by the Department of Health Care Services about potential fraud, investigators found that individuals bought personal information from non-California residents from the dark web and enrolled them in Medi-Cal, the state's equivalent of Medicaid. These individuals then bought 14 hospice companies and began billing for hospital services using the stolen identities. In total, they billed around $267 million in fraudulent services. The individuals involved in the scheme have been charged with conspiracy to commit healthcare fraud, healthcare fraud, money laundering, and identity theft with aggravated white-collar crime and money laundering enhancements. "For years, California has led the charge to protect public programs from fraud and abuse," said Gov. Gavin Newsom (D). "We hold accountable to the fullest extent of the law anyone who tries to rip off taxpayers and take advantage of public programs, particularly those as sensitive as hospice care." (Ding, Associated Press, 4/9)
• Maryland: CMS will pause its BALANCE model for Medicare after failing to get enough payer participants. The BALANCE model, which was announced last year, was designed to expand coverage and access to GLP-1 medications for weight loss in Medicare and Medicaid. The model was expected to launch on Jan. 1, 2027, but it would only go in effect if at least 80% of Part D plan sponsors agreed to participate. The deadline for Part D plan sponsors to apply was April 20, and CMS reported that it did not meet the necessary threshold of sponsors and would indefinitely delay the pilot for Medicare. According to a CMS official, insurers were wary about joining the model since they could not predict how many people would use the drugs. Instead of having the BALANCE model for Medicare, CMS will now extend a separate program called the Medicare GLP-1 Bridge until the end of 2027 instead of using it to transition to BALANCE. "The continuation of the Medicare GLP-1 Bridge through 2027 will both provide Medicare beneficiaries access to GLP-1 drugs and enable collection of data that will allow plans to prepare for the potential implementation of BALANCE in Part D," CMS said. Currently, the BALANCE model has only been paused for Medicare, with the Medicaid portion of the pilot still moving forward. State Medicaid programs have until July 31 to apply. (Casolo, Becker's Hospital Review, 4/21; Wilkerson, STAT+ [subscription required], 4/21)
• New Jersey: Novartis has agreed to purchase biotech company Excellergy for up to $2 billion, allowing the company to expand its immunology pipeline with a new experimental treatment for allergic diseases. Excellergy's lead drug is Exl-111, which targets the IgE antibody involved in allergic reactions. It uses a different mechanism than currently available drugs and could help provide earlier symptom relief, stronger disease control, and more convenient dosing for food allergies, hives, allergic asthma, and more. In November, Excellergy reported that it had raised $70 million to advance its pipeline and presented data on the potential of its drug candidate at a scientific congress. According to the Wall Street Journal, this is the latest in a series of acquisitions from Novartis over the last few months, with the most recent being an agreement to buy a breast cancer drug candidate from Synnovation Therapeutics for up to $3 billion. (Calatayud, Wall Street Journal, 3/27)

A one‑stop guide to all 25+ CMMI models now shaping Medicare and Medicaid. See what’s active, what’s coming, and what just ended.