Coverage and Payment

Coverage and reimbursement shapes patient access and affordability. Life sciences companies rely on favorable coverage decisions to ensure market access and adoption of their products, while health plans need effective reimbursement strategies to manage costs and provide comprehensive benefits to their members.

Mark Gooding

Innovation Spurs Growth in Medicare NTAP

Recent growth in the NTAP designation alters dynamics for manufacturers considering pursuing the designation for new technologies.

Emily Belowich

2024: An Era of Innovation and Disruption in Kidney Care

A dynamic regulatory landscape, technological advancements, and investments in R&D offer new opportunities and challenges in kidney care.

Pranathi Sana

CMS Creates New Codes to Reimburse for Navigation Services

Newly developed HCPCS codes will support increased access to oncology navigation services, which have been shown to improve patient outcomes.

Eric Levine

Trends in Risk Adjustment Coding Operations

Plans adapt to market changes in risk adjustment coding. Interviews with plan professionals reveal three trends for efficiency, effectiveness, and compliance.

Jessica Cortez

Charting Change: CPT Coding and Remote Monitoring

The AMA’s upcoming CPT Editorial Panel meeting on coding and billing for remote monitoring will shape the future of digital health technology.

Jack Fagan

How the Transitional Drug Add-On Payment Adjustment Works

The TDAPA supports payment and patient access to new therapies introduced to the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS). CMS has continued to refine the payment designation through rulemaking. Stakeholders should continue to monitor this payment-adjustment policy, as it has evolved since its introduction and may continue to change in future rulemaking cycles.

Physician Payment for Some Services Lags Behind Inflation

Physician reimbursement for some services under Medicare FFS has declined, while payment increased for the same services in the hospital outpatient setting.

Mark Gooding

How a New Technology Add-On Payment (NTAP) Works

Additional Medicare payment in the inpatient setting may be available to certain qualifying new technologies, but requires successful navigation of application processes.

Brigit Kyei-Baffour

Coding, Billing, and Reimbursement Barriers to Obesity Care

Assessing barriers that impact patient access to obesity care and educating stakeholders on how to mitigate them can advance solutions toward improving care.

Kolton Gustafson

340B Reimbursement Proposal Could Reduce Payments for 80% of Hospitals

To assess how changes in OPPS payment for reimbursement of drugs under the 340B program would affect hospital reimbursement and Medicare Part B beneficiary cost sharing, Avalere estimated the impact of increasing reimbursement for 340B drugs in Medicare Part B to ASP + 6%. The analysis finds that most hospitals would see overall payment decreases, while payments would be subject to higher cost sharing.

Megan West

Final CMS Alzheimer’s Coverage Memo Will Impact Access Beyond Medicare

The final CMS NCD for amyloid beta-targeting monoclonal antibodies for Alzheimer’s Disease establishes a dual pathway to Medicare coverage based on FDA approval and likely creates access and operational challenges for stakeholders.

Milena Sullivan

Medicare Draft Coverage for Alzheimer’s Drugs May Challenge Access

Thirty-one percent of rural Medicare fee-for-service beneficiaries with early-onset Alzheimer’s disease or a mild cognitive impairment diagnosis do not have access to a hospital outpatient department in their county, and fewer than 1% live near an Alzheimer’s disease research center.

Video: The Coverage Gap and Medicaid Expansion

Tune into another episode of Avalere Health Essential Voice. In this segment, our experts discuss the forthcoming debate around the coverage gap in non-Medicaid expansion states, potential policy options, and the impact on key stakeholders.

PACHA Highlights Need to Address HIV PrEP Coverage Disparities

On March 8–9, the Presidential Advisory Council on HIV/AIDS (PACHA) discussed avenues to achieving equitable access to HIV prevention products for at-risk populations as well as next steps in revising the National Strategic Plan to End the HIV Epidemic.

SCOTUS Ruling on ACA Could Impact Coverage and Policy Outlook

With the US Supreme Court set to hear arguments starting November 10 on California v. Texas, and Judge Amy Coney Barrett’s nomination under consideration in the Senate, questions remain regarding the future of the law.

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