Insights & Analysis
There’s one constant in healthcare: change. Count on us to break down the trends so you can stay up to date. Follow our take on each piece of this deep, intertwined, and often perplexing industry to find opportunities and practical approaches to move healthcare forward.
Final NCD for VADs Largely Consistent With Draft Decision
On Oct. 30, CMS released a final decision memo on ventricular assist devices (VADs) used for bridge to transplant (BTT) and for destination therapy (DT).
Join Avalere experts Kathy Hughes and Richard Chapman at ISPOR Dublin This Week
Avalere experts to present at ISPOR Dublin's Poster and Workshop sessions.
CMS Publishes Final Program Integrity Rule
On Oct. 24, CMS released its final program integrity standards rule, detailing: advance payments of the premium tax credit (APTCs) and cost-sharing reductions (CSRs); the premium stabilization programs; issuers offering coverage in the Federally Facilitated Marketplace; and standards for enrollee satisfaction survey vendors.
HHS: Exchange Plans Not Federal Programs
On Oct. 30, HHS sent a letter to Rep. McDermott, R-Wash., indicating that it does not consider qualified health plans (QHPs) purchased through insurance exchanges to be federal healthcare programs.
CMS Releases 2014 Benefit Parameters for Medicare Parts A and B; Part B Premium and Deductible to Remain The Same
On Oct. 28, CMS released the calendar year (CY) 2014 benefit parameters for Medicare Parts A and B, which cover hospital inpatient and all outpatient drugs and services, and begins Jan. 1, 2014.
FDA’s Statement on Proposed Hydrocodone Reclassification
On October 24, Janet Woodcock, Director of the Center for Drug Evaluation and Research (CDER) at FDA, issued a statement indicating the Agency's intent to recommend reclassifying hydrocodone combination products from Schedule III to Schedule II products.
Current Exchange Applications Outpace Part D Enrollment Pattern
A new analysis from Avalere Health found that the number of applications submitted to date for exchange coverage exceeded comparable enrollment in Medicare Part D over the same time period during each program's launch.
Analysis: Number of Plans with High Star Ratings Will Increase in 2014
The share of Medicare Advantage (MA) plans with a star rating of 4 stars or higher in 2014 (43 percent) will increase substantially relative to 2013 (27 percent) according to a new Avalere Health analysis of the Centers for Medicare & Medicaid Services' (CMS) recently released data on 2014 plan quality performance.
CMS Plan Formulary and Cost-Sharing Information Reveals Continued Shift to Five-Tier Formularies
In early October, CMS released the Medicare Part D plan formulary and cost-sharing information for the 2014 benefit year.
Study by PBM Further Highlights Extensive Use of Copay Assistance Programs
Prime Therapeutics, America's largest privately held PBM, conducted a study examining member use of cost-sharing assistance programs across a variety of specialty drugs during the first half of 2013.
Infographic: A View of Broad-Based Efforts to Engage Patients
As regulators struggle to find answers to differing needs across the healthcare sector, patients are becoming a more integral part in shaping policy.
In 30 States, Plans Serving Medicaid Beneficiaries Also Offer Exchange Coverage, Improving Continuity of Care
Consumers in 30 states (60%) will have the option of at least one plan operating as both a qualified health plan (QHP) in the health insurance exchange and as a Medicaid managed care organization (MMCO), according to an Avalere analysis.
Exchanges off to a Slow Start; Medicaid Expansion Continues
Insurance exchanges were set to launch October 1, but technical glitches and enrollment delays have plagued most exchanges.
Avalere Reviewing New Medicare Advantage Plan Star Ratings on Medicare.gov
The Centers for Medicare and Medicaid Services (CMS) posted the star ratings for 2014 Medicare Advantage (MA) and Part D plans on the Medicare.gov website. Avalere Health is available to answer questions about this new information.
CMS Solicits Comments on Revised 2013 Gapfill Payments for MolDx Tests and Denies Payment for MAAA Codes
On September 30, CMS posted revised gapfill prices for molecular pathology Current Procedural Terminology (CPT®) codes, including calculations of the 2014 National Limit Amounts (NLAs).
Largest PBM Enhances Formulary Control with “Not Covered” List
Express Scripts Inc., the world's largest PBM for employers and health plans, recently released a list of 44 drugs that they will now exclude from coverage beginning January 1, 2014.
More Variable Molecular Diagnostic Rates Likely
As molecular diagnostics become more common in treating certain diseases - especially cancer - their reimbursement will be an important part of value messaging for many drug therapies.
In 26 States, Plans Serving Medicaid Beneficiaries Will Also Offer Exchange Coverage
Health insurance exchange marketplaces opened on October 1 for enrollment across the country, as well as premium subsidies for those with limited incomes.
Analysis on Health Plan Offerings on the Federally-Facilitated Marketplace
Avalere Health is carefully analyzing the landscape file of health plan offerings on the federally-facilitated marketplace recently released by the Department of Health and Human Services (HHS).
Despite Lower Than Expected Premiums, Exchange Consumers Will Face High Cost-Sharing Before the Out-of-Pocket Cap
Initial data suggest that exchange plans under the Affordable Care Act (ACA) will include high out-of-pocket costs for enrollees-including deductibles and cost-sharing for medical services and prescription drugs-before consumers reach their out-of-pocket maximum.