Federal and State Policy
As the largest US healthcare payer, the federal government plays a dominant role in shaping the healthcare marketplace, while states take center stage when it comes to developing novel policy approaches. Our experts track, interpret, and model policies that affect insurance coverage, access, and consumer choice so you can see around the bend.
The Hospital Insurance Trust Fund would remain solvent until 2048 if FFS utilization levels were similar to Medicare Advantage utilization levels.
New analysis finds that just over 40,000 Medicare Fee-for-Service (FFS) patients with end-stage renal disease (ESRD) elected to enroll in Medicare Advantage (MA) during the 2021 open enrollment period—the first time all ESRD patients had access to an MA plan. This enrollment shift increased the proportion of ESRD patients enrolled in MA from 23% to 30%.
Insurance coverage of anti-obesity medications is increasing, but patient access under Medicare remains uncertain.
While the premium stabilization program under the IRA limits the growth of the base beneficiary premium, individual plan premiums vary.
Over 8 million enrollees in standalone PDPs could see an increase of more than 25% in their premium in 2024.
A district court’s decision to strike down the 2021 NBPP is the latest policy update on the use of copay adjustment programs, but questions persist.
Use of the 3-day waiver was stable over the course of the pandemic, though shifts in admission sources were observed.
In Part 2 of our video series on the negotiated drug list, Avalere experts discuss topics including effectiveness measures that will inform CMS’s maximum fair price determinations, evidence generation strategies for manufacturers with products that have been selected for negotiation, or that are eligible for selection in the future, and CMS’s definition of therapeutic alternatives.
Avalere experts discussed how IRA’s Part D redesign may affect plan behavior in Plan Year 2025 and how manufacturers should approach contracting and market access.
Physician reimbursement for some services under Medicare FFS has declined, while payment increased for the same services in the hospital outpatient setting.
IRA policies and growing enrollment in Medicare Advantage could begin to destabilize the standalone PDP and LIS benchmark plan market.
Avalere experts explore how key policy changes, such as the Risk Adjustment Data Validation final rule, Inflation Reduction Act, and Medicare Advantage payment shifts, are shaping the landscape for health plans.
Uncover how shifting dynamics around pharmaceutical research and development will influence and shape paths forward in drug development.
Comments on initial negotiation guidance significantly shaped the revised guidance, underscoring the importance of stakeholder engagement in IRA implementation.
Avalere's policy experts discuss the key provisions and potential impacts of the recent CMS proposed rule related to the Medicaid drug rebate program (MDRP.)
The CMMI’s EOM began on July 1 with 44 participants. A recent OCM evaluation report described net losses to CMS and lessons that can be applied to EOM.
The revised guidance contains significant changes to the initial guidance released in March, but important outstanding questions remain.
Starting July 1, providers must report the JZ modifier on all claims for single-use Part B drugs when applicable, including for products billed with an NOC code.
The IRA will increase health plans’ financial risk, elevating the importance of Medicare Part D risk adjustment.
Avalere experts discuss Congress’ ongoing consideration of pharmacy benefit manager (PBM) legislation.