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.
Medicare HI Trust Fund Solvency Assuming MA Utilization
The Hospital Insurance Trust Fund would remain solvent until 2048 if FFS utilization levels were similar to Medicare Advantage utilization levels.
ESRD Enrollment in MA Now Exceeds 30% of Dialysis Patients
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%.
CBO Considers Cost of Increasing Anti-Obesity Medication Use
Insurance coverage of anti-obesity medications is increasing, but patient access under Medicare remains uncertain.
Part D Premiums Increasing Despite Stabilization Program
While the premium stabilization program under the IRA limits the growth of the base beneficiary premium, individual plan premiums vary.
Part D Premium Increases, Market Disruption Expected in 2024
Over 8 million enrollees in standalone PDPs could see an increase of more than 25% in their premium in 2024.
Court Ruling Will Limit Accumulators
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.
SNF 3-Day Waiver Use During the COVID-19 Pandemic
Use of the 3-day waiver was stable over the course of the pandemic, though shifts in admission sources were observed.
Video: Unpacking the Implications of the Negotiated Drug List, Part 2
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.
Webinar: Part D Redesign’s Impact on Plan-Manufacturer Contracting
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 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.
How May the IRA Shift Part D Market Dynamics?
IRA policies and growing enrollment in Medicare Advantage could begin to destabilize the standalone PDP and LIS benchmark plan market.
Video: Navigating Major Policy Changes: Insights for Medicare Advantage Plans
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.
Webinar: Adapting to Change: Strategies for Pharma Service Providers, CROs, and R&D Partnerships in the Era of the IRA
Uncover how shifting dynamics around pharmaceutical research and development will influence and shape paths forward in drug development.
How Did Public Comments Shape Revised Negotiation Guidance?
Comments on initial negotiation guidance significantly shaped the revised guidance, underscoring the importance of stakeholder engagement in IRA implementation.
Video: Understanding the Medicaid Drug Rebate Program Proposed Rule
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.)
CMMI Releases EOM Participation and Lessons Learned from OCM
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.
Avalere Experts Respond to Revised CMS Negotiation Guidance
The revised guidance contains significant changes to the initial guidance released in March, but important outstanding questions remain.
Wastage Update: New JZ Claims Modifier Applies to NOC Billing
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.
How Do IRA Policies and Part D Risk Adjustment Interact?
The IRA will increase health plans’ financial risk, elevating the importance of Medicare Part D risk adjustment.
Video: Congressional Debate Over PBM Legislation
Avalere experts discuss Congress’ ongoing consideration of pharmacy benefit manager (PBM) legislation.