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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.

Nicole Meyerson

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.

Matt Kazan

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%.

Kate Sikora

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.

Marisa Aurora

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.

Michael Ciarametaro

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.

Blair Burnett

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.

Kylie Stengel

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.

Matt Kazan

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.

Gina Krupp

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.

Kelly Brantley

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.

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