Federal Policy
As the largest, single US healthcare payer, the government plays a dominant role in shaping the healthcare marketplace. Our experts track, interpret, and model federal policies that affect insurance coverage, access, and consumer choice so you can see around the bend.
Featured Content
Select Part D Plans Have Higher PMPM Spending for LIS in Most Protected Classes
As plans continue to assess the proposed changes to their liability in the Medicare Part D benefit, understanding variations in spending by enrollee can help elucidate how policy changes might affect their spending. This Avalere analysis examines a subset of MA-PD and PDP plans with at least 75% of their enrollment comprising those with LIS. This analysis aims to quantify spending on drugs within the 6 protected classes for low-income subsidy (LIS) and non-LIS beneficiaries in this subset of PDP and MA-PD plans.
What the Rollover from Drugs to Biologics Means
On Monday, March 23, over 90 products that had historically been regulated as drugs were deemed to be licensed as a biologic. This includes insulin products. During the past several years, the Food & Drug Administration (FDA) has released guidance about their interpretation of the provision to guide sponsors and provide information about what to expect for the transition.
States Act to Ensure Coverage Protections in Advance of ACA Decision
The majority of 2020 state legislative sessions are either approaching crossover deadlines or adjournment. In 2019 and 2020, at least 15 states (CT, DE, FL, HI, IN, LA, MD, ME, NH, NJ, NM, NV, OR, VT, and WA) have enacted laws to create or study coverage protections against pre-existing condition exclusions or coverage of all essential health benefits (EHB) provided for in the Affordable Care Act (ACA).
SCOTUS Decision to Review ACA Case Could Undermine Coverage and Access
On March 2, the Supreme Court (SCOTUS) announced that it will review an appeal of the 5th Circuit Court of Appeal’s decision in Texas v. Azar regarding the legality of the Affordable Care Act’s (ACA’s) individual mandate and other provisions.
Over 1 Million MA Enrollees Are in Plans Offering New Benefits for the Chronically Ill in 2020
Medicare Advantage (MA) plans are using new flexibilities to provide additional supplemental benefits to beneficiaries with chronic illnesses.
Variations in Part D OOP Costs for Insulin Across the Year
Avalere analysis finds that average beneficiary out-of-pocket (OOP) spending for 3 commonly used insulin products remains similar throughout the year, ranging from $95 in December to $136 in June and July.
ESRD Patients Set to Enroll in MA in 2021 Differ in Key Demographics
Avalere analysis finds differences in the demographics of patients with End Stage Renal Disease (ESRD) enrolled in Medicare Advantage (MA) compared to ESRD patients in Fee-for-Service (FFS) Medicare
MS Patients Face High OOP Costs for Prescription Medicines
Avalere analysis finds that out-of-pocket (OOP) spending on prescription drugs for beneficiaries with multiple sclerosis (MS) could be as high as one third of their income.
CMS Proposed Changes to MA D-SNP Look-Alikes May Especially Impact Duals in CA MA Plans
Avalere analysis finds that many CA beneficiaries enrolled in D-SNP look-alike plans may not be able to a transition to a D-SNP.
Recent Federal Rule Could Undermine Some Patient Support Programs
The Center for Medicare & Medicaid Services (CMS) recently issued its proposed Notice of Benefit and Payment Parameters (NBPP) for the 2021 plan year. The proposed rule would significantly expand commercial payer flexibility to not count manufacturer copay support toward deductibles or out-of-pocket (OOP) maximums.
OOP Costs for MS Drugs Are Substantially Higher for Non-Employer-Based Part D Plans
Employer Group Waiver Plans (EGWPs) have lower out-of-pocket (OOP) costs for multiple sclerosis (MS) drugs than beneficiaries enrolled in other types of Part D plans.
CMS Proposal May Increase Obstacles for State-Mandated Benefits
In the Notice of Benefit and Payment Parameters (NBPP) for the 2021 plan year, CMS questioned whether states were appropriately deciding if the state was required to defray the premium impacts of new benefit mandates added since 2011. CMS proposes requiring states to report on and justify defrayal decisions for all state benefit mandates.
Patient Costs Among Medicare Part D Users of Mental Health Drugs
According to a new analysis from Avalere, Medicare Part D beneficiaries who are taking mental health drugs and do not receive low-income cost-sharing support are responsible for a higher share of the cost of mental health drugs (46%) than for non-mental health drugs (23%).
5 High Impact Areas in the MA Advance Notice & Proposed Rule
This month, the Centers for Medicare & Medicaid Services (CMS) proposed changes to Medicare Advantage (MA) through the annual Advance Rate Notice and Proposed Rule. These proposals impact MA in many ways, including changes to quality bonus payments, network adequacy requirements, coverage of End Stage Renal Disease (ESRD), plans targeting dual eligibles, and supplemental benefit offerings. Stakeholders should examine each of these areas closely as they respond to CMS.
CMS Proposes Allowing Part D Plans to Implement a New Preferred Specialty Tier
Implementation of a preferred specialty tier could have various impacts on Part D plans’ formulary and benefit designs and could affect manufacturer contracting strategies.
For the First Time, a Majority of Generic Drugs Are on Non-Generic Tiers in Part D
According to a new analysis from Avalere, Medicare Part D plans place generic prescription drugs on non-generic tiers 53% of the time in 2020.
What to Watch for in this Week’s Call Letter and Proposed MA-PD Rule
CMS is set to release its annual proposed changes to Medicare Advantage (MA) this week. Some of the topics that may be addressed include End-Stage Renal Disease (ESRD), network adequacy requirements, payment to MA plans that offer the hospice benefit, and the MA quality bonus program.
Variation in Generic Substitution Rates Among Part D Plans
New analysis from Avalere finds 52% of Part D plans achieve generic substitution1 rates above 75%.
Device Regulation Modernization Efforts Continue to Accelerate
The Food and Drug Administration’s (FDA) efforts to modernize medical device oversight in the agency’s Center for Devices and Radiological Health (CDRH) have continued with the release of multiple draft and final guidances in 2019, as well as a plan for additional releases in 2020.
CMMI’s Financial Impact on Medicare Spending Challenging to Project (Updated)
CMMI’s impact on Medicare spending has not reached earlier projections by the Congressional Budget Office (CBO), demonstrating the difficulty in projecting savings from untested and future unknown alternative payment models