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.
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.
Nearly 80% of Uninsured Population in Super Tuesday States Are Eligible for Assistance
New Avalere analysis finds that 76% of uninsured individuals lawfully present in the 14 Super Tuesday states are currently eligible for Medicaid, the Children’s Health Insurance Program (CHIP), or exchange plan subsidies.
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.
Webinar: What’s Next for Medicaid Drug Pricing?
View the webinar recording to learn more about the latest policy, pricing, and reimbursement challenges in Medicaid.
States Choosing Healthy Adult Opportunity Program Will Need to Generate Savings to Stay Below Capped Funding Levels
New analysis from Avalere finds that states currently covering non-mandatory adult populations who choose to participate in the Healthy Adult Opportunity (HAO) initiative may need to generate up to 8% in Medicaid savings to keep spending below new capped funding levels.
2020 Election: Healthcare Coverage Landscape Varies in Early Primary States
As the early presidential primaries unfold, healthcare remains a top issue among voters. As recently as the November Democratic primary debate, polls showed that 24% of Democrats or Democratic-leaning independents said healthcare was the number one issue they wanted to hear discussed, ahead of the environment (12%), immigration (6%), jobs and the economy (5%), education (4%), and gun control (4%).
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.
CMS’s Healthy Adult Opportunity Program Includes Significant Changes to Medicaid Drug Benefit
The Centers for Medicare & Medicaid Services (CMS) announced the Healthy Adult Opportunity, a new Section 1115 demonstration initiative allowing states to shift toward capped Medicaid financing models with an opportunity for shared savings. If the option is chosen by states, it could be the largest change to Medicaid since the ACA.
Avalere Statement on CMS’s Healthy Adult Opportunity Program
CMS’s Healthy Adult Opportunity program, a new Section 1115 demonstration initiative, will allow state Medicaid programs to move toward capped financing models for some non-disabled adult beneficiaries with an opportunity for shared savings and additional flexibilities.
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
CMS RADV White Paper Outlines Potentially Significant Program Changes
CMS is considering changes to its commercial market Risk Adjustment Data Validation (RADV) program to improve the accuracy of risk adjustment transfers and to increase stability and predictability for issuers. This follows issuer experiences with the 2017 RADV process in which some issuers saw substantial, unforeseen changes to their risk adjustment transfers. These RADV changes have the potential to impact issuer participation and premiums in future years depending on the direction (positive or negative) and magnitude of those transfers.