Federal & State 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 and state policies that affect insurance coverage, access, and consumer choice so you can see around the bend.
Featured Content
CMMI Program Savings Fall Below CBO’s 2016 Projections
CMMI’s impact on Medicare spending has so far not reached earlier projections by the Congressional Budget Office, demonstrating the difficulty in projecting savings from new and unknown alternative payment models.
Avalere Experts Discuss 2020 Regulatory Changes to the Insulin Market
On August 6, Avalere’s regulatory experts published an article in BioDrugs highlighting upcoming regulatory changes for insulin.
3.7M Part D Beneficiaries Are Projected to Reach the Catastrophic Phase in 2020
As policymakers consider reforms to Part D, new Avalere analysis shows that congressional proposals to cap out-of-pocket (OOP) costs in the catastrophic phase are likely to reduce OOP for many beneficiaries
States Explore Increasing Access to Telehealth as New Opportunity for Quality Care
States are increasingly seeking to improve access and health outcomes for their underserved, rural, or homebound populations, and many are turning to telehealth as a solution.
Impact of Proposed CMS Methodology for Calculating Payment Errors May Vary Based on Plan Enrollee Characteristics
In 2018, CMS proposed to revise its Risk Adjustment Data Validation (RADV) methodology to exclude the FFS Adjuster in its payment recoupment calculations. New analysis from Avalere finds that the payment impact associated with fee-for-service (FFS) Medicare coding discrepancies would be greater for certain subgroups of beneficiaries (e.g., dual-eligible, those with certain common and potentially serious health conditions) enrolled in the MA program.
The VA National Formulary for Top Medical Benefit Drugs Is Narrower than Current Medicare Part B Drug Coverage
Avalere analysis finds that 24 of the top 50 non-vaccine Part B drugs are not on the U.S. Department of Veterans Affairs’ National Formulary.
Fentanyl Supply Levels Declined in All States from 2014 to 2017 as Deaths from Overdoses Increased
New analysis from Avalere finds that the quantity of retail fentanyl sold across the US dropped by an average of 28%, between 2014 and 2017.
States Taking Action to Ensure Coverage Protection Should the ACA Be Overturned
While the majority of state legislative sessions have adjourned for 2019, at least 11 states (CT, FL, LA, IN, MD, ME, NH, NM, NV, VT, and WA) have enacted laws to create or study coverage protections against pre-existing condition exclusions and coverage of all essential health benefits (EHB) provided for in the Affordable Care Act (ACA).
1 in 5 Medicare Beneficiaries Taking a Part D Cancer Therapy Reached Catastrophic Level in 2017
Avalere analysis finds that a larger proportion of beneficiaries taking a Part D cancer therapy reached catastrophic compared to all Part D enrollees.
Methodology and Analysis of the Center for American Progress’s Medicare Extra Policy Proposal
The Center for American Progress (CAP) commissioned Avalere to evaluate ‘Medicare Extra’ as a package of reform polices implemented and phased in over time across the US healthcare system.
Capped Funding Policies Could Reduce Funding for Children Covered by Medicaid
New research from Avalere finds that capped funding policies could reduce federal funding to states, specifically for children, by $89B to $163B nationally for FY 2020–2029.
Strategic Opportunities for Health Plans: 2020 and Beyond
Health plans today have a range of strategic opportunities that align well with emerging policy themes for 2020.
Transitioning RA Drugs from Part B to Part D Would Increase Catastrophic Benefit Fills
New Avalere analysis finds that shifting Part B-covered rheumatoid arthritis (RA) drugs to Part D benefit would increase the share of prescriptions occurring in the catastrophic phase for impacted beneficiaries by more than 5 times.
Avalere Analysis Examines Drug Spending in Medicare Part D
As policymakers increasingly consider policy options to reform Medicare Part D and reduce program expenditures, an Avalere analysis examines spending across classes with various availability of brand and generic drugs.
The Administration Provides Employers and Employees with Enhanced Flexibility in Connection with Health Reimbursement Arrangements
Final rule by the Treasury Department, Department of Labor, and the Department of Health and Human Services reverses previous Treasury Department guidance blocking tax-advantaged HRAs that were not integrated with a comprehensive employer-sponsored plan.
Is Tiered Provider Reimbursement on the Horizon for Medicare Part B?
As policymakers explore opportunities to reform Medicare Part B, a tiered average sales price (ASP) add-on payment may be under consideration to align system incentives and curb spending.
Proposed Rebate Rule May Impact Commercial Coverage in Some States
While the Department of Health & Human Services (HHS) did not intend for proposed changes to Anti-Kickback Statute (AKS) regulations to impact commercial market drug negotiations, some state laws may indirectly lead to commercial market implications.
Medicare Advantage Plans Outperform Fee-For-Service Medicare in Caring for Dual-Eligible Beneficiaries with Chronic Conditions
Avalere experts will present “Comparing Utilization, Cost and Quality in Dual Eligible Medicare Advantage and Fee-For-Service Medicare Beneficiaries” at the International Society for Pharmacoeconomics and Outcomes Research meeting on May 21.
CMS Finalizes Modified Medicare Advantage and Part D Changes
On May 16, the Centers for Medicare & Medicaid Services (CMS) released its final rule, Modernizing Part D and Medicare Advantage to Lower Drug Prices and Reduce Out-of-Pocket Expenses.
CMS Grants Flexibility to Counter Drug Manufacturers’ Coupons
The Centers for Medicare & Medicaid Services released the final Notice of Benefit and Payment Parameters (NBPP) for the 2020 plan year. This annual rule, released today, updates guidance and regulations related to exchanges as well as the broader individual, small group, and large group insurance markets.