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.
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.
On August 6, Avalere’s regulatory experts published an article in BioDrugs highlighting upcoming regulatory changes for insulin.
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 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.
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.
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.
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.
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).
Avalere analysis finds that a larger proportion of beneficiaries taking a Part D cancer therapy reached catastrophic compared to all Part D enrollees.
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.
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.
Health plans today have a range of strategic opportunities that align well with emerging policy themes for 2020.
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.
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.
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.
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.
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.
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.
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.
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.