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
Expanding LIS Subsidies Could Save Part D Beneficiaries Money
Avalere assessed the impacts of select policies to expand low-income subsidy (LIS) eligibility under Medicare Part D
Majority of API in US-Consumed Medicines is Produced in the US
New analysis of trade data finds that 54% of API, in dollars, used in domestically consumed medicines came from the US in 2019.
Proposed Medicaid Line Extension Definition Alters Rebate Calculation
The CMS proposes to define line extension under the MDRP to broadly include any product that has at least one ingredient in common with the original drug, even if it is a different dosage form. If finalized, this change would have significant implications on classification and rebate liability for a wide set of current and future products.
Comparison of Dually and Non-Dually Eligible Patients with ESRD
Dually eligible beneficiaries in Pennsylvania with end-stage renal disease (ESRD) are more often people of color and have higher costs compared to non-duals, but their utilization patterns are similar.
Melissa Morley Joins Avalere Health
She deepens the firm’s post-acute and policy analytics capabilities, bringing nearly 15 years' worth of policy analytics experience to Avalere with a specific focus on the provider sector.
Medicare FFS Risk Scores Vary Based on Eligibility and Entitlement
An analysis of CMS’s Hierarchical Condition Category (HCC) model shows that fully dual-eligible beneficiaries have the highest risk scores.
Medicaid VBP Rule May Facilitate Drug Contracts, But Questions Remain
CMS proposes to alleviate drug price reporting barriers that have hindered the adoption of innovative contracting models for prescription drugs. Stakeholders should contemplate the details and implications of CMS’ proposals—including how the changes would impact current contracting—as well as remaining areas of ambiguity.
Will Your Organization Be Ready for the MA-ESRD Coverage Expansion?
With the release of the 2021 Medicare Advantage (MA) and Part D Final Rule, the details of the upcoming policy change that allows beneficiaries with end-stage renal disease (ESRD) to enroll in MA are set. Stakeholders need to adapt quickly to be prepared.
Impact of H.R.3 as Passed by the House on Federal Spending and Drug Manufacturer Revenues
Scenario analysis of varying levels of negotiation under H.R.3 (as passed in the House on December 12, 2019) finds that the bill could reduce federal spending by $850B to $1,060B and decrease manufacturer revenues by $1,275B to $1,655B for CY 2020–2029.
Prostate Cancer Patients in Employer Part D Plans Stay in the Coverage Gap Longer Than Those in Non-Employer Part D Plans
New Avalere analysis finds that Medicare Part D patients taking brand prostate cancer drugs enrolled in Employer Group Waiver Plans (EGWPs) have more prescriptions in the coverage gap than patients in non-employer plans.
Impact of Protected Class Utilization Management in Medicare Part D
Health plans, including Medicare prescription drug plans, commonly apply utilization management (UM) tools to manage spending on prescription drugs.
Utilization and Spending by Medicare Beneficiaries in Employer Part D
An Avalere analysis finds that, on average, non-LIS Medicare beneficiaries in Employer Group Waiver Plans (EGWPs) have higher utilization but lower out-of-pocket (OOP) costs than non-EGWP enrollees.
Cannabidiol: A Regulatory Snapshot
The US market has seen a recent surge in cannabidiol (CBD) use and sales, despite many of these marketed CBD products being unregulated and untested for most of the claimed indications.
State Medicaid Waivers for SUDs Present Opportunities for Stakeholder Engagement
1115 Waivers approved by CMS allow state Medicaid programs to better address substance use disorders among beneficiaries.
Patients with Undermanaged RA Have Higher Medicare Costs than Other RA Patients
Avalere analysis finds that Medicare fee-for-service (FFS) patients with an RA diagnosis and conditions associated with undermanaged disease have 121% higher medical costs than other RA patients. Part D costs were 30% higher for those with undermanaged disease than for other RA patients.
Medicare Spending on Treatments for Ophthalmic Conditions
Avalere analysis finds that new users account for a large share of Medicare spending on opthalmic medications.
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.
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.