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
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.
US Healthcare Spending Projected to Grow 5.5% Annually Through 2027
Healthcare spending is expected to represent 19.4% of US GDP in 2027.
FDA Reform: It’s Time to Act, But Not as an Independent Agency
As former federal officials, Dan Troy, David Beier, and I share our perspectives on the call by former FDA officials representing both political parties to make the FDA an independent agency separate from its parent, HHS.
CMS Methodology for Calculating Payment Errors May Result in Underpayments to Health Plans
In February 2012, the Centers for Medicare & Medicaid Services (CMS) announced a final payment error calculation methodology for its contract-level Risk-Adjustment Data Validation (RADV) audits of Medicare Advantage (MA) plans.
State-Run Reinsurance Programs Reduce ACA Premiums by 19.9% on Average
New analysis from Avalere finds that states with their own reinsurance programs reduce individual market premiums by 19.9% on average in their first year.
Top 4 Steps to Ensure Operational Readiness for RAPS to EDS Transition
As CMS continues to transition from the Risk Adjustment Processing System (RAPS) to the Encounter Data System (EDS) for Medicare Advantage (MA) risk score calculation, plans must evaluate operations and close gaps to minimize the impact of risk score differences using this claims data source.
Effect of Potential Policy Change to Part D Generic Tiering on Patient Cost Sharing and Part D Plan Costs
In a new analysis, Avalere examines the implications of CMS’ potential new requirement that Part D plans place generics only on generic tiers.
Medicare Reimbursement of Virtual Care Delivery and Remote Monitoring
Beginning in 2019, CMS will reimburse for 5 codes relating to virtual care delivery and remote monitoring
Uses and Limitations of Medicare Advantage Encounter Data
In a recent post on the Health Affairs Blog, we examine the potential uses and limitations of Medicare Advantage (MA) encounter data.
HHS Proposed Changes Could Reduce ACA Coverage and Increase Premiums
New analysis from Avalere finds that exchange plan sign-ups could decline by 1.1 million, while premiums could increase by 6.3%, by 2025 should HHS finalize recently proposed changes to auto-reenrollment in the exchange and the calculation of tax credit subsidies.
Avalere Welcomes Jason Altmire as Senior Advisor
Former U.S. Congressman Jason Altmire has joined Avalere Health as a senior advisor, offering his deep understanding of the policy-making process to inform business strategy.
CMS Highlights Potential Changes that Could Restrict Access to and Increase the Costs of Certain Brand Drugs to Obamacare Enrollees
The Centers for Medicare & Medicaid Services released the proposed Notice of Benefit and Payment Parameters (NBPP) for the 2020 plan year. The rule could limit exchange plan enrollees' access to certain brand name drugs and increase the out-of-pocket costs within plans.
Landscape for Diagnostics Will Continue to Change in 2019
While precision medicine is expected to revolutionize patient therapy, the increasing complexity of diagnostics is leading policymakers to revamp the way these tests are regulated and paid for.
Podcast: Key Takeaways on the Ruling Declaring the Affordable Care Act Unconstitutional
Listen to Avalere experts discuss the implications for a recent decision ruling the Affordable Care Act is Unconstitutional.
New HRA Rule Could Reshape Enrollment and Access in Individual and Employer Markets
A proposed rule released by the Treasury Department, Department of Labor, and Department of Health and Human Services would expand the allowed uses of employer-sponsored Health Reimbursement Arrangements (HRA). Comments on the rule can be submitted until December 28, 2018.
Free Exchange Plan Options Are Available in Most Counties for 2019
New analysis from Avalere finds that over 95% of counties with exchanges operated by HealthCare.gov have free plan options for low-income consumers.
Health Plans with More Restrictive Provider Networks Continue to Dominate the Exchange Market
Narrow network plans comprise nearly three-quarters of the exchange market.
Out-of-Pocket Costs for Oncology Drugs Vary Substantially Between Employer and Non-Employer Based Part D Plans
New Avalere analysis finds that beneficiaries enrolled in Employer Group Waiver Plans (EGWPs) have lower out-of-pocket (OOP) costs for select drugs than beneficiaries enrolled in other types of Part D plans.
