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
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
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.
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.
Note on Avalere’s Recent Biosimilars Policy Modeling
Avalere was recently commissioned to project how policy proposals related to biosimilars would impact government spending and patient costs, including modeling and scoring analyses created for 3 proposals publicly released by the Biosimilars Forum in May 2019.
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.
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.
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.
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.