Federal and State Policy
As the largest US healthcare payer, the federal government plays a dominant role in shaping the healthcare marketplace, while states take center stage when it comes to developing novel policy approaches. Our experts track, interpret, and model policies that affect insurance coverage, access, and consumer choice so you can see around the bend.
Part D Premiums Increasing Despite Stabilization Program
While the premium stabilization program under the IRA limits the growth of the base beneficiary premium, individual plan premiums vary.
Part D Premium Increases, Market Disruption Expected in 2024
Over 8 million enrollees in standalone PDPs could see an increase of more than 25% in their premium in 2024.
SNF 3-Day Waiver Use During the COVID-19 Pandemic
Use of the 3-day waiver was stable over the course of the pandemic, though shifts in admission sources were observed.
Video: Unpacking the Implications of the Negotiated Drug List, Part 2
In Part 2 of our video series on the negotiated drug list, Avalere experts discuss topics including effectiveness measures that will inform CMS’s maximum fair price determinations, evidence generation strategies for manufacturers with products that have been selected for negotiation, or that are eligible for selection in the future, and CMS’s definition of therapeutic alternatives.
Webinar: Part D Redesign’s Impact on Plan-Manufacturer Contracting
Avalere experts discussed how IRA’s Part D redesign may affect plan behavior in Plan Year 2025 and how manufacturers should approach contracting and market access.
Physician Payment for Some Services Lags Behind Inflation
Physician reimbursement for some services under Medicare FFS has declined, while payment increased for the same services in the hospital outpatient setting.
How May the IRA Shift Part D Market Dynamics?
IRA policies and growing enrollment in Medicare Advantage could begin to destabilize the standalone PDP and LIS benchmark plan market.
Video: Navigating Major Policy Changes: Insights for Medicare Advantage Plans
Avalere experts explore how key policy changes, such as the Risk Adjustment Data Validation final rule, Inflation Reduction Act, and Medicare Advantage payment shifts, are shaping the landscape for health plans.
How Did Public Comments Shape Revised Negotiation Guidance?
Comments on initial negotiation guidance significantly shaped the revised guidance, underscoring the importance of stakeholder engagement in IRA implementation.
Video: Understanding the Medicaid Drug Rebate Program Proposed Rule
Avalere's policy experts discuss the key provisions and potential impacts of the recent CMS proposed rule related to the Medicaid drug rebate program (MDRP.)
CMMI Releases EOM Participation and Lessons Learned from OCM
The CMMI’s EOM began on July 1 with 44 participants. A recent OCM evaluation report described net losses to CMS and lessons that can be applied to EOM.
Avalere Experts Respond to Revised CMS Negotiation Guidance
The revised guidance contains significant changes to the initial guidance released in March, but important outstanding questions remain.
Wastage Update: New JZ Claims Modifier Applies to NOC Billing
Starting July 1, providers must report the JZ modifier on all claims for single-use Part B drugs when applicable, including for products billed with an NOC code.
How Do IRA Policies and Part D Risk Adjustment Interact?
The IRA will increase health plans’ financial risk, elevating the importance of Medicare Part D risk adjustment.
Video: Congressional Debate Over PBM Legislation
Avalere experts discuss Congress’ ongoing consideration of pharmacy benefit manager (PBM) legislation.
How Does the IRA Affect Providers’ and Pharmacies’ Strategies?
Providers and pharmacies are two critical stakeholders that should prepare their own IRA strategies to adequately react to a changing landscape.
Oxygen a Large and Growing Share of Medicare DME Spending
Oxygen expenditures as a share of total Medicare DME expenditures grew from 8.5% in 2018 to 9.8% in 2021, with significant variation across states.
First 2023 HCPCS Meeting Focuses on Non-Drug Products
CMS recently convened stakeholders for a public HCPCS meeting to discuss billing, coding, and reimbursement of non-drugs and non-biological products.
Plan Finder Will Play a Key Role in Part D Redesign
Beneficiary interviews show the importance of Medicare Plan Finder as a resource and generated ideas to incorporate IRA reforms and improve user experience.
How Will the IRA’s Part D Changes Affect Plan Strategies?
Plans preparing MA-PD and PDP bids for Plan Year 2025 should consider how Part D redesign will affect enrollee costs, plan payment, and market dynamics.