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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.

Katie Patton

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).

5 High Impact Areas in the MA Advance Notice & Proposed Rule

This month, the Centers for Medicare & Medicaid Services (CMS) proposed changes to Medicare Advantage (MA) through the annual Advance Rate Notice and Proposed Rule. These proposals impact MA in many ways, including changes to quality bonus payments, network adequacy requirements, coverage of End Stage Renal Disease (ESRD), plans targeting dual eligibles, and supplemental benefit offerings. Stakeholders should examine each of these areas closely as they respond to CMS.

CMS RADV White Paper Outlines Potentially Significant Program Changes

CMS is considering changes to its commercial market Risk Adjustment Data Validation (RADV) program to improve the accuracy of risk adjustment transfers and to increase stability and predictability for issuers. This follows issuer experiences with the 2017 RADV process in which some issuers saw substantial, unforeseen changes to their risk adjustment transfers. These RADV changes have the potential to impact issuer participation and premiums in future years depending on the direction (positive or negative) and magnitude of those transfers.

Zachary Zalewski

USMCA Compromise Drops Key Biologics Exclusivity Provisions

The replacement to North American Free Trade Agreement (NAFTA), the United States-Mexico-Canada Agreement, was originally proposed to increase biologics exclusivity in Mexico and Canada to 10 years. As part of the Administration’s compromise with the House of Representatives, these provisions have been removed from the amended version that was recently agreed to by the US, Mexico, and Canada. While exclusivity in the US remains unchanged at 12 years, that it is not increased for Canada and Mexico may impact market entry for biologics ex-US.

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