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
Assessment of Regulatory Proposal to Eliminate the FFS Adjuster from Medicare Advantage Plan Audits
In a recent post on the RISE website, Sean Creighton examines the methodology and evidence behind CMS’s proposal to eliminate the Fee-for-Service (FFS) Adjuster from Risk Adjustment Data Validation (RADV) audit methodology.
2020 Exchange Plan Networks Are the Most Restrictive Since 2014
Restrictive network plans comprise over 75% of the exchange market.
Medicare Advantage Plans May Be Paid Below Actual ESRD Patients’ Costs in Large Metropolitan Areas in 2021
Avalere analysis finds that payment to Medicare Advantage (MA) plans for end-stage renal disease (ESRD) patients in highly populated regions may be significantly below actual patient costs.
Medicare Advantage Beneficiaries Will Again See a Jump in Supplemental Benefit Offerings in 2020
Medicare Advantage (MA) plans continue expanding coverage of supplemental benefits following administration’s policy changes from a year ago.
More Practices Would Receive a Novel Therapy Adjustment in Medicare’s New Oncology Care First Model
New Avalere analysis finds that practices currently participating in the Oncology Care Model (OCM) would be more likely to receive a Novel Therapy Adjustment (NTA) in the newly proposed Oncology Care First (OCF) Model.
Webinar: Get the 411 on Healthcare Consulting
Are you interested in a career in healthcare consulting? Are you passionate about solving the challenges of the healthcare system? Avalere Health, a leading healthcare consulting firm, held an informational webinar on November 18 to provide information about the company and our Associate Immersion Program.
Affordable Patient Access to PCSK9 Inhibitors Remains Challenging Across Part D Plans in 2020
Avalere analysis finds that, despite substantial list price decreases across the PCSK9 inhibitor class, out-of-pocket costs for the majority of 2020 Part D beneficiaries remain significant
Policy and Market Access Trends in Kidney Care
A shifting policy landscape and emerging market forces could introduce significant disruption in the kidney care space in the coming years. Understanding the risks and opportunities that these changes may present will be critical for patients, providers, payers, and manufacturers alike.
Free Exchange Plan Options Are Available to Many Low-Income Consumers for 2020
New analysis from Avalere finds that over 96% of counties with exchanges operated by HealthCare.gov have free plan options for low-income consumers.
5 Key Trends from the 2020 CMS Star Ratings Report
Join Avalere experts on our webinar on October 29, 2019, to unpack CMS’ 2020 Star Ratings and look at what’s to come for 2021.
3 Trends to Watch in this Medicare Open Enrollment Season
As Medicare Advantage enrollment grows and benefits continue to evolve, beneficiaries must keep pace with these changes and investigate plan options amidst current healthcare debates.
Healthcare 2020: Facts and Figures in Advance of the Next Democratic Debate
With the 2020 presidential election nearly 1 year away, healthcare reform remains one of the top issues for voters heading into the election year.
Issue Brief: OOP Costs Among Medicare Part D Enrollees Reaching the Catastrophic Threshold
As policymakers consider reforms to the Part D benefit to address rising out-of-pocket (OOP) costs by adding a maximum OOP cap, an Avalere analysis examines the types of beneficiaries mostly likely to be helped by such a policy.
What’s Next for Biologics Under USMCA?
The USMCA’s intellectual property provisions add additional layers of ambiguity to the already complex issues surrounding biological product exclusivity and its future in US law.
SFC Drug Pricing Proposal Would Increase Part D Manufacturer Discounts for Some Therapeutic Areas
Avalere analysis finds that tying Medicare Part D manufacturer discounts to utilization in the catastrophic phase instead of in the coverage gap would have differential impacts by disease area.
Tom Kornfield Returns to Avalere Health, Expanding Firm’s Depth in Medicare Policy
Healthcare industry veteran brings decades of Medicare Advantage, Part D, risk adjustment, and business expertise to payer, life sciences, and provider clients.
CMMI Program Savings Fall Below CBO’s 2016 Projections
CMMI’s impact on Medicare spending has so far not reached earlier projections by the Congressional Budget Office, demonstrating the difficulty in projecting savings from new and unknown alternative payment models.
Avalere Experts Discuss 2020 Regulatory Changes to the Insulin Market
On August 6, Avalere’s regulatory experts published an article in BioDrugs highlighting upcoming regulatory changes for insulin.
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.