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.
Recently, Avalere took a look at the gubernatorial elections happening this year, their outlooks, and where they stand on the Exchanges and the Medicaid expansion.
Between now and November, Avalere will to bring election content—including podcasts—to the public dialogue. Our experts provide a glimpse into the role healthcare will play in the 2016 elections and hot topics you can expect to hear about on the campaign trail.
Cost-sharing changes could increase costs for many beneficiaries.
Popular low cost options see smaller increases.
In 2016, more than 18 of 56 million Medicare beneficiaries receive their benefits from Medicare Advantage (MA) plans. MA plans are private managed care organizations that contract with the federal government to coordinate care for Medicare beneficiaries.
A new Avalere analysis finds that nearly 13 million Americans age 50 or over who are currently uninsured or have individual coverage purchased through the private market-inside and outside the exchange- could be eligible to buy-in to the Medicare program under a plan proposed by Democratic presidential candidate Hillary Clinton.
As the discussion intensifies, one of Avalere's experts provides keen observations on what you need to know about this topic.
An analysis from Avalere shows that more health insurance plans offered through the Affordable Care Act exchanges are making some drugs used to treat complex diseases—such as HIV, cancer, and MS—more accessible to patients in 2016 than in the previous years. Specifically, plans were less likely to place all drugs in a class on the highest cost-sharing tier.
Rule Would Decrease Medicare Reimbursement for Drugs That Cost More than $480 per Day; Seven of the 10 Most Affected Drugs Treat Cancer
One third of those who enrolled in a health insurance plan on Healthcare.gov this year picked the same plan as last year, according to a new analysis from Avalere. In total, 3.2 million of the 9.6 million exchange shoppers in 2016 kept their previous plan.
Avalere Experts Estimate MedPAC Proposal to Change Calculation of Part D Enrollees' True Out-of-Pocket Spending Would Increase Beneficiary Costs by $4.1 Billion Between 2017-2020
New Avalere report identifies opportunities to refine the risk-adjustment model that could improve the way Affordable Care Act plans are paid
Almost every state has introduced Right-to-Try bills to try to offer patients another avenue to access investigational drugs outside of the Food and Drug Administration's (FDA) expanded access program. However, it is unclear whether these laws will impact patient access given their questionable legal standing, reduced patient protections due to lack of FDA oversight, and the risks to manufacturers of providing products under Right-to-Try laws.
Percentage of Medicare Advantage enrollees in plans with at least four stars continues to grow.
Percentage of drugs in Part D plans that require coinsurance increased significantly since 2014. Medicare Advantage plans require coinsurance far less often than Part D plans.
The Centers for Medicare & Medicaid Services (CMS) will release the Advance Notice and Call Letter describing CMS' proposed 2017 payment policies for Medicare Advantage (MA) plan sponsors on February 19. Based on previously released information in the fall of 2015, CMS is likely to propose modifications to the risk adjustment model and the current MA Star Ratings methodology.
The CalPERS Basic Plan Drug List, which is the formulary for all California public employees, includes 222 brand drugs and 287 generic drugs. In contrast, drug coverage in the Veterans Administration (VA) and Medi-Cal (California's Medicaid program) is far more limited than the CalPERS drug list.
President Obama released his budget for the 2017 fiscal year today. Avalere offers the following observations on the healthcare proposals:
Today, the Department of Health and Human Services (HHS) announced that 9.6 million individuals selected a health insurance plan on HealthCare.gov during the recent open enrollment season. Avalere estimates that 2016 year-end enrollment will slightly exceed the Obama administration's goal of enrolling 10 million people.
In an article published in The American Journal of Managed Care, Avalere's Caroline Pearson and Deirdre Parsons examine provider networks and benefit design for oncology care in health insurance exchanges.