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.
Featured Content
Changing the Way Insurers are Paid Could Increase Stability in the Exchange Market and Beyond
New Avalere report identifies opportunities to refine the risk-adjustment model that could improve the way Affordable Care Act plans are paid
Right-to-Try Bills Grow in Popularity yet Success Is Unclear
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.
More than 70 Percent of Medicare Advantage Enrollees in Plans with Four or More Stars
Percentage of Medicare Advantage enrollees in plans with at least four stars continues to grow.
Majority of Drugs Now Subject to Coinsurance in Medicare Part D Plans
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.
Webinar: Avalere and Inovalon Webinar: Understanding the CMS Advance Notice
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.
Veterans Administration and California Medicaid Drug Lists Cover Less than 60 Percent of Drugs Available to California Public Employees
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.
Avalere’s Take: President Obama’s FY2017 Healthcare Budget
President Obama released his budget for the 2017 fiscal year today. Avalere offers the following observations on the healthcare proposals:
Exchange Enrollment Is on Track to Meet Administration’s Goal
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.
Spotlight On: Patient Access to Oncology Care in Exchange Plans
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.
Prescription-Only Pseudoephedrine-Containing Products Contribute to Growing Primary Care Physician Shortage
According to a new analysis by Avalere, a prescription requirement for pseudoephedrine-containing products also fuels the growing shortage of primary care physicians, thereby increasing the cost, time, and difficultly of obtaining the treatment for legitimate users.
Nearly 60 Percent of New Medicare Advantage Plans Are Sponsored by Healthcare Providers
A new analysis from Avalere Health finds that hospitals and health systems are increasingly taking risk for the cost of Medicare patients and the quality of the care they receive.
Federal Government Underpays Medicare Advantage Plans for Enrollees with Multiple Diseases
A new analysis by Avalere finds that the Centers for Medicare and Medicaid Services (CMS) underpay Medicare Advantage (MA) plans for the costs of treating individuals with multiple chronic conditions.
Proposed Exchange Standardized Benefit Designs Expand First-Dollar Coverage for Services and Drugs
As the government considers rules for 2017 insurance plans offered through exchanges, a new analysis by Avalere finds that proposed 2017 benefit designs could increase coverage of certain services and drugs, while lowering out-of-pocket costs for many consumers.
Webinar: How to Develop Compassionate Use Policies
FDA oversees access to investigational treatments by eligible patients (compassionate use) through its expanded access program. But how do you decide whether to give these patients the unapproved treatments they seek?
Webinar: Medicare Advantage Star Ratings: CMS Proposes Changes
Recently, stakeholders have raised concerns around whether the current star rating methodology appropriately adjusts for the socioeconomic impacts on quality ratings.
New Study Analyzes FDA Advisory Committees’ Trends in First Three Years of Current User Fee Era
The U.S. Food and Drug Administration's (FDA) Advisory Committee (AdComm) process remains a source of significant uncertainty for medical product manufacturers, despite FDA's guidelines in the Code of Federal Regulations (C.F.R.)1 and in guidance.2 While the AdComm process is generally the same across Centers,3 each AdComm is unique and subject to the expertise and opinions of individual panel members, opinions voiced during the public comment period, and challenges exclusive to each new product or indication.
Podcast: Compassionate Use
When life sciences companies consider whether to allow compassionate use—access to unapproved investigational treatments outside of clinical trials—there are no easy answers. Brenda Huneycutt gleans insight from Arthur Caplan, PhD, and Alison Bateman-House, PhD, from the New York University Langone Medical Center Division of Medical Ethics on some of the many questions that life sciences companies should ask themselves before implementing a compassionate use policy.
Webinar: FDA’s Regulation of Laboratory Developed Tests—Where Do We Go Next?
The FDA has shown growing interest in regulating laboratory developed tests (LDTs) to ensure their safety and effectiveness.
MACRA and the Promise of Better Patient/Family Engagement in Post-SGR World
The story of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) actually begins in the previous millennium. In 1997, when the Congress passed the Balanced Budget Act, it ushered in the era of the Sustainable Growth Rate (SGR) formula. In theory, the SGR payment adjustment would raise or lower physician reimbursement each year based on spending relative to the target SGR. The caveat, however, was that Congress had the authority to suspend or adjust this benchmark, a "patch" that they regularly deployed through a "doc fix" for nearly two decades.
Where Are the States Going on Payment and Delivery Reform? Tracking SIM Grant Developments
Believing that states are productive incubators of innovation, the Center for Medicare & Medicaid Innovation (CMMI) launched a State Innovation Model (SIM) grant program in 2013 to encourage state-by-state testing of innovative payment and delivery models.