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.
2027 Advance Notice Materially Alters Part D Risk Adjustment
Proposed updates to the Part D risk adjustment model to further separate MA-PDs and PDPs will change plan payments for certain conditions if finalized.
Video: Federal and State Dynamics in AI Regulation
Avalere Health Advisory experts unpack the recent state legislative activity around AI in healthcare, exploring recent trends, the impact of federal executive orders, and key considerations for industry stakeholders as they navigate these shifts.
2026 MPFS Rule: Part B MFPs Included in ASP, but Questions Remain
The 2026 MPFS final rule clarifies how MFP discounts will be included in ASP, confirming stakeholder expectations and introducing new market uncertainties.
Video: Impacts to Insurance Markets, 2026 and Beyond
Avalere Health experts discuss how they developed and deployed an analytic model to predict likely enrollment changes to assist clients in understanding the impacts on all lines of business as a result of upcoming federal policy changes.
IPAY 2028 Guidance Finalizes Some Part B Details, Others Remain
The guidance clarifies some draft policies, adds MA encounter data to Part B drug selection, revises Part B 30DES calculations, and defers some issues to 2029.
Key Health Policy Actions to Watch for the Rest of 2025
Policy initiatives announced in early 2025 are now at an inflection point as they converge with regulatory cycles and are set to drive significant activity.
What Do Risk Adjustment Model Updates Mean for Part D Plans?
CMS’s post-IRA updates to the RxHCC risk adjustment model have varying effects on plan loss ratios across therapeutic areas.
Policy Changes to Expect for Medicare Advantage in 2027
In the CY 2027 Medicare Advantage policymaking cycle, the Trump administration is expected to propose changes to payments, oversight, and Star Ratings.
Implications of PBM-Pharmacy Co-ownership Legislation
Avalere Health examines how new federal and state efforts to oversee PBM-pharmacy ownership may affect stakeholders systemwide.
State Oversight of AI in Healthcare: Status and Impacts
State oversight of AI in healthcare has primarily focused on prior authorization, disclosure and operations requirements, and scope of practice.
Clinicians and Several Lawmakers Unify in Support of USPSTF
Policymakers, professional societies, and advocates support the preservation of USPSTF’s evidence-based recommendations and independence amid reported plans for a sweeping overhaul.
CMS Rulemaking Can Have Immediate Impact on Site-of-Care Trends
A case study of musculoskeletal surgery site-of-care regulations indicates that proposed changes to the Medicare OPPS could trigger immediate site-of-care shifts.
CMS Modifies Part D Premium Stabilization Demonstration
Continued NAMBA increases and changes to the Part D Premium Stabilization Demonstration may signal further destabilization of the standalone PDP market.
OBBBA and Medicare Negotiation Eligibility: Considerations for Manufacturers
For IPAY 2028 and beyond, the OBBBA expands the exclusion for orphan drugs subject to Medicare negotiation, with implications for negotiation selection timing.
OBBBA Provider Tax Provisions Impact on Medicaid Stakeholders
The changes to provider tax provisions included in the One Big Beautiful Bill Act will impact state Medicaid funding, and its effects will be felt by plans and providers.
2025 Update: Biosimilar Substitution State Statute Report
The 2025 edition of the annual report provides insights into state statutes on point-of-service substitution of biosimilar products and is available
IRA, MFN, and Ongoing Fiduciary Pressures Creates Ripple Effect Across the Healthcare Ecosystem
IRA Medicare provisions, increased focus on price regulations including Most-Favored Nation pricing, and broad fiduciary pressures have ripple effects across the healthcare ecosystem.
Supreme Court Upholds Zero-Cost Preventive-Care Rule
In Kennedy v. Braidwood, the Supreme Court affirmed HHS’s USPSTF appointment power, keeping the ACA’s no-cost preventive-service mandate fully in force.
Variability of Comparator Drugs in Ex-US HTAs Offers Lessons for the IRA
Ex-US HTAs often select different therapeutic alternatives when assessing the effectiveness of the same therapies, highlighting the complex factors that influence such decisions.
Video: Inside the Latest RADV Regulatory Developments
Avalere Health Advisory experts break down major updates to the CMS Medicare Advantage (MA) Risk Adjustment Data Validation (RADV) audit process, including enhanced technology, workforce expansion, and increased audit volume, and how health plans can prepare.