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.
Video: Navigating Medicaid Work Rules: Strategies for Uncertain Terrain
Avalere Health experts break down how states and payers can approach Medicaid work requirements amid shifting policy signals and legal uncertainty.
Navigating State Variability in Medicaid Work Requirements
State discretion over work requirement implementation may create significant variability, impacting patients, providers, and health plans.
Video: Compliance on Alert: The New Era of Program Integrity
This episode spotlights the rising compliance pressures facing health plans, from tougher Fraud, Waste, and Abuse oversight to expanding Program Integrity requirements and new federal scrutiny across operations. In five minutes, Avalere Health experts break down the policies driving these shifts and what plans must watch now to stay compliant.
Video: Clover Health Wins MA Stars Lawsuit: What’s Next?
Avalere Health experts discuss the recent court decision on Clover Health's Medicare Advantage Stars results lawsuit, and what health plans should be assessing for future potential impacts while appeals and next decisions play out.
Video: Predictably Unpredictable: Medicare Risk Adjustment
Medicare risk adjustment is shifting. In five minutes, Avalere explains policy changes, RADV expansion, and how evolving models may affect payments and market strategy.
Video: The Impact of CMS and HHS Rules on Responsible AI Use
CMS and HHS regulations are shaping AI use in health plans, driving transparency and accountability, and speeding responsible adoption across an increasingly automated system.
Video: What’s Shaping Healthcare Right Now?
Introducing On the Record: Health Plan Perspectives—A rapid-fire series delivering expert clarity on major CMS and HHS rules. In five minutes, get the insights, implications, and decisive perspective leaders need now.
Physician Payment Changes and MFP May Strain Independent Physicians
Medicare payment and Part B drug pricing changes may increase financial pressure on certain independent physician practices, varying by specialty and site of care.
2027 Part D Risk Adjustment Changes Will Alter Plan Payment
Finalized updates to the Part D risk adjustment model to further separate MA-PDs and PDPs will change plan payments for certain conditions.
2027 Medicare Advantage Payments: Market Implications
MA payment growth slows in 2027, possibly signaling further disruption in plan availability and enrollment.
Marking National Kidney Month with An Outlook in the 2026 Kidney Care Policy, Payment, and Treatment Landscape
Evolving kidney transplant regulations, payment reforms, and accelerated innovation in treatments are opening new opportunities across the kidney care landscape.
GLP-1 Use in Medicare Part D Sharply Increases from 2021 to 2023
Between 2021 and 2023, GLP-1 drug claims increased by 71% for Medicare beneficiaries enrolled in standalone Part D plans.
PDP Enrollment Increases in 2026 While MA-PD Enrollment Declines
In a reversal of recent trends, PDP enrollment rose 7% in 2026, while MA-PD enrollment fell 0.5%, with shifts among large sponsors.
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.