Coverage and Payment
Coverage and reimbursement shapes patient access and affordability. Life sciences companies rely on favorable coverage decisions to ensure market access and adoption of their products, while health plans need effective reimbursement strategies to manage costs and provide comprehensive benefits to their members.
A Deep Dive Into Hospice Utilization Trends
Avalere analysis reveals an opportunity to support more Medicare beneficiaries with hospice care, as evolving diagnoses and ALOS prompt reevaluation of program metrics
Patterns in Patient Access to MS Drugs
Avalere analysis finds that less clinically efficacious MS drugs have better coverage, more advantageous tiering, and lower UM compared to more efficacious drugs.
MA Plans Increase Use of Step Therapy for Part B Drugs
In 2023, 54% of Medicare Advantage enrollees were in plans that required step therapy for 10 commonly used rheumatoid arthritis drugs covered under Part B.
Medicaid Managed Care Rule: Three Things Plans Should Know
CMS’s new Medicaid and CHIP managed care rule will impact wait time standards, In Lieu of Service and Setting usage, and quality rating.
Health Plans 2030: Evolving Operational Approaches
The first installment of our Health Plans series explains how plans can evolve their approaches to provider contracting and utilization management for the future.
Innovation Spurs Growth in Medicare NTAP
Recent growth in the NTAP designation alters dynamics for manufacturers considering pursuing the designation for new technologies.
2024: An Era of Innovation and Disruption in Kidney Care
A dynamic regulatory landscape, technological advancements, and investments in R&D offer new opportunities and challenges in kidney care.
CMS Creates New Codes to Reimburse for Navigation Services
Newly developed HCPCS codes will support increased access to oncology navigation services, which have been shown to improve patient outcomes.
Trends in Risk Adjustment Coding Operations
Plans adapt to market changes in risk adjustment coding. Interviews with plan professionals reveal three trends for efficiency, effectiveness, and compliance.
Charting Change: CPT Coding and Remote Monitoring
The AMA’s upcoming CPT Editorial Panel meeting on coding and billing for remote monitoring will shape the future of digital health technology.
CMS Site-Neutral Payments Affect Small Share of Spending
Payments to off-campus hospital sites affected by site-neutral payment policy amount to only 2.3% of Medicare outpatient spending.
How the Transitional Drug Add-On Payment Adjustment Works
The TDAPA supports payment and patient access to new therapies introduced to the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS). CMS has continued to refine the payment designation through rulemaking. Stakeholders should continue to monitor this payment-adjustment policy, as it has evolved since its introduction and may continue to change in future rulemaking cycles.
Physician Payment for Some Services Lags Behind Inflation
Physician reimbursement for some services under Medicare FFS has declined, while payment increased for the same services in the hospital outpatient setting.
IRA Question of the Week: How Will Negotiation Affect Reimbursement?
The introduction of the maximum fair price through the Medicare drug price negotiation process is expected to lower provider reimbursement.
Coding, Billing, and Reimbursement Barriers to Obesity Care
Assessing barriers that impact patient access to obesity care and educating stakeholders on how to mitigate them can advance solutions toward improving care.
340B Reimbursement Proposal Could Reduce Payments for 80% of Hospitals
To assess how changes in OPPS payment for reimbursement of drugs under the 340B program would affect hospital reimbursement and Medicare Part B beneficiary cost sharing, Avalere estimated the impact of increasing reimbursement for 340B drugs in Medicare Part B to ASP + 6%. The analysis finds that most hospitals would see overall payment decreases, while payments would be subject to higher cost sharing.
Final CMS Alzheimer’s Coverage Memo Will Impact Access Beyond Medicare
The final CMS NCD for amyloid beta-targeting monoclonal antibodies for Alzheimer’s Disease establishes a dual pathway to Medicare coverage based on FDA approval and likely creates access and operational challenges for stakeholders.
Medicare Draft Coverage for Alzheimer’s Drugs May Challenge Access
Thirty-one percent of rural Medicare fee-for-service beneficiaries with early-onset Alzheimer’s disease or a mild cognitive impairment diagnosis do not have access to a hospital outpatient department in their county, and fewer than 1% live near an Alzheimer’s disease research center.
Video: The Coverage Gap and Medicaid Expansion
Tune into another episode of Avalere Health Essential Voice. In this segment, our experts discuss the forthcoming debate around the coverage gap in non-Medicaid expansion states, potential policy options, and the impact on key stakeholders.
PACHA Highlights Need to Address HIV PrEP Coverage Disparities
On March 8–9, the Presidential Advisory Council on HIV/AIDS (PACHA) discussed avenues to achieving equitable access to HIV prevention products for at-risk populations as well as next steps in revising the National Strategic Plan to End the HIV Epidemic.