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.
What the Latest Federal Shifts Mean for Mental and Behavioral Health
The Trump administration is shifting behavioral health priorities, moving away from integration and parity, towards cost containment and structural reform.
Stakeholder Considerations for IPAY 2028 Guidance
Draft guidance for IPAY 2028 Medicare drug price negotiation includes the first-time inclusion of Part B drugs, refinement to MFP effectuation, and considerations around what qualifies as a single-source drug.
White Paper: Provider Survey on Part B Step Therapy in Medicare Advantage
Step therapy is a form of utilization management increasingly used by health plans, including Medicare Advantage plans, with the stated intent to guide prescribing decisions toward cost-effective, evidence-based therapies.
Part D Cost Pressures May Shape Future Alzheimer’s Drug Management
As new Alzheimer’s drugs are developed, increased plan liability pressures may shape future Part D plan management strategies
Avalere Health Experts React to the Most-Favored Nation Executive Order
A new EO revives international reference pricing as a core Trump administration priority, with a focus on Most-Favored Nation pricing through direct-to-consumer models, regulatory action, and broader enforcement measures.
Stakeholder Considerations for MFP Effectuation in Part B
Several pathways exist to effectuate the MFP for Part B negotiation with benefits and drawbacks for stakeholders across the drug supply chain.
Early Enrollment Data Indicates More Beneficiaries Could Benefit from MPPP
Avalere Health’s analysis of early MPPP enrollment shows that only a small portion of beneficiaries who are likely to benefit from the program have enrolled.
Revisiting Medicaid Work Requirements
Federal policymakers are considering Medicaid work requirements as a mechanism to reduce spending; recent state experiences offer important considerations.
PBM Delinking: Policy Considerations
Legislation aimed at changing how PBMs operate, including “delinking” bills, could have unforeseen consequences for drug prices, contracting and competition.
Recent Part D Final Policies Leave Open Areas for Future Action
After the release of the CY 2026 MA and Part D final rules, CMS may take further action on several key policy areas, including anti-obesity medications and premium stabilization.
Video: Unpacking the Final CY2026 CMS Part C and D Rule and Rate Announcement
Avalere Health Advisory experts explore how the Trump Administration approached Medicare Advantage and Medicare Part D policies proposed by the Biden Administration, ranging from anti-obesity medication coverage to plan payment increases
Update: Health Plans’ Perceptions of PDABs and UPLs
In interviews and a survey, health plans communicate concerns with UPLs’ potential impact on patient access, pharmacists, providers, and their own financial positions.
MA and Part D Enrollment Growth Slows in 2025
Year-over-year enrollment growth in MA and Part D slowed in 2025. Although, enrollment in chronic condition special needs plans experienced significant growth.
Updated: Key Considerations for MFP Effectuation and the 340B Rebate Model
With less than a year until the first MFPs take effect, stakeholder concerns remain, especially as it relates to 340B duplicate discount risk.
Video: Unpacking CMS RADV: The Selection Process and Planning for the Future
Avalere experts discuss the CMS Medicare Advantage (MA) Risk Adjustment Data Validation (RADV) audit process and provide insight on how health plans can proactively plan and prepare for these audits.
Vaccine Policy and Access Under New HHS Leadership
Policy actions in the first days of the Trump administration raise questions about the future role of key vaccine advisory committees.
Rare Disease Advisory Councils: Opportunities for Engagement
Stakeholders should seek to engage with RDACs to develop a better understanding of rare disease care access, treatment, and populations in different states.
What the Election Results Mean for Health Policy in the Year Ahead
A second Trump administration and Republican Congress will mark a shift in healthcare policy priorities in 2025 on both legislative and regulatory fronts.
Webinar: Part D Patient Access 2025: Drug Formulary Changes
Join Avalere experts to learn about the changes to Part D formularies for 2025 and implications for patient access.
Webinar: Part D Patient Access 2025: Plan Options and Premiums
Avalere experts will examine changes in Part D plan options and premiums for 2025 and will explore how these shifts may affect patient costs and choice.