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.
How May the IRA Shift Part D Market Dynamics?
IRA policies and growing enrollment in Medicare Advantage could begin to destabilize the standalone PDP and LIS benchmark plan market.
Video: Navigating Major Policy Changes: Insights for Medicare Advantage Plans
Avalere experts explore how key policy changes, such as the Risk Adjustment Data Validation final rule, Inflation Reduction Act, and Medicare Advantage payment shifts, are shaping the landscape for health plans.
How Did Public Comments Shape Revised Negotiation Guidance?
Comments on initial negotiation guidance significantly shaped the revised guidance, underscoring the importance of stakeholder engagement in IRA implementation.
Video: Understanding the Medicaid Drug Rebate Program Proposed Rule
Avalere's policy experts discuss the key provisions and potential impacts of the recent CMS proposed rule related to the Medicaid drug rebate program (MDRP.)
CMMI Releases EOM Participation and Lessons Learned from OCM
The CMMI’s EOM began on July 1 with 44 participants. A recent OCM evaluation report described net losses to CMS and lessons that can be applied to EOM.
Avalere Experts Respond to Revised CMS Negotiation Guidance
The revised guidance contains significant changes to the initial guidance released in March, but important outstanding questions remain.
Wastage Update: New JZ Claims Modifier Applies to NOC Billing
Starting July 1, providers must report the JZ modifier on all claims for single-use Part B drugs when applicable, including for products billed with an NOC code.
How Do IRA Policies and Part D Risk Adjustment Interact?
The IRA will increase health plans’ financial risk, elevating the importance of Medicare Part D risk adjustment.
Video: Congressional Debate Over PBM Legislation
Avalere experts discuss Congress’ ongoing consideration of pharmacy benefit manager (PBM) legislation.
How Does the IRA Affect Providers’ and Pharmacies’ Strategies?
Providers and pharmacies are two critical stakeholders that should prepare their own IRA strategies to adequately react to a changing landscape.
Oxygen a Large and Growing Share of Medicare DME Spending
Oxygen expenditures as a share of total Medicare DME expenditures grew from 8.5% in 2018 to 9.8% in 2021, with significant variation across states.
First 2023 HCPCS Meeting Focuses on Non-Drug Products
CMS recently convened stakeholders for a public HCPCS meeting to discuss billing, coding, and reimbursement of non-drugs and non-biological products.
Plan Finder Will Play a Key Role in Part D Redesign
Interviews show the importance of Medicare Plan Finder as a resource and generated ideas to incorporate IRA reforms and improve user experience.
How Will the IRA’s Part D Changes Affect Plan Strategies?
Plans preparing MA-PD and PDP bids for Plan Year 2025 should consider how Part D redesign will affect enrollee costs, plan payment, and market dynamics.
Alternative Funding Programs Present Stakeholder Challenges
Increased use of alternative funding programs has introduced new access challenges for patients, plans, and manufacturers for specialty therapies.
US Supreme Court Will Hear Case Affecting Agency Power
The Supreme Court is expected to hear oral arguments in Loper Bright Enterprises v. Raimondo, which challenges Chevron deference.
Braidwood Ruling’s Impact on Preventive Service Access
168 million individuals could lose access to $0 preventive services, creating pressure for healthcare stakeholders to address access and equity concerns.
PBM Reform on Top of Congress’s Healthcare Agenda
Avalere Policy Edge survey of bipartisan health policy experts suggests that PBM oversight and reform legislation will pass during this Congress.
Video: IRA Impacts on Evidence and Strategy
Ahead of the Asembia and ISPOR 2023 conferences, Avalere experts discuss the increasing importance of value and evidence strategies as part of Inflation Reduction Act (IRA) implementation planning.
Avalere Health Welcomes Lisa Joldersma as Strategic Advisor
As a strategic advisor to the Policy Practice, Lisa Joldersma adds deep expertise in Medicare, commercial and employer-based insurance, and state policy issues.