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.
Medicaid Expansion Map
Since passage of the Affordable Care Act (ACA), 39 states and DC have expanded Medicaid. Some of the remaining states may reconsider expansion given new federal funding incentives.
Part D Out-of-Pocket Smoothing Policy Raises Implementation Questions
Implementation of the OOP smoothing program will require additional clarity from the Centers for Medicare & Medicaid Services (CMS) on elements that will affect beneficiary experience, access, and overall sustainability of the smoothing program.
Navigating the Post-PHE Telehealth Policy Landscape
The end of the public health emergency (PHE) raises policy questions around implications for reimbursement, patient access, and operationalization of telehealth service delivery.
Medicare Waste Refunds Could Cost Manufacturers Over $210M Annually
Forty-four Part B drugs could be subject to new CMS wastage refund requirements according to an Avalere analysis of Medicare claims.
CMS Requests Input on Payment Policy for New ESRD Therapies
Recent Medicare rulemaking requested stakeholder feedback on potential payment system changes to support access to therapies for patients on dialysis.
What Braidwood Management v. Becerra Means for Preventive Services
The court’s ruling could impact $0 cost-sharing coverage of PrEP and other USPSTF-recommended services.
Interview: NCDs, Part III: Agency Mandates, Decisions, Coverage and Access
Tune into the third episode in the Avalere Health Essential Voice podcast series focused on Agency decisions define patient access. In this segment, our experts continue the conversation around national coverage determinations (NCDs) by considering how potential policy and market catalysts 3 to 5 years out may help stakeholders think through opportunities and risks at key decision points ranging from early in development to implications for Part D.
Video: NCDs, Part III: Agency Mandates, Decisions, Coverage and Access
Tune into the third episode in the Avalere Health Essential Voice podcast series focused on Agency decisions define patient access. In this segment, our experts continue the conversation around national coverage determinations (NCDs) by considering how potential policy and market catalysts 3 to 5 years out may help stakeholders think through opportunities and risks at key decision points ranging from early in development to implications for Part D.
Analysis of CMMI Models Projects Costs Rather than Savings
Avalere estimates that the CMMI will produce net costs of approximately $9.4 billion through 2026, in contrast to the CBO’s projected net savings of $34 billion.
Overview and Implications of CMS’s Proposed Changes to MA RADV
If finalized as proposed, the changes to the Risk Adjustment Data Validation process could have a substantial impact on Medicare Advantage plans and enrollees.
Value-Based Pricing and Payment Expert Joins Avalere
Veteran health policy professional brings deep expertise in value assessment, pharmaceutical value-based pricing, and payment reform.
Webinar: Preparing for Legislative Change and Connecting Equity and Outcomes
Join us for a live, expert discussion on life sciences industry trends to watch in Q4.
Drug Pricing Policies Under Inflation Reduction Act Raise Operational Questions
Understanding where federal agencies will make key determinations on details of the IRA’s policies will be crucial for stakeholders seeking to shape implementation and prepare for their impact.
Medicaid Coverage Processes for Innovative Therapies Vary by State
Avalere research finds that state Medicaid programs have taken a variety of approaches to coverage policy development for innovative therapies, highlighting opportunities for increased consistency and transparency.
Video: Medicare Advantage, Part III: Performance Measures and STAR Ratings
Tune into the third episode in our video series focused on Medicare Advantage. In this segment, Avalere quality measures experts, Michael Lutz and Taylor Musser, discuss the shift toward member-reported measures and implications of recent measure reporting methodology updates.
Video: Medicare Advantage, Part II: Influencing CMS Policy
Tune into the second episode in our video series focused on Medicare Advantage. In this segment, Avalere experts and former Center for Medicaid and Medicare (CMS) employees Sean Creighton and Tom Kornfield discuss their thoughts on the best ways for health plans to influence CMS decision making, including timing of engagement and critical messaging elements.
Video: Medicare Advantage, Part I: The Future of MA
Tune into the first episode in our video series focused on Medicare Advantage. In this segment, Avalere experts and former Centers for Medicare & Medicaid Services (CMS) employees, Sean Creighton and Tom Kornfield, discuss the outlook for Medicare Advantage, factors that will influence growth of the program, and a behind-the-scenes look at CMS policymaking considerations.
Video: NCDs, Part II: Evidence Development to Fulfill CED Requirements
Tune into the second episode in the Avalere Health Essential Voice podcast series focused on the how CMS and Medicare coverage decisions define patient access. In this segment, our experts continue the conversation around national coverage determinations (NCDs)that have coverage with evidence development (CED) requirements, how FDA and CMS’s evidence questions can be complimentary, and the ways in which manufacturer evidence generation plans can address those goals, using the NCD on monoclonal antibodies for Alzheimer's disease as an example.
Survey: Health Policy Experts Expect BBBA Passage Before Midterms
Avalere Policy Edge survey of bipartisan Congressional and health policy experts suggests the Build Back Better Act (BBBA) will likely pass in 2022.
SCOTUS Ruling and Other Trends May Shape the 340B Policy Landscape
The SCOTUS decision is the most prominent action related to the 340B program, but ongoing litigation among stakeholders and growing activity at the state level are catalyzing developments that could shape the 340B landscape