Health plans and TPAs
Health plans are insurance policies that private companies or government programs offer to cover healthcare costs for enrolled individuals. Third-party administrators manage and process insurance claims for these health and employee benefit plans, often serving as intermediaries among healthcare providers, payers and beneficiaries.
Top Stories
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13 Dec 2024
High health costs force small employers to up cost-sharing
As small businesses struggle to keep up with rising healthcare costs, many have increased cost-sharing for their workers in both single and family coverage. Continue Reading
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01 Nov 2024
ACA open enrollment for 2025: What you need to know
CMS pursued proven outreach strategies for ACA open enrollment 2025, sought to lower costs for consumers, and announced that the number of ACA plans had increased. Continue Reading
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21 Aug 2023
How Does Medicaid Cover Obesity Treatments for Children?
New guidelines from the American Academy of Pediatrics may help improve Medicaid coverage of obesity treatments for children. Continue Reading
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15 Aug 2023
KLAS: Payers Want Efficient Claims and Administration Platforms
Payers recognized claims and administration platforms Cognizant and HealthEdge for their efficiency and functionality. Continue Reading
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08 Aug 2023
ACA Marketplace Premiums Set to Rise Again, Inflation a Key Factor
Inflation-driven increases in medical care and prescription drug costs could make consumers pay more for 2024 Affordable Care Act Marketplace premiums Continue Reading
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01 Aug 2023
How One MA Plan Prioritized SDOH to Improve Diabetes Care Access
Zing Health facilitated access to diabetes care by providing continuous glucose monitors at pharmacies for no cost. Continue Reading
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01 Aug 2023
CMS Projects 2024 Medicare Part D Premiums Will Fall by 1.8%
The projected decrease in Medicare Part D premiums reflects premium stabilization and improved Part D benefits, both tied to the Inflation Reduction Act. Continue Reading
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31 Jul 2023
Medicare Coverage Associated with Higher Cancer Screening Rates
Breast cancer screenings increased by 50 percent and colorectal cancer screenings doubled after individuals started receiving Medicare coverage. Continue Reading
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27 Jul 2023
Why CMS Paused Medicaid Coverage Redeterminations in 6 States
In some states, Medicaid coverage redeterminations have led to improper disenrollments due to procedural reasons. Continue Reading
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24 Jul 2023
CA, KY Expand Behavioral Health Services Through Mobile Crisis Teams
The mobile crisis teams will offer Medicaid beneficiaries behavioral health services such as screenings, de-escalation support, and care coordination. Continue Reading
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18 Jul 2023
Medicare Advantage Plans Have Narrow Psychiatrist Networks, Study Finds
Almost 65 percent of psychiatrist networks were narrow in Medicare Advantage plans, compared to around 40 percent in Medicaid managed care and ACA plans. Continue Reading
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17 Jul 2023
10 Top-Selling Drugs Accounted for 22% of Medicare Part D Spending
Medicare Part D spending reached $216 billion in 2021, with the top ten drugs accounting for $48 billion. Continue Reading
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13 Jul 2023
Medicaid Expansion Improved Palliative Care Access for Cancer Patients
Although access improved, utilization of these services remained low in states with and without Medicaid expansion. Continue Reading
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11 Jul 2023
Medicare Advantage Quality Bonus Program Needs Reform, Report Finds
A reformed Medicare Advantage quality bonus program should penalize contracts for poor performance and determine plan quality at the local level. Continue Reading
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11 Jul 2023
English Proficiency Can Impact Care Disparities, Coverage Rates
Limited English proficiency puts individuals at risk of care disparities, but Medicaid agencies can take steps to secure beneficiaries’ access to coverage. Continue Reading
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10 Jul 2023
ARPA Reduced Fiscal Challenges on CA Affordable Care Act Marketplace
Affordable Care Act marketplace enrollees may have had lower costs in 2021, but affordability barriers persisted. Continue Reading
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06 Jul 2023
Healthcare Spending Lower in MA for Beneficiaries with Chronic Conditions
Total monthly healthcare spending ranged up to $1,532 for Medicare Advantage beneficiaries with chronic conditions compared to $2,204 for fee-for-service beneficiaries. Continue Reading
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30 Jun 2023
High-Risk Medication Use Lower Among Medicare Advantage Beneficiaries
Medicare Advantage beneficiaries received 24.3 fewer high-risk medications per 1,000 beneficiaries compared to those in traditional Medicare. Continue Reading
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28 Jun 2023
Beneficiaries’ Chronic Conditions Did Not Drive MA to FFS Switching Rates
Among beneficiaries with multiple chronic conditions, the rate of switching from Medicare Advantage to fee-for-service was low, ranging from 2.8 percent to 4.0 percent. Continue Reading
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27 Jun 2023
Medicare Advantage Plan Payment Cuts Did Not Impact Enrollment Growth
Counties that faced large Medicare Advantage plan payment cuts from the ACA and those that had smaller cuts saw similar enrollment growth. Continue Reading
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27 Jun 2023
How Medicaid Network Adequacy Rules Affect Children with Special Needs
Children with special needs may struggle to access specialty care with the new Medicaid network adequacy standards. Continue Reading
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23 Jun 2023
Judge Blocks FL Ban on Medicaid Coverage for Gender-Affirming Care
Following the ruling, all transgender beneficiaries in Florida can seek Medicaid coverage for gender-affirming care. Continue Reading
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22 Jun 2023
Cash Payments Could Help Medicaid Beneficiaries Obtain Better Coverage
Medicaid beneficiaries have worse care than private payer enrollees; cash payments may offer access to higher-quality care. Continue Reading
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21 Jun 2023
MedPAC Offers Changes to Medicare Advantage Benefits, Payment Policies
In addition to recommending standardized benefits and payment policy reform in Medicare Advantage, MedPAC addressed high drug prices in Medicare Part B. Continue Reading
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16 Jun 2023
New York Extends Medicaid Postpartum Coverage to 12 Months After Birth
The state joins 34 others that have extended Medicaid postpartum coverage from 60 days to one year following childbirth. Continue Reading
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15 Jun 2023
Medicare Advantage Overpayments Expected to Surpass $75B in 2023
The estimation of Medicare Advantage overpayments is more than twice as high as MedPAC’s prediction of $27 billion. Continue Reading
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14 Jun 2023
Inflationary Rebates for Generic Drugs Offset Medicaid Spending
Inflationary rebates for generic drugs totaled between 2 and 12 percent of the $53.6 billion Medicaid spent on the drugs between 2017 and 2020. Continue Reading
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14 Jun 2023
How COVID-19 Policies Impacted Medicaid Enrollment Among Children
Some states experienced an increase in children’s Medicaid enrollment of more than 14 percent. Continue Reading
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13 Jun 2023
Lawmakers Request More Info on Medicaid Redetermination Compliance
Florida and Arkansas have seen high disenrollment numbers due to procedural reasons, generating concerns about Medicaid redetermination compliance. Continue Reading
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13 Jun 2023
Coronavirus Pandemic Policies May Have Improved Care Affordability
Coronavirus pandemic policies such as continuous Medicaid enrollment may have reduced unaffordability barriers. Continue Reading
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12 Jun 2023
Rising Enrollment, Higher Costs Spur Medicare Spending Growth
Total Medicare spending is projected to increase from $744 billion in 2022 to $1.7 trillion in 2033. Continue Reading
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09 Jun 2023
5 Strategies for Designing a Medicaid Family Planning Program
Medicaid family planning programs provide critical services to beneficiaries who experience access to care barriers. Continue Reading
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05 Jun 2023
Medicare Coverage of Alzheimer’s Drugs Relies on FDA Traditional Approval
In addition to the Alzheimer’s drugs receiving FDA traditional approval, Medicare coverage hinges on clinicians collecting evidence on how the drugs work. Continue Reading
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01 Jun 2023
Extending Medicaid Postpartum Coverage May Reduce Disenrollment
Individuals caring for newborns face various barriers in renewing coverage, making Medicaid postpartum coverage critical. Continue Reading
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30 May 2023
Midwives, Birth Centers Improve Maternal Health Outcomes in Medicaid
Medicaid beneficiaries who gave birth with a midwife present or in a birth center had better maternal health outcomes and higher rates of prenatal care visits. Continue Reading
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26 May 2023
How to Increase Access to Prenatal Vaccines for Medicaid Beneficiaries
States should establish adequate provider reimbursement standards and leverage managed care organizations to improve access to prenatal vaccines for Medicaid and CHIP beneficiaries. Continue Reading
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25 May 2023
Partnership to Improve Care Access for Florida Medicaid Beneficiaries
A two-year collaborative effort between Sunshine Health and Johns Hopkins All Children’s Hospital aims to expand pediatric primary care access to Florida Medicaid beneficiaries. Continue Reading
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24 May 2023
CMS Proposed Rule Addresses Drug Cost Transparency in Medicaid
In addition to increasing drug cost transparency in Medicaid, the proposed rule would improve transparency around the costs of administering drug benefits in managed care plans. Continue Reading
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23 May 2023
Medicare Coverage of Weight Loss Drugs May Reduce Access Disparities
Despite potentially reducing access disparities, covering weight loss drugs could increase annual Medicare spending by up to $26.8 billion. Continue Reading
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23 May 2023
Improve Coverage, Health Equity By Diversifying Broker Recruitment
Access to care can vary based on access to health insurance brokers, so when broker pools lack diversity health equity suffers. Continue Reading
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22 May 2023
The History of Medicare Advantage: From Inception to Growing Popularity
Medicare Advantage offers beneficiaries supplemental benefits and out-of-pocket spending limits, two factors that may contribute to its growing popularity. Continue Reading
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19 May 2023
Biden Admin Increases Access to School-Based Mental Health Services
The initiatives to improve access to school-based mental health services include a proposed rule, a comprehensive guide on payment for Medicaid services, and state plan amendment approvals. Continue Reading
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16 May 2023
Medicare, Medicaid Spending Similar Among Dual Eligible Beneficiaries
Combined total spending on dual eligible beneficiaries was almost evenly distributed, with Medicare spending $14,175 per person-year and Medicaid spending $12,698. Continue Reading
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12 May 2023
Medicaid Coverage Losses Less Likely During First Year of Pandemic
Around 14 percent of people lost Medicaid coverage in 2019, compared to 10.7 percent in 2020, likely due to the federal Medicaid continuous eligibility policy. Continue Reading
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10 May 2023
1.7M Beneficiaries May Lose Coverage Under Medicaid Work Requirements
If beneficiaries did not meet Medicaid work requirements, the federal government would stop paying its share of Medicaid expenses, potentially shifting all of the costs to states. Continue Reading
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08 May 2023
4 Barriers to Coverage Among Uninsured Individuals in Massachusetts
The report analyzed what barriers inhibited access to coverage among uninsured individuals in the state and suggested policy measures to rectify these issues. Continue Reading
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05 May 2023
Medicare Advantage Provider Directories Are Inaccurate, Study Finds
Senate Finance Committee staff could only make appointments with 18 percent of mental health specialists listed in Medicare Advantage provider directories. Continue Reading
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04 May 2023
Potential Outcomes of Basic Health Programs for States, Consumers
Only two states employ Basic Health Programs, but these states offer insight into the opportunities and challenges that the model could present for low-income consumers. Continue Reading
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03 May 2023
Half of Medicare Beneficiaries Are Enrolled in Medicare Advantage
Between 2007 and 2023, the share of Medicare beneficiaries enrolled in Medicare Advantage has increased from 19 percent to 50 percent. Continue Reading
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03 May 2023
How to Protect Integration Progress As Medicare-Medicaid Plans Sunset
With Medicare-Medicaid plans set to sunset by the end of 2025, states, CMS, Congress, and other stakeholders must take steps to protect the Medicare-Medicaid integration progress. Continue Reading
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02 May 2023
Report: Public Insurance Option Would Not Exacerbate Racial Disparities
With a public insurance option, hospital spending on behalf of Black non-Hispanic individuals is estimated to fall by 1.1 percent nationally compared to 1.4 percent for White non-Hispanic people. Continue Reading
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01 May 2023
States Use Managed Care, PACE, FAIs to Boost Dual Eligible Care Coordination
Care coordination is challenging in the dual eligible market, so states rely on managed care organizations and other supports to streamline processes. Continue Reading
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01 May 2023
Medicare Advantage, Part D Premiums Increased Slightly in 2023
From 2022 to 2023, Medicare Advantage premiums grew from $6 to $9 per month, while Part D premiums increased from $22 to $32 per month. Continue Reading
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28 Apr 2023
CMS Proposes Transparency, Access Standards for Medicaid Managed Care
The proposed rules include standards on maximum appointment wait times and state requirements to report Medicaid managed care and fee-for-service payment rates. Continue Reading
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27 Apr 2023
Medicaid Work Requirements Could Disrupt Coverage Access for 21M People
If Medicaid work requirements were implemented, 4 million beneficiaries in California alone could potentially lose health insurance coverage, HHS found. Continue Reading
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27 Apr 2023
The Range for Projected, Post-PHE Medicaid Disenrollment Is Broad
Experts indicated that Medicaid disenrollment could range from 8 million to more than 24 million, although it is unlikely that the actual disenrollment levels will land in the extremes. Continue Reading
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26 Apr 2023
50% of MN Adults Were Uninsured Following Medicaid Disenrollment
The share of uninsured adults fell from 50.1 percent at six months after Medicaid disenrollment to 39.1 percent at 12 months, likely due to individuals re-enrolling in Medicaid. Continue Reading
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26 Apr 2023
Medicaid Supplemental Payments Are Inefficient, Demand Change
Medicaid supplemental payments would be difficult to change, but the current payment distribution models are inefficient. Continue Reading
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25 Apr 2023
HHS Proposal Could Boost Health Insurance Coverage for DACA Recipients
The proposal would amend the definition of “lawfully present” to include DACA recipients, allowing them to enroll in public health insurance coverage. Continue Reading
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20 Apr 2023
CMS Approval Expands School-Based Health Services in Illinois
The state plan amendment will provide Illinois with more Medicaid funding to cover school-based health services for all children who receive Medicaid. Continue Reading
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19 Apr 2023
Adjusting Medicare Drug Price Negotiation Criteria May Increase Savings
Estimated savings from Medicare drug price negotiation increased by 109 percent for the first ten Part D drugs when the selection criteria included drugs with generic or biosimilar alternatives. Continue Reading
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18 Apr 2023
HHS Guidance Increases Care Access for Incarcerated Medicaid Beneficiaries
The new section 1115 demonstration opportunity would allow state Medicaid programs to cover healthcare services for incarcerated Medicaid beneficiaries up to 90 days before their expected release date. Continue Reading
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17 Apr 2023
How a Consolidated Payments Platform Positively Impacts Payers
Consolidating payment infrastructure and working with a strategic partner can improve payer productivity, reduce waste, and prepare health plans and TPAs for future change. Continue Reading
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14 Apr 2023
DACA Recipients Might Gain Access to ACA, Public Payer Coverage
DACA recipients, also known as Dreamers, have been unable to access public payer coverage under the current regulations, but a proposal from HHS might change that. Continue Reading
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13 Apr 2023
Younger Medicare Beneficiaries Report More Issues with Care Access, Costs
Almost a quarter of younger Medicare beneficiaries reported a care delay because of costs compared to just 8 percent of beneficiaries aged 65 and older, the study found. Continue Reading
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12 Apr 2023
Lacking Medicaid Supplemental Insurance Tied to Racial Care Disparities
Black and Hispanic beneficiaries ineligible for Medicaid supplemental insurance had more cost-related barriers to care and fewer outpatient visits than White beneficiaries, highlighting racial care disparities. Continue Reading
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12 Apr 2023
Personalized Outreach Impacts ACA Enrollment Among Low Income Households
Targeted low-income households that received personalized emails and letters urging them to sign up for the lowest-cost ACA plans were more likely to enroll. Continue Reading
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11 Apr 2023
AHIP: More Medicare Beneficiaries Have Medicare Supplement Insurance
Medicare beneficiaries with Medicare Supplement insurance were almost three times less likely to experience problems paying medical bills than those without the additional coverage. Continue Reading
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06 Apr 2023
Extended Medicare Advantage VBID Model Will Address SDOH, Health Equity
Under the third phase of the Medicare Advantage VBID model starting in 2025, Medicare Advantage organizations must offer supplemental benefits that address social determinants of health. Continue Reading
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06 Apr 2023
Medicaid Expansion Could Prevent Coverage Loss During Redeterminations
States that have adopted Medicaid expansion have seen lower uninsurance rates, making expansion a potential tool in the effort to prevent unnecessary coverage loss. Continue Reading
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05 Apr 2023
Medicare Advantage Final Rule Addresses Prior Authorization, Health Equity
The final rule requires Medicare Advantage plans to review prior authorization policies annually and ensure approvals are valid for as long as medically necessary. Continue Reading
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05 Apr 2023
Community Health Centers Seek Enrollment Support Amid Medicaid Redeterminations
As Medicaid redetermination restarts, community health centers with sizable Medicaid populations ask for funding to help their enrollment and outreach efforts. Continue Reading
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04 Apr 2023
Medicare Advantage Has Lower Healthcare Use, Higher Clinical Quality
Based on HEDIS measures and patient-reported outcomes, clinical quality performance was generally higher for Medicare Advantage HMOs and PPOs than traditional Medicare in 2010 and 2017. Continue Reading
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04 Apr 2023
Update on the Massachusetts Medicaid Redetermination Process
As the Medicaid redetermination process gets underway, MassHealth has released an update on its plans. Continue Reading
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03 Apr 2023
Insurer Competition Contributes to Affordable Care Act Benchmark Premiums
Affordable Care Act premiums are influenced by insurer competition; ultimately, the marketplace premiums grew from 2022 into 2023. Continue Reading
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31 Mar 2023
Medicaid Eligibility Status Remains Elusive as Continuous Coverage Ends
Beneficiaries were still uncertain about their Medicaid eligibility status in March 2023, merely weeks before the continuous coverage provision was set to expire. Continue Reading
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28 Mar 2023
Vertical Integration Raises Spending for Medicare Advantage Plans
Gross spending per beneficiary was 4.6 percent higher for Medicare Advantage plans that owned related businesses compared to those not pursuing vertical integration. Continue Reading
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24 Mar 2023
MA Beneficiaries Satisfied With Coverage but Face Financial Barriers
More than half of Medicare Advantage beneficiaries cannot afford out-of-pocket costs higher than $1,000, leading to financial barriers to care. Continue Reading
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23 Mar 2023
OIG Finds CMS Overpaid Geisinger Medicare Advantage Plan by Over $566K
The Office of the Inspector General determined that 224 out of 270 enrollee-years of the Medicare Advantage plan’s diagnosis codes were unsupported. Continue Reading
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23 Mar 2023
Medicaid Expansion Tied to Higher Coverage Gains, Fewer Disparities
In Medicaid expansion states, 9.1 percent of adults were uninsured in 2021 compared to 18 percent in non-expansion states. Continue Reading
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22 Mar 2023
States Plan Various Continuity of Coverage Strategies Post-PHE
Medicaid programs are pursuing continuity of coverage by rethinking renewals, eligibility, transparency, and outreach. Continue Reading
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22 Mar 2023
Medicaid Waivers Reduced Disenrollment Among Autistic Adolescents
Living in a state with Medicaid waivers was associated with a six-fold or greater decrease in the probability of disenrollment among autistic adolescents. Continue Reading
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21 Mar 2023
MedPAC Calls on Congress to Modify Medicare Advantage Payment Policies
MedPAC urged Congress to address coding intensity, noting how it contributes to higher Medicare Advantage payments relative to Medicare fee-for-service spending. Continue Reading
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20 Mar 2023
How Medicaid Covered Behavioral Health Services in 2022
The most common behavioral health services Medicaid covered in 2022 were substance use disorder and outpatient services, KFF found. Continue Reading
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20 Mar 2023
The Critical Task of Assessing Healthcare Payment Infrastructure
Assessing healthcare payment infrastructure is a critical first step toward payers ensuring that continued digital transformation does not lead to inefficiency and risk. Continue Reading
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17 Mar 2023
Growing ESRD Enrollment Prompts MA Plans to Form Value-Based Arrangements
Medicare Advantage plans are often underpaid for covering ESRD treatment but provide high reimbursement rates to dialysis facilities, leading plans to form value-based arrangements with kidney care organizations. Continue Reading
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16 Mar 2023
Stakeholder Groups Oppose Medicare Advantage Risk Adjustment Changes
Healthcare stakeholder groups have urged CMS to delay the Medicare Advantage risk adjustment changes and assess the potential impact on payers, providers, and beneficiaries. Continue Reading
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16 Mar 2023
Feds Share Details on Inflation Rebates for Medicare Prescription Drugs
Beneficiaries may have an inflation-adjusted coinsurance rate as low as 10.27 percent on certain Medicare prescription drugs, depending on their coverage. Continue Reading
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15 Mar 2023
Americans Who Lose Medicaid Post-PHE May Choose Employer-Sponsored Coverage
After Medicaid redetermination, disenrolled beneficiaries may turn to employer-sponsored health plans in most states. Continue Reading
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13 Mar 2023
AHIP Reveals Org to Support Stakeholders during Medicaid Redetermination
The organization pulls together a variety of stakeholders across the healthcare industry in order to provide up-to-date information and practices around Medicaid redetermination. Continue Reading
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10 Mar 2023
How Medicaid Managed Care Orgs Can Better Invest in SDOH Interventions
Jointly issuing financial bonds would allow Medicaid managed care organizations to receive upfront funding from investors that can be used to advance social determinants of health interventions. Continue Reading
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08 Mar 2023
BMA Asks CMS to Rethink Medicare Advantage Risk Adjustment Model Changes
The proposed changes to the risk adjustment model would result in a 3.12 percent reduction to Medicare Advantage payments in 2024, BMA said. Continue Reading
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07 Mar 2023
States with Highest COVID Medicaid Enrollment May See Big Losses Post-PHE
Medicaid enrollment could drop significantly once the coronavirus public health emergency’s continuous enrollment policy ends. Continue Reading
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02 Mar 2023
Medicare Advantage Beneficiaries See Lower Hospitalization Rates
Lower hospitalization rates among Medicare Advantage beneficiaries may reflect the program’s goal of shifting members to lower-cost care settings. Continue Reading
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28 Feb 2023
MT Medicaid Expansion Leads to More Preventive Care Use, Lower Costs
Medicaid expansion brought an influx of federal dollars and a new focus on behavioral and mental healthcare, leading to changes in Montana’s Medicaid program. Continue Reading
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27 Feb 2023
How the Inflation Reduction Act Impacted Medicare Part D Benefit Design
The new law and policymakers’ decision to increase plan liability could lead to changes in Medicare part D benefit design. Continue Reading
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23 Feb 2023
Hospice Enrollment from Community Setting More Common in Medicare Advantage
In 2018, 46.4 percent of Medicare Advantage beneficiaries in hospice enrolled from a community setting compared to 38.3 percent of those in traditional Medicare. Continue Reading
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22 Feb 2023
Considering the Costs of Complex Healthcare Payment Infrastructure
The time is ripe for payers to address the unintended consequences of a complex payment infrastructure to reduce inefficiency, mitigate risk, and remain competitive. Continue Reading
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21 Feb 2023
AHIP: Proposed 2024 Medicare Advantage Advance Notice Cuts MA Rates
AHIP stated that the proposed 2024 Medicare Advantage advance notice would lower rates by 2.27 percent in 2024, despite HHS assertions to the contrary. Continue Reading
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16 Feb 2023
Trends in Deductibles Among Affordable Care Act Marketplace Plans
An annual analysis of Affordable Care Act marketplace deductibles revealed that deductible costs were trending upward in 2023. Continue Reading
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16 Feb 2023
AHIP Asks CMS to Reconsider Proposed Medicare Advantage Policy Changes
The extensive policy changes included in the proposed rule will negatively impact Medicare Advantage beneficiaries and plans, AHIP said. Continue Reading
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15 Feb 2023
HHS Introduces Models for Lowering Prescription Drug Spending
The three models would standardize a $2 drug list, enable multi-state, outcomes-based agreements, and accelerate confirmatory trials to reduce prescription drug spending. Continue Reading