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 Jul 2022
ACA Marketplace Premiums Projected to Increase by 10% in 2023
Insurers said that rising prices paid to hospitals and utilization expectations will account for up to eight percent of ACA marketplace premium growth in 2023. Continue Reading
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20 Jul 2022
Medicaid Beneficiaries Face Barriers to Cancer Care Access
Medicaid beneficiaries faced barriers to accessing care for colorectal, breast, kidney, and skin cancer, as less than 70 percent of facilities did not accept Medicaid for all four cancer types. Continue Reading
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19 Jul 2022
ARPA Subsidy Expiration will Impact Reproductive Healthcare Access
Almost 600,000 women who will lose coverage if ARPA premium subsidies expire live in states that have not expanded Medicaid, making reproductive healthcare access harder to come by. Continue Reading
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18 Jul 2022
Medicare Advantage Plans Increase Profits by Dodging MLR Limitations
Related businesses from parent companies of Medicare Advantage plans can account for up to 70 percent of spending, offering the chance for plans to treat revenues as costs and avoid MLR rules. Continue Reading
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15 Jul 2022
Seniors, People with Disabilities Will Lose Medicaid Coverage After PHE
Streamlining eligibility and enrollment processes, such as ex parte renewals, could help seniors and people with disabilities maintain Medicaid coverage after the public health emergency ends. Continue Reading
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14 Jul 2022
63% of Medicare Beneficiaries Paid Full Generic Drugs Cost in 2020
A new study found that more Medicare Part D beneficiaries paid the entire generic drug cost at least once in 2020 compared to 2017. Continue Reading
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13 Jul 2022
Seniors Find Medicare Enrollment Confusing, Avoid Changing Plans
Medicare enrollment can be a mystifying process for seniors, who might resort to staying in the same plan instead of seeking out new options. Continue Reading
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07 Jul 2022
HHS Resources Address Oversight of Medicaid, CHIP Quality of Care
HHS has released a suite of resources intended to support Medicaid and CHIP programs in order to boost quality of care in managed care organizations. Continue Reading
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05 Jul 2022
New ACAP Center Aims to Support Social Determinants of Health Efforts
The center will serve payers, policymakers, and other stakeholders as they pursue social determinants of health efforts. Continue Reading
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30 Jun 2022
AHIP Calls For More Accurate Federal Reporting on Medicare Advantage
AHIP pointed to instances when federal agencies such as GAO, OIG, and MedPAC have drawn conclusions about Medicare Advantage based on what AHIP called inaccurate reporting. Continue Reading
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29 Jun 2022
States May See Higher Uninsurance Rates Among Children When PHE Ends
Uninsurance rates among children were steady from early 2019 through 2021, but could grow as flexibilities from the pandemic expire. Continue Reading
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28 Jun 2022
ARPA Subsidy Expiration Could Drive 2023 Premium Rate Changes
The individual market’s risk pool composition may worsen if American Rescue Plan Act premium subsidies expire, leading to 2023 premium rate changes. Continue Reading
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27 Jun 2022
Removing Prior Authorizations Had Mixed Effect On OUD Care Uptake
Removing prior authorizations on an opioid use disorder (OUD) medication-assisted treatment produced mixed results for two Medicaid programs. Continue Reading
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23 Jun 2022
HHS: ARPA Premium Subsidy Expiration Will Boost Uninsurance, Costs
The American Rescue Plan Act’s premium subsidy expiration could impact insurance coverage and affordability for millions of Americans, according to HHS. Continue Reading
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21 Jun 2022
Black Beneficiaries Generated Lower Medicaid Spending, Utilization
Researchers found that Black Medicaid enrollees had lower Medicaid spending and used fewer services than White Medicaid enrollees. Continue Reading
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21 Jun 2022
Affordable Care Act Impacted Patient Experience, Not Utilization, Cost
The implementation of the Affordable Care Act may have influenced patient experience and access to care, but researchers did not find a sizable impact on cost and utilization trends. Continue Reading
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20 Jun 2022
More States Extend Medicaid Postpartum Coverage to a Full Year
Comprehensive Medicaid postpartum coverage may improve patient outcomes after childbirth, which is why three more states and Washington, DC have expanded their coverage timeframes. Continue Reading
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16 Jun 2022
OIG: Medicare Race, Ethnicity Data Is Inaccurate, Thwarts Health Equity
Medicare’s race and ethnicity data does not comply with federal standards for data collection and requires improvement. Continue Reading
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16 Jun 2022
Medicare Advantage Represents a Growing Share of Medicare Enrollment
Medicare Advantage continues to absorb a higher amount of Medicare beneficiaries and garners more bipartisan support. Continue Reading
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14 Jun 2022
How States Can Evaluate, Improve Ex Parte Medicaid Renewal Processes
Medicaid renewal processes may need to be revamped in order to prepare for the end of the coronavirus public health emergency. Continue Reading
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13 Jun 2022
LGBT Medicaid Beneficiaries Have Higher Rates of Unmet Care Needs
LGBT Medicaid beneficiaries reported high rates of unmet behavioral health needs and negative provider interactions, highlighting room for improvement in Medicaid coverage for this population. Continue Reading
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08 Jun 2022
How Medicare Out-of-Pocket Healthcare Spending Cap May Impact Beneficiaries
A Medicare out-of-pocket healthcare spending cap could halve out-of-pocket spending for beneficiaries, but could boost overall traditional Medicare spending. Continue Reading
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02 Jun 2022
CMS May Use 2022 Savings to Lower 2023 Medicare Part B Premiums
Medicare Part B premiums soared in 2022 due to a new drug’s price, but with that factor resolved the agency is considering using savings to lower 2023 Medicare Part B premiums. Continue Reading
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31 May 2022
How CMMI is Addressing Social Determinants of Health, Health Equity
CMMI’s Accountable Health Communities model helped address social determinants of health and health equity by screening Medicare and Medicaid beneficiaries for health-related social needs. Continue Reading
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26 May 2022
CMS, HHS Leaders Commend 4 States for Expanding Postpartum Coverage
Four states have expanded postpartum coverage from the typical 60-day period to twelve months, joining the ranks of seven other states that already expanded coverage. Continue Reading
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24 May 2022
No Surprises Act May Have Blocked 2M Surprise Billing Claims
The No Surprises Act went into effect in December 2021 and may have prevented millions of surprise billing claims in its first two months. Continue Reading
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23 May 2022
How ACA Insurer Participation May Perpetuate Care Disparities
Affordable Care Act insurer participation in the individual marketplace may have been tied to a lack of health equity in the first years of the Affordable Care Act. Continue Reading
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23 May 2022
How Medicaid Programs Provide Coverage for Maternal Health Services
Many state Medicaid programs cover maternal health services such as prenatal and postpartum visits, ultrasounds, and vitamins, but some states impose utilization controls on coverage. Continue Reading
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19 May 2022
AHIP Supports Using Texts, Calls for Medicaid Enrollment Processes
AHIP supported connecting with enrollees via texts and pre-recorded calls to ease Medicaid enrollment processes when redeterminations return. Continue Reading
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19 May 2022
CMS Updates Medicare.gov To Simplify, Support Navigation
The agency indicated that improvements to Medicare.gov were based on consumer feedback and that the public should expect more changes in the next few months. Continue Reading
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18 May 2022
Health Plans Falter at Providing Medicaid Redetermination Info
Medicaid beneficiaries with higher incomes were more likely to report receiving Medicaid redetermination and re-enrollment information compared to lower-income beneficiaries. Continue Reading
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18 May 2022
Provider Acceptance High for Privately Insured, Medicare Patients
Psychiatrists were less likely to accept new Medicare patients and privately insured patients compared to other specialists and primary care physicians. Continue Reading
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16 May 2022
Payer Establishes Culturally Specific Alternative Payment Model
CareOregon and the payer’s partner aimed to improve payments for providers offering culturally-specific services with an alternative payment model. Continue Reading
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12 May 2022
Complaint Filed Against Alabama Medicaid for Hepatitis C Coverage
The Alabama Medicaid program denies HCV treatment coverage if a patient has used alcohol or illicit drugs in the past six months, which the complaint argues impedes access to care. Continue Reading
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11 May 2022
How Medicaid Can Address Youth Homelessness, Behavioral Health
States can leverage Medicaid programs to expand the continuum of care and improve coordination between state agencies to address youth homelessness and behavioral health needs. Continue Reading
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09 May 2022
Rural Residents See Higher Premiums, More ARPA Premium Subsidies
Rural benchmark premiums were higher than urban area premiums, meaning that rural residents received greater financial assistance through ARPA premium subsidies. Continue Reading
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04 May 2022
How One Medicaid Program May Prevent Coverage Loss Post-COVID
The Massachusetts Medicaid program has a few tools at its disposal in order to prevent widespread loss of coverage when the public health emergency lifts. Continue Reading
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04 May 2022
Contracted Medicaid Managed Care Providers Treated Few Beneficiaries
Treatment from contracted Medicaid managed care providers was highly concentrated, with a quarter of physicians and specialists accounting for the majority of claims. Continue Reading
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03 May 2022
Telehealth Waiver Boosted Care Access for Medicare Beneficiaries
Less than one percent of Medicare beneficiaries had a virtual care visit before a CMS telehealth waiver expanded coverage, compared to nearly 10 percent after the waiver. Continue Reading
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02 May 2022
Trends in Medicare Savings Programs, Part D Subsidy Enrollment
States that expanded income and asset thresholds above the federal limit for the Medicare Savings Programs had higher enrollment numbers. Continue Reading
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21 Apr 2022
CMS Introduces Health Equity Strategy for Public Payer Programs
The agency released a detailed strategy for all of its centers and offices to pursue related to health equity and outlined actions that these programs had already taken to align. Continue Reading
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20 Apr 2022
The Status of Uninsurance Among Immigrants, Barriers to Coverage
Immigrants face higher rates of uninsurance due to a variety of coverage barriers including misconceptions about the public charge rule and language barriers. Continue Reading
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19 Apr 2022
Part D Out-of-Pocket Costs Pose a Barrier to Treatment Access
Medicare beneficiaries with a low-income subsidy may pay under $10 in out-of-pocket costs for a cancer drug under Part D coverage, while those without subsidies may pay over $3,000. Continue Reading
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18 Apr 2022
Medicaid Expansion Boosted Coverage for Adults with Legal Involvement
In Medicaid expansion states, 82 percent of low-income adults with criminal legal involvement received healthcare coverage, compared to 54 percent in nonexpansion states. Continue Reading
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18 Apr 2022
ARPA Tax Credit Expiration Will Increase Uninsured Population by 3M
If the ARPA tax credits expire, the uninsured population will rise, with young adults, Black individuals, and low-income people experiencing significant coverage losses. Continue Reading
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15 Apr 2022
LA Care Health Plan Tackles Provider Workforce Shortage
The health plan is offering grant funding to attract workers to safety-net care and address the provider workforce shortage. Continue Reading
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11 Apr 2022
CMS National Coverage Determination May Worsen Health Inequities
Most racial minorities with early onset Alzheimer’s do not have access to health systems approved for clinical trials under the CMS national coverage determination. Continue Reading
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07 Apr 2022
Trends in Medicaid MCO, Marketplace Network Adequacy Standards
Despite federal requirements, network adequacy standards for Medicaid MCOs and marketplace plans varied by state and provider type. Continue Reading
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06 Apr 2022
OIG: CMS Should Promote Biosimilars To Reduce Part D Spending
Biosimilars could be key to reducing Medicare Part D spending, but utilization would have to increase for significant savings to be realized. Continue Reading
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06 Apr 2022
ART Impacts Spending, Care for Medicare Beneficiaries with HIV
Medicare beneficiaries with HIV who received ART for a full year had a lower mean total spending than beneficiaries with HIV who did not receive ART. Continue Reading
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04 Apr 2022
CMS Updates Medicare Part B OTC COVID-19 Testing Coverage
Medicare Part B beneficiaries can receive eight free, at-home, over-the-counter coronavirus tests each month in addition to the eight tests per month provided to all Americans. Continue Reading
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30 Mar 2022
Org Streamlines Billing, Authorizations in Public Payer Coverage
CalOptima sought to make claims processing and prior authorizations more efficient for members with public payer coverage by revamping its technologies. Continue Reading
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29 Mar 2022
National Healthcare Spending May Grow 5% in the 2020s
From 2021 to 2030, national healthcare spending will return to its steady upward growth as the unusual impacts of the coronavirus pandemic dissipate. Continue Reading
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29 Mar 2022
4 Tools for Managing Risk in Medicaid Managed Care Organizations
Since Medicaid managed care organizations provide coverage for challenging beneficiary populations, states and organizations need to manage risk well. Continue Reading
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28 Mar 2022
State-Based Marketplace Premiums to Increase Without ARPA Expansion
State-based marketplace enrollees will likely see premium increases between 15 and 70 percent in 2023 if Congress lets the subsidies under the American Rescue Plan Act expire. Continue Reading
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28 Mar 2022
Benefits of an Integrated Healthcare Payments Platform to Payers
Payers need a new platform approach to capitalize on the healthcare consumerization and personalization movement. Continue Reading
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24 Mar 2022
Securing Temporary Public Payer Policies Following the PHE
Making temporary public payer policies permanent would help ensure beneficiaries maintain access to telehealth and other healthcare services after the public health emergency ends. Continue Reading
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23 Mar 2022
Feds Reflect on the Impact of the Affordable Care Act
CMS and HHS leaders touted critical outcomes from the first 12 years of the Affordable Care Act, citing lower premiums on the marketplace and higher enrollment and coverage. Continue Reading
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21 Mar 2022
The Unintended Consequences of Complex Healthcare Payment Systems
Payers must first make an honest assessment of their current payment systems and consider whether they are truly capable of enabling success in the years to come. Continue Reading
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17 Mar 2022
Tobacco Surcharge May Limit Affordable Care Act Enrollment
While the surcharge is intended to disincentivize smoking, it might instead disincentivize enrollment in Affordable Care Act plans particularly in rural counties. Continue Reading
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16 Mar 2022
Trends, Changes in 2020 Medicare Supplement Plan Enrollment
Medicare Supplement plan enrollment increased for plans G, D, and N with 86 companies offering policies to 490,000 beneficiaries across 39 states. Continue Reading
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16 Mar 2022
92% of Counties Have Affordable Care Act Plans with 3 to 5 Stars
Counties with higher-rated Affordable Care Act plans were less likely to be rural, had strong access to care, and had substantial payer participation. Continue Reading
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15 Mar 2022
What Public Payers Can Do To Stop Public Charge Misinformation
Misunderstandings about the public charge rule continue to impact healthcare coverage among immigrants, but public payers can rectify this trend. Continue Reading
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14 Mar 2022
National Coverage Determination May Limit Access to AD Treatment
The national coverage determination draft does not account for access to hospital outpatient departments, which may impact access to the new Alzheimer’s treatment, researchers noted. Continue Reading
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14 Mar 2022
Understanding the Complexity of Healthcare Claims, Payments
The complexity around healthcare claims is creating ongoing challenges for payers, providers, and members. Continue Reading
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14 Mar 2022
Behaviorally Informed Letters Boost Affordable Care Act Enrollment
Affordable Care Act marketplace enrollment increased by 0.3 percentage points among individuals who received behaviorally informed letters during the final weeks of the open enrollment period. Continue Reading
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10 Mar 2022
How Ending the Public Health Emergency Impacts Medicaid Spending
States should prepare for fluctuations in Medicaid spending on nonelderly acute care after the declaration ends. Continue Reading
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10 Mar 2022
Medicaid Spending on Home, Community-Based Services Up by $116B
The increase in the federal matching rate from the American Rescue Plan helped expand access to and boost Medicaid spending for home and community-based services. Continue Reading
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04 Mar 2022
Top Benefits, Challenges of NC Medicaid Managed Care Model
North Carolina’s Medicaid managed care program is less than a year old, but it has already accrued insights into the benefits and challenges of implementing a managed care model. Continue Reading
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03 Mar 2022
How Ending the Public Health Emergency Impacts Medicaid Enrollees
Terminating the public health emergency means terminating certain flexibilities that have kept Medicaid beneficiaries covered during the pandemic. Continue Reading
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02 Mar 2022
Medicare Advantage Plans Boost Supplemental Benefits Offerings
Supplemental benefits offerings from Medicare Advantage plans have increased this year, including benefits for members with chronic conditions and expanded supplemental benefits. Continue Reading
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25 Feb 2022
How 2020 Healthcare Spending Trend Fits Within Decades of Growth
The 2020 coronavirus-driven healthcare spending spike certainly was an anomaly, but it also continued a decades-long upward trend. Continue Reading
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23 Feb 2022
Medicare Premiums, Inflation Create Affordability Challenges
After a historic increase in Medicare Part B premiums, seniors struggle to cover healthcare expenses. Continue Reading
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23 Feb 2022
4 Ways That 1115 Medicaid Demonstrations Can Address Health Equity
Section 1115 Medicaid demonstrations can help reduce care disparities among underserved populations in various ways. Continue Reading
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21 Feb 2022
Smokers in Medicaid Rarely Accessed Cessation Medication, Counseling
Less than 10 percent of smokers in Medicaid-fee-for-service who recently tried to quit reported a claim for cessation medication or counseling services. Continue Reading
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17 Feb 2022
State, Medicaid Coverage For Obesity Treatments Varies Widely
The factors behind how states decide whether or not to offer state or Medicaid coverage for obesity treatments remain unclear. Continue Reading
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09 Feb 2022
High Health Insurance Literacy Tied to Medicare Advantage Enrollment
Enrollment in Medicare Advantage plans with low premiums and high star ratings was higher among Medicare beneficiaries with high health insurance literacy. Continue Reading
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08 Feb 2022
MACPAC Shares Spending Trends Among Dual Eligible Beneficiaries
Dual eligible beneficiaries spent more per beneficiary on long-term supports and services than non-dual eligible Medicaid beneficiaries, which pushed Medicare and Medicaid spending. Continue Reading
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08 Feb 2022
How States Are Addressing The Youth Mental Health Crisis With ARPA
Stemming the growing youth mental health crisis is significant for states and funding from the American Rescue Plan Act has provided some tools for responding. Continue Reading
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01 Feb 2022
US Reps Urge CMS to Maintain Medicare Advantage Benefits in 2023
In a bipartisan effort, the policymakers commended CMS for supporting the program and urged them to protect and ensure Medicare Advantage benefits for next year’s plan. Continue Reading
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31 Jan 2022
How OR Plans to Use a Public Option to Advance Health Equity
Oregon’s public option will seek to reduce care disparities and improve affordability of care for all of the state’s residents. Continue Reading
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31 Jan 2022
Adolescents with SUDs in Medicaid Rarely Get Substance Abuse Care
Only half of adolescents enrolled in Medicaid received substance use screenings at their last medical visits and few adolescents with substance use disorders accessed substance abuse care. Continue Reading
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27 Jan 2022
Uninsurance Rate Drops to 8.9% in Q3 2021, Nears Record Low
After years of a gradual incline, the uninsurance rate dropped from the fourth quarter of 2020 to the third quarter of 2021; CMS announced measures to drive it down further among children. Continue Reading
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24 Jan 2022
Payer Affordable Care Act Marketplace Participation Grew in 2022
Payer Affordable Care Act marketplace participation expanded considerably in 2022, with one state seeing an 83 percent increase in the number of plan offerings. Continue Reading
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24 Jan 2022
5 Reasons Why Payers Should Bolster Payment Integrity
Payment integrity strategy should go beyond fraud, waste, and abuse prevention. Cost containment, compliance, and member experience are just some of the reasons why payers should bolster this area. Continue Reading
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20 Jan 2022
The Role of Medicaid Plans in Assuring LGBTQI+ Access to Care
Medicaid plans and community-affiliated plans are in critical positions to eliminate barriers that prevent LGBTQI+ members from accessing care. Continue Reading
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18 Jan 2022
CHIP Coverage Option May Help Improve Prenatal Care for Immigrants
The CHIP coverage option provides prenatal and postpartum care to immigrants and their children, regardless of their immigration status or Medicaid eligibility. Continue Reading
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11 Jan 2022
CMS Releases Medicare Coverage Proposal for Alzheimer’s Treatment
CMS is requesting public comments on their proposal for Medicare coverage of monoclonal antibodies directed against amyloid as treatment for Alzheimer’s. Continue Reading
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11 Jan 2022
Medicaid Expansion Shrinks Distance to Care, Improves Equity
After Medicaid expansion, Black beneficiaries—particularly in rural areas—had to travel fewer miles to access care. Continue Reading
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10 Jan 2022
How Medicaid Enrollment Assistance Supports Incarcerated Persons
Medicaid enrollment assistance may be an effective tool that could improve care utilization among previously incarcerated individuals who have substance use disorders. Continue Reading
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06 Jan 2022
Medicare Coverage Policies Can Result in Millions of Denied Claims
Denied claims in Medicare and Medicare Advantage amounted to $416 million in denied spending from 2014 through 2019. Continue Reading
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05 Jan 2022
How Phone Calls Impact Affordable Care Act Marketplace Enrollment
Researchers assessed how personalized phone calls affect Affordable Care Act marketplace enrollment, specifically among certain subgroups of potential enrollees. Continue Reading
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29 Dec 2021
More Medicare Beneficiaries with COPD Enrolled in FFS Than MA
Medicare beneficiaries with chronic obstructive pulmonary disease were more likely to be in a fee-for-service Medicare plan, have dual eligible status, and be younger than 76. Continue Reading
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28 Dec 2021
CMS Blocks Work Requirements, Cost-Sharing in 1115 Medicaid Demo
The agency alerted Georgia that the state would no longer have the authority to implement work requirements or cost-sharing in its Medicaid program. Continue Reading
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28 Dec 2021
CMS Updates Affordable Care Act, Public Payer Enrollment Numbers
Affordable Care Act enrollment for 2022 and public payer enrollment midway through 2021 saw some record-breaking surges. Continue Reading
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23 Dec 2021
Medicaid Managed Care Organizations Help Address SDOH, Health Equity
Many states include contract requirements that encourage Medicaid managed care organizations to address social determinants of health and health equity in members. Continue Reading
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22 Dec 2021
MA Quality Bonus Program Did Not Boost Overall Performance Quality
The Medicare Advantage quality bonus program was associated with improvements in some plan quality measures but decreases in others. Continue Reading
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21 Dec 2021
Medicaid Asset Test Revisions May Increase Dual Eligibility for Seniors
More low-income and non-White Medicare beneficiaries could receive dual eligible coverage if the Medicaid asset test limits increased. Continue Reading
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20 Dec 2021
Medicaid Expansion May Be Associated with Lower Mortality Rates
All-cause mortality rates were lower in states that enacted Medicaid expansion compared to nonexpansion states. Continue Reading
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15 Dec 2021
ACHP Asks CMS To Set At-Home COVID-19 Testing Coverage Standards
Manual claims submissions for at-home COVID-19 testing coverage could place a burden on the healthcare industry and upfront testing costs could pose SDOH barriers, ACHP said. Continue Reading