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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News
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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27 Sep 2024
Top health insurance trends based on quality measures
The 2024 NCQA Health Plan Ratings revealed quality measure performance trends that could guide payers’ decisions on major topics like health equity and diabetes care going forward. Continue Reading
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14 Dec 2021
Dual Eligible Beneficiaries Prefer Medicare Advantage Over FFS
Dual eligible beneficiaries enrolled in Medicare Advantage plans sought preventive care more often and saw lower healthcare costs compared to beneficiaries in fee-for-service Medicare. Continue Reading
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13 Dec 2021
ACA Marketplace Open Enrollment Sees 4.6M Enrollees So Far
Almost 4 million enrollees have found coverage on HealthCare.gov while 625,000 joined through state-based marketplaces during the ACA marketplace open enrollment period. Continue Reading
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13 Dec 2021
As High-Dollar Claims Come In, Focus on Payment Integrity Is Key
High-dollar claims are a persistent challenge for payers; a comprehensive payment integrity strategy can help payers ensure higher dollar claims are accurate and necessary. Continue Reading
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09 Dec 2021
Few Seniors Have Changed Plans During 2022 Open Enrollment
Many seniors chose not to make a shift during the 2022 open enrollment season because they did not think they could find a health plan better than their current one. Continue Reading
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08 Dec 2021
2022 ACA Marketplace Premiums Depend on Enrollee Income, Location
Enrollees may experience distinct ACA marketplace premium amounts depending on their subsidy eligibility and the county they live in. Continue Reading
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06 Dec 2021
MS Medicaid Expansion Could Reduce State Medicaid Spending
Mississippi’s Medicaid program ranks poorly for its access to and quality of care, but Medicaid expansion could increase healthcare coverage along with lowering state Medicaid spending. Continue Reading
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06 Dec 2021
How Pre-Payment Review Elevates Payer Payment Integrity
Payers tend to rely on post-payment reviews to ensure appropriate reimbursement, but payer payment integrity is lagging without comprehensive pre-payment reviews. Continue Reading
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30 Nov 2021
Medicaid Managed Care Models May Improve Outcomes for Elderly, Disabled
Elderly and disabled Medicaid beneficiaries may see better health outcomes if their state transitions them from fee-for-service plans to a managed care model. Continue Reading
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30 Nov 2021
Size of Medicaid Expansion Influenced Administrative Spending
States that enacted Medicaid expansion and had high uninsurance rates among low-income residents were considered large expansion states and subsequently saw a slight decrease in administrative spending. Continue Reading
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29 Nov 2021
Solidifying Coronavirus Policies Might Improve Access to Coverage
Policymakers can learn from the temporary policies that supported Americans during the coronavirus pandemic and improve access to coverage. Continue Reading
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29 Nov 2021
Trends in 2021 Affordable Care Act Marketplace Insurers, Locations
Insurer participation in the Affordable Care Act marketplace has increased since 2018 with notable trends in counties that saw higher participation. Continue Reading
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24 Nov 2021
$0 Premium Plans Are Pushing Medicare Advantage Premiums Lower
Selected Medicare Advantage premiums have dropped to an average of $4 in the first half of the 2022 open enrollment period. Continue Reading
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24 Nov 2021
Medicaid Expansion May Be Key To Permanently Closing Coverage Gap
The federal government’s Build Back Better Act would offer increased coverage access for three years, but Medicaid expansion would ensure permanent coverage for over 2 million individuals. Continue Reading
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23 Nov 2021
How COVID-19 Impacted The Individual Health Insurance Marketplace
Certain state-based individual health insurance marketplaces and California experienced favorable selection during 2020. Continue Reading
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17 Nov 2021
Public Payers See Higher Member Satisfaction on Network Size, Cost
Overall, 79 percent of respondents gave their Medicaid plans a high rating, compared to 70 percent of those in employer-sponsored health plans. Continue Reading
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16 Nov 2021
Centene Will Address Serious Mental Healthcare in AZ Medicaid
The payer’s contract to address serious mental healthcare needs in Arizona will last three years, with the opportunity to extend the contract. Continue Reading
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15 Nov 2021
ACA 2022 Open Enrollment Starts Off With 133K New Enrollees
CMS officials noted special enrollment period outcomes and emerging state-based exchanges as two factors influencing the 2022 open enrollment season. Continue Reading
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15 Nov 2021
Claims Payment Transformation Benefits Payer, Providers, and Members
Payers, providers, and members can all benefit from transforming the manual and patchwork claims payment process to a digital environment that also automates claims data delivery. Continue Reading
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10 Nov 2021
Trends in Medicare Advantage 2022 Open Enrollment Offerings
Nearly all Medicare Advantage plans are offering telehealth and remote patient monitoring benefits in 2022 during Medicare Advantage 2022 open enrollment. Continue Reading
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05 Nov 2021
Providers Share Benefits of Medicare Advantage During COVID-19
Providers’ experiences with Medicare Advantage plans’ capitated payment models, supplemental benefits, and overall influence gave them recommendations for CMS. Continue Reading
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03 Nov 2021
Affordable Care Act Marketplace Premium Growth Outpaced Income
Prior to the American Rescue Plan Act’s premium tax credits, Affordable Care Act plans were too costly for many middle class families. Continue Reading
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02 Nov 2021
Medicaid, ACA Enrollment Growth Attended Level Uninsurance in 2020
Experts expected enrollment growth in Medicaid and the Affordable Care Act marketplaces, but the growth rate was not as high as anticipated. Continue Reading
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28 Oct 2021
Survey Shows COVID-19 Toll on Senior Mental Health, Social Health
Seniors reported poor mental health conditions, but only three percent had accessed mental healthcare to address their needs. Continue Reading
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27 Oct 2021
CMS Shares Affordable Care Act Marketplace Open Enrollment Details
The 2022 Affordable Care Act marketplace open enrollment season will involve heightened Navigator presence and new HealthCare.gov features. Continue Reading
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27 Oct 2021
KLAS Identifies Top Vendor for Core Administration Platforms
HealthEdge surpassed most of its core administration platform competitors on KLAS performance metrics. Continue Reading
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25 Oct 2021
Modernizing Claims Payment to Improve Member Experience
Electronic claims payment adoption is key to delivering a modernized member experience that provides simplified, electronic communications about costs and benefits across providers. Continue Reading
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21 Oct 2021
BMA: Medicare Advantage Offers Lower Costs, Better Benefits Than FFS
The federal government and beneficiaries spend less on Medicare Advantage plans, which offer additional benefits and lower cost-sharing compared to FFS Medicare, experts found. Continue Reading
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18 Oct 2021
Impact of Fixed American Rescue Plan Act Subsidies on Families
Uninsurance rates among children and parents may fall if policymakers make the American Rescue Plan Act subsidies permanent, an Urban Institute report found. Continue Reading
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15 Oct 2021
How Medicaid Expansion Impacted Site of Care, Outcomes in MI
Michigan’s Medicaid expansion had generally positive results for racial and ethnic minorities in the state, but it did not improve poor mental health. Continue Reading
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14 Oct 2021
How MA Special Needs Plans Compare to Traditional Medicare, MA
Medicare Advantage plans have emphasized how Medicare Advantage beneficiaries differ from traditional Medicare beneficiaries, but special needs plan members exhibit more differences. Continue Reading
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13 Oct 2021
Plan Comparison Was Low During Medicare Open Enrollment 2018
Data shows that Medicare beneficiaries did not compare health plans during the 2018 open enrollment period, leaving payers to wonder how beneficiaries will engage in 2021. Continue Reading
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13 Oct 2021
CO Will Add LGBTQ+ Care As Marketplace Essential Health Benefit
CMS has approved Colorado’s request to add benefits such as breast and chest reconstruction and facial feminization to the list of essential health benefits. Continue Reading
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12 Oct 2021
How Payers Optimize Claims Payment to Reduce Provider Friction
Electronic claims payment adoption is key to reducing the friction between payers and providers, as long as the solution can enable secure, convenient access to EFT and ACH options. Continue Reading
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11 Oct 2021
Expanding Social Determinants of Health Benefits Among Public Payers
Medicaid programs have many opportunities to address social determinants of health, but HHS and CMS may need to provide even more flexibility, according to the Bipartisan Policy Center. Continue Reading
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08 Oct 2021
87 Contracts Score 5 Stars on 2022 Medicare Advantage Star Ratings
On average, Medicare Advantage-prescription drug plans scored 4.37 stars for the 2022 Medicare Advantage Star Ratings. Continue Reading
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06 Oct 2021
Medicaid Expansion May Improve Maternal Health Outcomes, Coverage
Medicaid expansion may be particularly impactful for pregnant persons during the prepregnancy period, supporting preventive care services through coverage. Continue Reading
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06 Oct 2021
CMS: KY, ME, NM Will Launch State-Based Marketplaces in 2022
The three states will transition from state-based marketplaces on the federal platform to become state-based marketplaces. Continue Reading
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05 Oct 2021
Top Payer Strategies for Overcoming Coronavirus Vaccine Hesitancy
Coronavirus vaccine hesitancy remains a pervasive challenge across members, providers, and community partners, but ACAP safety net health plans have identified successful strategies. Continue Reading
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05 Oct 2021
275K Missourians Eligible for Coverage Following Medicaid Expansion
After more than a year of pushback and legal barriers, individuals in Missouri can now apply for coverage under the state’s Medicaid expansion amendment. Continue Reading
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04 Oct 2021
Payers Share Benefits Before Medicare Advantage Open Enrollment
During the 2022 Medicare Advantage open enrollment season, payers are bringing back many traditional social determinants of health benefits and expanding benefit card offerings. Continue Reading
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30 Sep 2021
2022 Medicare Advantage Premiums Drop, Enrollment May Rise
Medicare Advantage premiums declined from an average of $21.22 per month to $19 per month, but Part D premiums rose. Continue Reading
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28 Sep 2021
Uninsured Adults Remain Unaware of ACA Coverage, Subsidy Options
Researchers found that Affordable Care Act coverage and subsidy awareness among uninsured adults had not seen significant improvement between September 2020 and April 2021. Continue Reading
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27 Sep 2021
OIG: Medicare Advantage Plans Improperly Used Chart Reviews, HRAs
A handful of Medicare Advantage plans were responsible for a large portion of improper risk-adjusted payments due to misuse of chart reviews and health risk assessments. Continue Reading
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23 Sep 2021
Medicare Advantage Double Bonus Payments Boost Racial Disparities
Medicare Advantage double bonus payments did not boost quality or enrollment in Medicare Advantage and drove racial disparities deeper. Continue Reading
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22 Sep 2021
Expanding Covered Medicare Benefits May Lower Out-of-Pocket Costs
Including dental, hearing, and vision coverage in Medicare plans may boost federal spending, but it would also close coverage gaps and lower out-of-pocket costs for beneficiaries. Continue Reading
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20 Sep 2021
CMS Makes Changes to Open Enrollment Period, Introduces New SEP
The agency has extended the open enrollment period, expanded its Navigator program, and increased community outreach to improve access to healthcare coverage on the ACA Marketplace. Continue Reading
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16 Sep 2021
BMA Asks Congress to Secure Medicare Advantage Benefits in Reform Bill
Better Medicare Alliance expressed its gratitude to Congress for protecting Medicare Advantage beneficiaries in its reform bill which adds benefits to fee-for-service Medicare. Continue Reading
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16 Sep 2021
The Changing Landscape of Healthcare B2B Payment Transactions
Higher adoption of electronic payment processes is driving healthcare B2B payment transactions in both volume and value. Continue Reading
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15 Sep 2021
Affordable Care Act Marketplace Sees Boost in Diversity, Savings
HHS announced that the Affordable Care Act market saw a higher share of Black enrollees and that nine in ten new enrollees saw reductions to their premiums. Continue Reading
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14 Sep 2021
How to Expand Access to Coverage for Former Foster Children
Researchers compared policies that expand access to coverage through Medicaid for young adults who were previously in the foster care system. Continue Reading
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09 Sep 2021
Downstream Impacts of Making American Rescue Plan Act Permanent
Solidifying the American Rescue Plan Act coverage changes could lead to better access to healthcare coverage and may impact racial care disparities. Continue Reading
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07 Sep 2021
Medicare Mortality Rates Reveal COVID-19 Racial Care Disparities
The coronavirus pandemic spotlighted racial care disparities in Medicare as minority beneficiary populations saw higher increases in mortality than their White counterparts. Continue Reading
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06 Sep 2021
Medicaid Subscription-Based Payment Models Show Mixed Results
Louisiana and Washington both implemented subscription-based payment models, but the states saw disparate results. Continue Reading
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03 Sep 2021
CMS Guidance Promotes COVID-19 Vaccine Coverage, Medicaid Expansion
New CMS guidelines emphasize COVID-19 vaccine and testing coverage and Medicaid expansion incentives. Continue Reading
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01 Sep 2021
How States Leveraged COVID-19 Medicaid Emergency Authorizations
All states leveraged some form of COVID-19 Medicaid emergency authorization, but their goals and strategies around these waivers varied broadly. Continue Reading
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01 Sep 2021
Electronic Payment Adoption Key to Healthcare Industry Savings
Electronic payments save the healthcare industry millions, but their increased use could lead to even more savings. Continue Reading
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01 Sep 2021
Highmark Will Distribute $12.3M in Affordable Care Act Rebates
Individual policyholders could receive around $405 per person in Affordable Care Act rebates and small businesses could receive over $1,500. Continue Reading
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31 Aug 2021
Medicaid Expansion Tied to Coverage Access, Lower State Spending
Medicaid expansion could lead to lower uninsurance, lower state spending, and potentially improve certain economic factors in states that adopt this approach. Continue Reading
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30 Aug 2021
CMS Announces Historic Navigator Grant Funding for 2022-2024
CMS will provide $80 million total in Navigator grant funding which the agency hopes will bolster organizations’ outreach to underserved populations. Continue Reading
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27 Aug 2021
DE Cites Delayed Care in 2022 Affordable Care Act Premium Boost
Delaware has experienced a surge in enrollment on its marketplace and anticipates, on average, a three percent higher base rate for its 2022 Affordable Care Act premium. Continue Reading
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26 Aug 2021
How New Medicare Benefits Would Impact Medicare Advantage Rebates
Medicare Advantage rebates would drop significantly if Congress chose to siphon some funding to cover additional benefits for traditional Medicare. Continue Reading
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24 Aug 2021
CMS Asks Medicare Advantage Plans to Relax Prior Authorizations
The agency emphasized relaxing prior authorizations that could impact transferrals between general acute-care hospitals and longer-term care facilities. Continue Reading
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19 Aug 2021
Top 4 Policy Strategies To Diminish State Healthcare Spending
As states seek to lower state healthcare spending, they have a number of tools at their disposal including advanced payment models and strategies that target low-value care spending. Continue Reading
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17 Aug 2021
CO Extends Reinsurance Program After 1.5 Years of Lower Premiums
The statewide average premium was 20.9 percent lower in 2020 than it would have been without the waiver and 20 percent lower in 2021, so far, due to the reinsurance program. Continue Reading
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13 Aug 2021
Medicare Covers COVID-19 Booster for Immunocompromised Americans
The coronavirus booster shot will be cost-free for immunocompromised Americans as the Delta variant sweeps across the globe. Continue Reading
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12 Aug 2021
Medicaid Programs Call for Medicare Coverage of Alzheimer’s Drug
Lack of Medicare coverage for the new Alzheimer’s therapy could force Medicaid programs to cut back on other necessary expenditures to cover the drug, Medicaid directors warned. Continue Reading
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11 Aug 2021
How State Support for Medicaid HCBS Impacts COVID-19 Vaccination
Medicaid HCBS providers play a key role in coronavirus vaccine uptake among Medicaid beneficiaries, but they need more support from state payers. Continue Reading
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09 Aug 2021
Medicaid Expansion Decreased Surgical Catastrophic Spending
States that embraced Medicaid expansion saw reductions in the uninsurance rate accompanied by lower surgical catastrophic spending. Continue Reading
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06 Aug 2021
American Rescue Plan Act Subsidies Reduce State Premiums by 40%
As the special enrollment period deadline approaches, CMS has released data showing that the American Rescue Plan subsidies have halved ACA premiums in some states. Continue Reading
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02 Aug 2021
CMS: Medicare Part D Monthly Premium May Be 5% Higher in 2022
The Medicare Part D monthly premium could rise to approximately $33.37 in 2022, the agency projected. Continue Reading
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28 Jul 2021
Medicare Survey Explores COVID-19 Vaccine Uptake Among Seniors
The survey data reveals seniors’ coronavirus vaccine uptake as well as how the coronavirus pandemic impacted Medicare beneficiaries’ mental health. Continue Reading
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27 Jul 2021
How Medicare Eligibility Impacts Racial Coverage Disparities
Medicare eligibility was associated with a 53 percent decrease in the healthcare coverage gap between Black individuals and White individuals. Continue Reading
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26 Jul 2021
HHS, CMS Urge States To Correct Public Charge Rule Misinformation
Under the current public charge rule, immigrants can receive public payer coverage, but not all immigrants are aware that the 2019 public charge rule is no longer in effect. Continue Reading
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22 Jul 2021
Uninsurance Rate Drops As Marketplace, Medicaid Enrollment Rises
The uninsurance rate declined from around 12.5 percent in the first half of 2020 to approximately 10 percent in the first half of 2021. Continue Reading
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19 Jul 2021
CMS Leads Final Outreach Push During Special Enrollment Period
The Biden administration and CMS are attempting to increase federal health insurance enrollment during the last month of the special enrollment period. Continue Reading
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15 Jul 2021
Public Option with ACA Subsidies Lowers Gains in Federal Spending
A public option with Affordable Care Act marketplace subsidies would produce lower increases in federal spending than expanding Affordable Care Act marketplace subsidies alone. Continue Reading
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14 Jul 2021
Medicare Coverage Determination for Alzheimer's Drug Is Underway
A month after the controversial FDA approval of aducanumab, CMS will begin establishing criteria for Medicare coverage of the Alzheimer’s drug. Continue Reading
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13 Jul 2021
How the American Rescue Plan Act Impact NY ACA Enrollee Costs
The American Rescue Plan Act reduced the Affordable Care Act marketplace’s subsidy cliff but did not rectify the family glitch. Continue Reading
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12 Jul 2021
Why States Should Collect Medicaid Retroactive Eligibility Data
Researchers are recommending that CMS require states to evaluate the effects of Medicaid retroactive eligibility after finding a lack of evidence on the subject. Continue Reading
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08 Jul 2021
Immigrant Healthcare Coverage Expansion Lowers Child Uninsurance
California lowered its noncitizen children's uninsurance rate by 34 percent due to immigrant healthcare coverage expansion. Continue Reading
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06 Jul 2021
Missouri Medicaid Expansion Disrupted Due to Legal Roadblock
The measure for Missouri Medicaid expansion, which was supposed to go into effect on July 1, 2021, has been successfully challenged and deemed unconstitutional in court. Continue Reading
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05 Jul 2021
AHIP: Set Lasting Affordable Care Act Subsidies for Low Premiums
If the ARPA’s Affordable Care Act subsidies are not made permanent, ACA members may face higher premiums in 2023, AHIP warned. Continue Reading
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02 Jul 2021
OK Adds 120K New Medicaid Enrollees Due to Medicaid Expansion
The law expanding the Medicaid program went into effect in early June in a state which was sharply divided on the issue of Medicaid expansion. Continue Reading
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24 Jun 2021
Medicaid, CHIP Saw Enrollment Boost During Coronavirus Pandemic
Almost 10 million individuals enrolled in Medicaid or CHIP health plans during a year-long period of the coronavirus pandemic. Continue Reading
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23 Jun 2021
Two Critical Impacts of 2021 Special Enrollment Period Gains
Due to the unique circumstances of the coronavirus pandemic, 2021 special enrollment period gains could have a major influence on customer service needs and risk adjustment. Continue Reading
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22 Jun 2021
CMS Supports Modernizing Enrollment on State-Based Exchanges
Twenty states with state-based exchanges are eligible to receive CMS grant funding, with each awardee receiving approximately $1.3 million. Continue Reading
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18 Jun 2021
How Medicare Advantage Member Engagement Influences Satisfaction
When member engagement and communication between members and health plans is strong, Medicare Advantage member satisfaction rose 54 points. Continue Reading
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16 Jun 2021
Aetna Expands Alignment Program for Dual Eligibles in Illinois
The payer has received positive feedback from dual eligibles in the program about having a designated care coordinator. Continue Reading
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14 Jun 2021
Costs Continue to Drop on Federal Health Insurance Marketplace
The boost to the advanced payments of premium tax credits not only drew more enrollees to the federal health insurance marketplace but also made marketplace costs lower. Continue Reading
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09 Jun 2021
Long-Term Solutions Can Improve Health of Children in Medicaid
NAMD released a report that details how Medicaid programs can actively work to improve children’s mental and physical health following the impacts of the coronavirus pandemic. Continue Reading
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08 Jun 2021
Payer Announces Partnership to Address Opioid Misuse, Disposal
CareSource is working to prevent opioid misuse by providing its members with access to a medication disposal solution. Continue Reading
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04 Jun 2021
Nevada Set to Become Second State with Public Option Health Plan
The public option health plan would require a bidding process and the state would prioritize applicants whose networks align with Medicaid managed care networks, among other factors. Continue Reading
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02 Jun 2021
CMS Raises Awareness of ACA Marketplace Coverage for Gig Workers
CMS is encouraging e-commerce platforms to inform their gig workers about Affordable Care Act marketplace healthcare plans and how they can enroll. Continue Reading
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01 Jun 2021
PAHCF Opposes Medicare Expansion, Suggests Extending ACA Policies
The organization has released a statement detailing their opposition to Medicare expansion and instead highlighting the benefits of extending the Affordable Care Act policies. Continue Reading
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27 May 2021
Defunct Public Charge Rule Still Impacts Immigrant Health Choices
The public charge rule is no longer in effect, but it continues to influence how immigrant families make healthcare decisions. Continue Reading
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21 May 2021
Expanding Medicare Could Increase Coverage but Raise Premiums
Lowering the Medicare age of eligibility to 60 could decrease uninsurance, but could boost costs for lower-income individuals. Continue Reading
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18 May 2021
FFS Medicare May Boast Lower Cost Barriers than Private Medicare
Over 15 percent of privately-insured Medicare seniors in the study would experience cost barriers, compared to 11 percent of traditional Medicare beneficiaries. Continue Reading
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14 May 2021
ACHP Urges Policymakers to Solidify Affordable Care Act Changes
ACHP provides several steps that will leverage the advancements of the Affordable Care Act and increase access to high-quality coverage and care. Continue Reading
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07 May 2021
HHS: ACA Premiums Drop 25% for New Enrollees on HealthCare.gov
For new enrollees who qualify for Affordable Care Act premium tax credits on HealthCare.gov, premiums could be much lower and out-of-pocket healthcare spending may decrease as well. Continue Reading
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05 May 2021
How Messaging Steers ACA Enrollees to Enhanced Silver Plans
States can leverage email and postal communications to improve awareness about enhanced silver plans among eligible Affordable Care Act enrollees. Continue Reading