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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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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22 Apr 2020
CMS Suspends Quality Reporting Measures Amid Pandemic
To promote safety and an effective provider response to COVID-19, CMS announced it is suspending data collection and reporting for several key quality survey programs. Continue Reading
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22 Apr 2020
OK Submits Healthy Adult Opportunity Waiver to Expand Medicaid
Oklahoma’s Healthy Adult Opportunity demonstration waiver would also implement work requirements and charge beneficiaries monthly premiums. Continue Reading
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13 Apr 2020
How to Improve Medicaid Member Engagement, Care Coordination
California’s Medicaid pilots shed light on effective Medicaid member engagement and care coordination, overcoming data sharing and partner engagement challenges. Continue Reading
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09 Apr 2020
Public, Private Payers Offer Upfront Reimbursement Amid COVID-19
Medicare, Blue Shield of California, and UnitedHealth Group are among those offering upfront reimbursement and relaxing billing requirements during the COVID-19 crisis. Continue Reading
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08 Apr 2020
CA Boosts Worker’s Comp, Insurance Benefits for COVID-19 Diagnosis
Worker's compensation is separate from health payer coverage, but will make a dent in healthcare costs should a patient contract COVID-19 on the job of an essential business. Continue Reading
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08 Apr 2020
UT Suspends Work Requirements Due To COVID-19 Unemployment Rates
After Utah’s unemployment claims jumped 1,391 percent in one week, the state decided to suspend work requirements attached to Medicaid expansion. Continue Reading
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26 Mar 2020
Block Grants Are Not The Solution to High Medicaid Spending
Block grants run the risk of higher spending, present challenges in accurately calculating growth rates, and will decrease access to care for beneficiaries during COVID-19. Continue Reading
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25 Mar 2020
CMS Enacts 6.2% FMAP Boost For Coronavirus Medicaid Spending
Medicaid programs must have continuous coverage and not raise premiums or further restrict eligibility in order to qualify for the FMAP boost against coronavirus. Continue Reading
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24 Mar 2020
CMS Approves 11 New 1135 Medicaid Demos, 25% Of States Approved
Within ten days of the president declaring coronavirus a national emergency, CMS has approved 13 states’ 1135 Medicaid demonstration waivers. Continue Reading
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24 Mar 2020
Payer Claims, Economics, Operations Will Suffer Due to COVID-19
Despite the many blows the payer industry will receive due to COVID-19, the industry’s outlook for 2020 continues to be stable. Continue Reading
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23 Mar 2020
CMS Releases Four Medicaid Waiver Templates To Fight Coronavirus
The Medicaid waiver templates are intended to make application processes faster and decrease administrative burden as states struggle to contain the coronavirus. Continue Reading
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17 Mar 2020
States Seek CMS Approval For Medicaid, ACA Exchange Flexibility
Florida receives CMS approval for a Medicaid 1135 waiver and New Jersey requests flexibility for its ACA exchange enrollment. Continue Reading
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17 Mar 2020
3 Forms of Medicaid Expansion that Can Increase COVID-19 Coverage
There is more than one way for states to implement Medicaid expansion as they seek to improve COVID-19 coverage. Continue Reading
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16 Mar 2020
Aligned Enrollment Improves Dual Eligible Care Coordination
However, CMS needs to provide more oversight for aligned enrollment to ensure quality of care for dual eligible beneficiaries. Continue Reading
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13 Mar 2020
How MA Special Needs Plans Could Reinvent Homeless Healthcare
With its increased flexibilities, the Medicare Advantage special needs plan would be better equipped to serve the diverse demands of homeless healthcare. Continue Reading
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03 Mar 2020
How CMS Can Standardize Prior Authorization Using MA Star Ratings
MGMA recommended that CMS use Medicare Advantage star ratings criterion to standardize the prior authorization process, easing providers’ administrative burden. Continue Reading
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03 Mar 2020
Block Grant Complexity, Vagueness May Limit Medicaid Uptake
The block grant may demand high Medicaid savings, could result in federal funding reductions, and the guidance is too vague, an Avalere report revealed. Continue Reading
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28 Feb 2020
GAO: New DOD Health Plan Fails to Improve Patient Satisfaction
Patient satisfaction still hovers around 68 percent for TRICARE health plans and access to mental healthcare providers for new TRICARE patients is more difficult. Continue Reading
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20 Feb 2020
CA Sees 41% New Enrollment Spike in State Health Insurance Market
State officials attribute the spike in new enrollment on the state health insurance market to the state’s individual mandate and additional state subsidies. Continue Reading
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20 Feb 2020
Challenges and Solutions of Medicaid Beneficiary Communication
The diversity of preferences makes Medicaid beneficiary communication and member engagement challenging but not insurmountable. Continue Reading
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19 Feb 2020
Appeals Court Strikes Down AR Medicaid Work Requirements
The appeals court found Secretary Azar’s approval letter failed to address concerns about Medicaid work requirements. Continue Reading
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18 Feb 2020
GAO Reveals Medicaid Eligibility Inaccuracies, Recoup Strategies
Sixty-two percent of states in a GAO report had incorrect or incomplete income or asset information in their Medicaid eligibility determinations. Continue Reading
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17 Feb 2020
VA Medicaid Program Reduces ED Admissions for Opioid Use Disorder
Virginia’s Medicaid programs responded to the opioid crisis by expanding treatment for beneficiaries with opioid use disorder, reducing ER admissions by 21.1%. Continue Reading
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05 Feb 2020
HIV Patients Could Lose Coverage Under Medicaid Work Requirements
Medicaid work requirements, if scaled nationally, could mean unstable coverage or ineligibility for patients with HIV. Continue Reading
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05 Feb 2020
What are Impacts of the Medicaid Fiscal Accountability Regulation?
The Medicaid Fiscal Accountability Regulation is a proposed rule from CMS that seeks to reform provider reimbursements and control Medicaid spending. Continue Reading
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04 Feb 2020
Medicaid Expansion May Improve Minority and Low-Income Employment
Minority and low-income employment and academic status increased in Michigan for the Medicaid population while the statewide trends were fairly static. Continue Reading
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03 Feb 2020
ACA Leads to Insurance Gains, Affordable Access to Care Wanes
The ACA successfully increased insurance rates in the US, but high healthcare costs continue to dampen patients’ access to care. Continue Reading
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30 Jan 2020
How State Budgets Impact Medicaid Funding, Reveal Priorities
Budget negotiations explore Medicaid expansion, leverage Medicaid privatization, pursue cost savings, and place Medicaid funding at the mercy of politics. Continue Reading
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29 Jan 2020
Medicaid Expansion May Impact Patient Outcomes in Southern States
While southern states debate Medicaid expansion, researchers find that Medicaid expansion led to better coverage and better patient outcomes. Continue Reading
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20 Jan 2020
Medicaid Expansion Means Better Postpartum Coverage, Utilization
Colorado’s Medicaid expansion may be responsible for its superior rate of postpartum coverage and utilization when compared to Utah, which did not expand Medicaid. Continue Reading
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16 Jan 2020
2017 State Medicaid Spending Rose as Feds Withdrew Funding
State Medicaid spending from states’ own revenues increased as states took on more responsibility for their own Medicaid spending in 2017. Continue Reading
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15 Jan 2020
Cost of Cancer Care Reaches Nearly $150B Nationally
Many cancer patients struggle with out-of-pocket cancer care expenses, with one drug costing nearly $12,000 annually and FDA approved drugs priced over $100,000 a year. Continue Reading
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03 Jan 2020
Despite Early Low Enrollment, Federal Exchange Enrollment Steady
The federal exchange enrollment was around 20 percent lower than last year in an early analysis but rose to just shy of last year’s overall enrollment. Continue Reading
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26 Dec 2019
Best Practices to Address Opioid Use Disorder for Medicaid Directors
A new toolkit identifies best practices for Medicaid directors to address opioid use and substance abuse in their states. Continue Reading
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19 Nov 2019
How Patient Navigators Drive the Medicare Open Enrollment Season
Patient navigators leading Medicare open enrollment season report that the multitude of plans, regulatory changes, and new technologies confuse enrollees. Continue Reading
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27 Aug 2019
Medicare Plan Finder Aims for Price Transparency, Plan Comparison
The new CMS Medicare Plan Finder seeks to streamline price transparency and plan comparison through new features and a refreshed design. Continue Reading
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13 Aug 2019
How Health Policy is Working to Reduce Medicare Drug Spending
Policymakers have targeted Medicare drug spending from many angles to drive down healthcare costs. Continue Reading
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31 Jul 2019
Expanding Medicare Supplemental Benefits to Benefit Seniors
With fewer Medicare beneficiaries receiving supplemental coverage through employer-sponsored insurance, Medicare’s supplemental benefits should expand. Continue Reading
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24 Jul 2018
Generic Drugs Could Have Saved $3B for Medicare Part D Program
The Medicare Part D program could have saved $3 billion in 2016 if the payer encouraged generic drug substitution over the use of brand-name therapies. Continue Reading
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29 May 2018
Preventing Provider Fraud through Health IT, Data Analytics
Payers that want to improve their ability to detect and react to provider fraud must invest in health IT and data analytics solutions to flag criminal activity. Continue Reading
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07 Jun 2017
Two Payers Liable for $32.5M in Medicare Advantage Fraud Suit
Freedom Health and Optimum Healthcare have been ordered to pay $32.5 million for systemic Medicare Advantage fraud alleged by a whistleblower lawsuit. Continue Reading
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23 May 2017
Understanding the Basics of Accountable Care Organizations
Since their inception, accountable care organizations (ACOs) have blazed a path of innovation in the healthcare industry, from delivery to quality of care. Continue Reading
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13 Jan 2017
How Payers Can Improve HEDIS Quality Measure Performance
Population health management, health IT investment, and provider engagement need to be targeted to improve HEDIS quality measure performance. Continue Reading
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07 Oct 2016
How Medicare, Medicaid, and CHIP Guide the Health Payer Industry
Public coverage programs like Medicare, Medicaid, and CHIP are leading the way in value-based care payment models. Continue Reading
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05 Jul 2016
Why HEDIS Quality Measures Matter for Value-Based Care
HEDIS measures are being followed by public health payers that are moving into the value-based care sphere as well. Continue Reading
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30 Dec 2015
The History and Evolution of CHIP and the Medicare Program
When Lyndon B. Johnson took the presidency in 1964, the Medicare program was finally established as a system to provide healthcare coverage to elderly citizens around the nation. Continue Reading