Healthcare policy and regulation
Policy and regulation significantly affect payers by dictating the standards for health plan offerings, determining coverage requirements, and influencing cost structures. These rules also guide patient data management, ensuring privacy and security, and play a crucial role in shaping overall healthcare market competition, payer strategies and healthcare spending.
Top Stories
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News
21 Oct 2024
HHS seeks to secure PrEP, birth control coverage
A proposed rule supports birth control coverage for FDA-approved therapies and devices with no prescriptions or cost-sharing and clarifies the exceptions process for enrollees. Continue Reading
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30 Sep 2024
Inflation Reduction Act cuts costs of 54 prescription drugs
Medicare Part B enrollees will see lower prescription drug costs due to a rebate program under the Inflation Reduction Act. Continue Reading
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02 Dec 2021
Medicaid Will Cover Coronavirus Vaccine Counseling for Kids
Coronavirus vaccine counseling will now be covered under the Medicaid Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. Continue Reading
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22 Nov 2021
Payers, Orgs React to Coverage Implications of Build Back Better
The industrywide reactions are nuanced and varied, but many healthcare leaders and their organizations have expressed reservations about the Build Back Better Act. Continue Reading
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22 Nov 2021
CMS: Virginia Will Expand Access to Postpartum Medicaid Coverage
Expanding postpartum Medicaid coverage is expected to provide greater insurance stability to around 6,000 new mothers. Continue Reading
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19 Nov 2021
US Drug Pricing Outstrips International Levels, Drives Spending
US drug pricing results in the US spending 30 percent more on prescription drugs than other well-resourced countries. Continue Reading
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18 Nov 2021
How Build Back Better Might Impact Medicare Part D Drug Spending
Medicare Part D drug spending has been increasingly difficult to control, but pending legislation attempts to address escalating drug prices. Continue Reading
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17 Nov 2021
CMS Rule Would Require Payers to Share Data on Drug Spending
Drug spending and its impact on premiums and out-of-pocket healthcare spending are at the heart of the Biden administration’s latest interim final rule related to the No Surprises Act. Continue Reading
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02 Nov 2021
Short-Term Insurance Policy To Pay Out $515K to MA Enrollees
Massachusetts residents may receive compensation for enrolling in a short-term insurance policy that engaged in deceptive practices. Continue Reading
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18 Oct 2021
Why Payers Must Go Beyond Compliance with the Interoperability Rule
Complying with a federal interoperability gives payers an opportunity to evaluate the quality of their data for improving clinical outcomes and risk management. Continue Reading
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07 Oct 2021
ACHP: 5 Policy Recommendations about COVID-19 Testing Coverage
Health plans asked for more guidance around coronavirus testing coverage as they continue to receive work-related testing claims which employers are expected to cover. Continue Reading
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20 Sep 2021
CMS Retreats from 2022 Payer-to-Payer Data Exchange Enforcement
The agency determined that the formatting requirements for the payer-to-payer data exchange were too complex. Continue Reading
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13 Sep 2021
Proposed Policy Would Boost Access to Medicare Dental Benefits
By covering Medicare dental benefits, Congress could improve access to care and lower costs for seniors. Continue Reading
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23 Aug 2021
How Medicaid Expansion Impacted Coronavirus Uninsurance Rates
In states that had adopted Medicaid expansion, uninsurance rates remained stable, but in nonexpansion states uninsurance grew to more than double the rate in expansion states. Continue Reading
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16 Aug 2021
Employers Support Empowering Medicare to Negotiate Drug Prices
The purchaser group argued that Medicare’s inability to negotiate drug prices has a downstream impact on job creation and wages. Continue Reading
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13 Aug 2021
ACHP: Current Medicare Advantage Benchmark Caps Penalize Seniors
Seniors in some areas may lose over a thousand dollars in Medicare Advantage benefits due to current Medicare Advantage benchmark caps, but Congress could fix that, according to ACHP. Continue Reading
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04 Aug 2021
How ARPA Addressed Employer-Sponsored Health Plan Coverage Losses
The American Rescue Plan Act responded to employer-sponsored health plan coverage losses in three ways, including expanding COBRA coverage and eliminating tax credit repayment. Continue Reading
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26 Jul 2021
Public Option Health Plans Continue to Progress at State Levels
With little action from the federal government to establish a public option health plan, leaders have started to implement public options at state levels. Continue Reading
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22 Jul 2021
AHIP, Other Stakeholders Support Medicare Value-Based Care Bill
Medicare value-based care efforts are crucial for moving forward value-based care in the healthcare industry overall. Continue Reading
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21 Jul 2021
Out-of-Network Price Gouging Still Plagues Coronavirus Testing
Price gouging of coronavirus tests has increased since the beginning of the pandemic, AHIP found. Continue Reading
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20 Jul 2021
MACPAC Notes Behavioral Healthcare Parity Compliance Challenges
The MACPAC brief found that assessing non-quantitative treatment limitations was one of the most challenging aspects of behavioral healthcare parity compliance. Continue Reading
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20 Jul 2021
Racial Coverage Disparity Trends Have Persisted Through 2019
Minority populations witnessed some relief from in racial coverage disparities in the years leading up to 2016, but from 2016 to 2019 these advances regressed. Continue Reading
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07 Jul 2021
ACHP: Extend Transparency, Interoperability Compliance Deadlines
ACHP penned a letter to CMS asking that the administration reassess its health data exchange policies and extend the surprise billing, cost transparency, and interoperability compliance deadlines. Continue Reading
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06 Jul 2021
HHS Addresses Surprise Billing in Commercial Health Plans
The interim rule is in response to the No Surprises Act, which directed multiple US departments to issue a rule that would quell surprise billing in commercial health plans. Continue Reading
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29 Jun 2021
CMS 2022 Payment Parameters Look to Boost Access to ACA Coverage
CMS has proposed increasing access to coverage through the Affordable Care Act marketplace by extending the timeframe for open enrollment and expanding Navigators' roles. Continue Reading
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28 Jun 2021
51% Emergency Ground Ambulance Rides Result in Surprise Billing
While the No Surprises Act addressed many forms of surprise billing, ground ambulance rides were excluded form the bill and continue to effect out-of-pocket emergency care costs. Continue Reading
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25 Jun 2021
SCOTUS Denies Petition on Cost-Sharing Reduction Reimbursements
Cost-sharing reduction reimbursements continues to be a contentious point between the federal government and payers as the Supreme Court rejected a hearing on the subject. Continue Reading
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21 Jun 2021
Experts Consider Impacts of SCOTUS Affordable Care Act Decision
The Supreme Court’s decision in California v Texas ended one lawsuit against the Affordable Care Act but may have left room for future legal action. Continue Reading
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17 Jun 2021
Supreme Court Dismisses Case Against Affordable Care Act
The Supreme Court has dismissed the case against the Affordable Care Act on the grounds that the plaintiffs did not have standing. Continue Reading
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26 May 2021
How to Assess the Future of Emergency, COVID-19 Medicare Policies
Payers and lawmakers will have to analyze the potential downstream impacts of solidifying over 200 emergency, COVID-19 Medicare policies. Continue Reading
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13 May 2021
How Extending ACA Premium Tax Credits May Fix the Family Glitch
Offering Affordable Care Act premium tax credits to any family member with unaffordable coverage could improve access to care for some families. Continue Reading
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11 May 2021
HHS Expands Interpretation of Sex Discrimination in Section 1557
The HHS will now take action against acts of sex discrimination in healthcare which include discrimination based on sexual orientation and gender identity. Continue Reading
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30 Apr 2021
CMS Finalizes Second 2022 Payment Notice with Cost-Sharing Limits
CMS released the second final payment notice which finalized changes to risk adjustment and cost-sharing limits on the Affordable care Act marketplace. Continue Reading
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19 Apr 2021
AHIP Protests Medicare Coverage of Innovative Technology Rule
AHIP stated that the Medicare Coverage of Innovative Technology rule still included unaddressed operational challenges and did not sufficiently protect beneficiaries. Continue Reading
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14 Apr 2021
Uninsurance May Drop 14% If ACA Subsidy Increases Are Solidified
Making the ACA subsidy increases permanent could also impact marketplace enrollment and premiums on the individual health insurance market. Continue Reading
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13 Apr 2021
CMS Approves IL Waiver to Support Rural, Black Maternal Health
The waiver will provide critical data around the impact of extended coverage on rural and Black maternal health. Continue Reading
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12 Apr 2021
Rectifying the ACA Family Glitch Could Drive ACA Premiums Down
The ACA family glitch affects millions of individuals, most of whom are children or women, and the vast majority of whom report being in good health. Continue Reading
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01 Apr 2021
HHS Will Spend $50M on Outreach for Special Enrollment Period
The campaign for the special enrollment period will use digital and broadcast advertising and email and text communications to inform Americans about their eligibility for lower premiums. Continue Reading
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24 Mar 2021
Biden Administration Extends Federal Special Enrollment Period
The administration added three more months to the original timeframe for the federal special enrollment period. Continue Reading
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22 Mar 2021
How Coronavirus Influenced Medicare Chronic Disease Management
While Medicare chronic disease management has never been easy, the coronavirus pandemic’s particularly intense challenges may produce long-lasting changes. Continue Reading
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17 Mar 2021
How to Compare Impacts of Capped Provider Payment, Public Option
Both a public option and capped provider payment rates could diminish healthcare spending, but there are many factors that could influence the extent of that impact. Continue Reading
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15 Mar 2021
New CMS Guidance Could Increase COVID-19 Testing Rates, Spending
Coronavirus testing rates and costs have fluctuated with CMS guidance, but the most recent changes may spur an increase in coronavirus testing rates and costs. Continue Reading
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09 Mar 2021
How the $1.9T COVID-19 Relief Package Impacts Medicaid, CHIP
The relief bill included many elements that could benefit Medicaid and CHIP beneficiaries and state programs, particularly by increasing the federal medical assistance percentage. Continue Reading
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02 Mar 2021
Perpetrators of National ACA Enrollment Fraud Case Sentenced
The case is considered unprecedented as an Affordable Care Act enrollment fraud case due to its national scope which encompassed at least 12 states. Continue Reading
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02 Mar 2021
CMS Puts $2.3M Toward Navigator Funding for Special Enrollment
The navigator funding underscores distinctions between the Biden administration’s approach to outreach as opposed to the previous administration’s strategy. Continue Reading
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24 Feb 2021
Cost Could Still Be A Deterrent In ACA Special Enrollment Period
Although 4.0 million uninsured Americans qualify for free bronze level plans during the special enrollment period, deductible costs could continue to be a deterrent. Continue Reading
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23 Feb 2021
AHIP: Medicaid Managed Care Orgs Deserve Greater SDOH Flexibility
Medicaid managed care organizations have proven that they can boost savings and control costs around non-clinical care, AHIP pointed out. Continue Reading
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23 Feb 2021
How Expanding ACA Premium Tax Credits Could Effect ESI Coverage
Extending the Affordable Care Act’s premium tax credit policy to include higher incomes may not impact employer-sponsored health plans as expected. Continue Reading
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22 Feb 2021
Payer Orgs Outline Steps Toward Achieving Universal Coverage
The payers suggested providing better funding for outreach and education about coverage options and targeting individuals with serious conditions as steps toward universal coverage. Continue Reading
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16 Feb 2021
CMS Moves to Rescind Medicaid Work Requirements As Anticipated
The agency sent letters to Medicaid programs with active and not yet implemented Medicaid work requirements to alert them that these policies were under review. Continue Reading
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11 Feb 2021
DOJ Supports the Affordable Care Act in Supreme Court Case
The department defended the individual mandate as constitutional in its letter and stated that the Affordable Care Act is constitutional even without the individual mandate. Continue Reading
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10 Feb 2021
Humana, Roche Settle False Claims Act Lawsuit, Agree to Pay $12.5M
The whistleblower in the anti-kickback and false claims act lawsuit will receive over $3.6 million for testifying that the payer had favored a manufacturer’s diabetes testing products. Continue Reading
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05 Feb 2021
Downstream Impacts of Recent Surprise Billing Law Remain Uncertain
The surprise billing law included consumer protection, independent review, and reporting requirements that could impact the healthcare industry once implemented. Continue Reading
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04 Feb 2021
AHIP, ACAP Call for Reversals on Prior Administration’s Policies
AHIP and ACAP pushed for a close review of--and potentially permanent changes to--rules such as the rebate rule, Medicaid work requirements, and the Healthy Adult Opportunity waivers. Continue Reading
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03 Feb 2021
How Biden’s Executive Order May Impact Medicaid, ACA Marketplaces
The document represents a departure from the previous administration’s policies, setting the scene for profound changes in the role of Medicaid and the Affordable Care Act marketplaces. Continue Reading
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28 Jan 2021
White House Sets Up Federal Marketplace Special Enrollment Period
In its second week in office, the Biden Administration has established a three-month special enrollment period for the Affordable Care Act marketplace on the federal platform. Continue Reading
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21 Jan 2021
Biden Selects CMS Official as Temporary, Acting CMS Administrator
Liz Richter has served at CMS for decades and her experience centers on fee-for-service Medicare payment. Continue Reading
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20 Jan 2021
Biden Administration Plans to Expand COBRA, ACA Premium Subsidies
Extending and increasing premium subsidies for COBRA and Affordable Care Act enrollees would cost approximately $57.0 billion over the next three years and may lower uninsurance. Continue Reading
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15 Jan 2021
CMS 2022 Final Rule Requires Part D Real-Time Drug Benefits Tool
The rule requires Part D plans to incorporate a benefits comparison tool, submit pharmacy performance metrics to CMS, and educate enrollees about opioids. Continue Reading
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14 Jan 2021
ACA Federal Marketplace Sees 7% Enrollment Increase in 2021
Although enrollment technically increased, the number of new consumers on the Affordable Care Act federal marketplace was lower than the previous year. Continue Reading
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12 Jan 2021
CMS Rule Aims to Accelerate Medicare Coverage of Breakthrough Tech
As part of its Patients over Paperwork Initiative, CMS has taken aim at the prolonged Medicare coverage approval process for FDA-approved products. Continue Reading
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06 Jan 2021
Surprise Billing Law Covers Contract Disputes, Price Transparency
The No Surprises Act seeks to eliminate surprise billing by targeting several common causes for surprise medical bills, but payers are not entirely supportive. Continue Reading
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06 Jan 2021
CARES Act Funding Not Enough for Orgs in Medically Underserved Areas
Medicare fee-for-service providers received CARES Act Funding to keep doors open during pandemic, but sustainable funding is still needed for medically underserved areas, according to a new Data Insight from Xtelligent Health Media. Continue Reading
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04 Jan 2021
Congress Repeals Anti-Trust Exemptions Over AHIP Objections
The Competitive Health Insurance Reform Act of 2020, which would repeal 75-year-old anti-trust exemptions for healthcare payers, will move on to the White House. Continue Reading
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31 Dec 2020
What Final Medicaid Value-Based Purchasing Rule Means for Payers
In the finalized rule, CMS addressed two concerns that payers and other stakeholders had about the definition of value-based purchasing and implications for “best price” policies. Continue Reading
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28 Dec 2020
Payers Expect Biden to Expand Affordable Care Act in 2021
A divided Congress could block Biden’s public ACA option, but payers should expect other bipartisan action such as COVID-19 relief and ACA expansion. Continue Reading
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14 Dec 2020
AHIP, BCBSA Call For Federal COVID-19 Relief Funding
The two organizations are urging legislators to ensure access to testing and a vaccine, provide additional funding for hospitals, and improve Medicaid and Medicare support. Continue Reading
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01 Dec 2020
CMS Finalizes ACA Risk Adjustment, Error Rate Calculation Changes
The new ACA risk adjustment program will average the current and previous benefit year’s error rates, instead of relying solely on the previous year’s error rate, to adjust risk scores. Continue Reading
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25 Nov 2020
What Payers Need to Know About 2020 Medicaid Managed Care Changes
The changes do not overhaul Medicaid managed care, but the alterations to network adequacy, beneficiary protection, quality measures, and payment deserve payers’ attention. Continue Reading
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23 Nov 2020
What the New Rebate Rule Means for Medicare Part D Plans, MCOs
The finalized rebate rule would prevent pharmacy benefits managers and Medicare Part D plans from receiving pharmaceutical manufacturers’ rebates except in certain situations. Continue Reading
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19 Nov 2020
How 6 Patient Populations Receive Coronavirus Vaccine Coverage
Payers will benefit from being well-versed on the various approaches to coronavirus vaccine coverage. Continue Reading
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18 Nov 2020
Medicaid Expansion Improves Access to Care, Population Health
States with Medicaid expansion under the ACA had increased access to acute care hospitals for low-income people and the overall population. Continue Reading
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16 Nov 2020
Legal, Payer Experts Unpack SCOTUS Affordable Care Act Hearing
While the final outcome is unpredictable, payer and legal experts shared their expectations regarding the Affordable Care Act case and reviewed the progress of the law itself. Continue Reading
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10 Nov 2020
Supreme Court Hears Case on Affordable Care Act Constitutionality
The Supreme Court will consider the three questions at the heart of this debate regarding the states’ standing, and the individual mandate’s and the Affordable Care Act’s constitutionality. Continue Reading
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05 Nov 2020
AHIP Issues Criticism on Final CMS Price Transparency Rule
The final CMS rule that requires price transparency will drive healthcare prices up and decrease industry competition, according to AHIP. Continue Reading
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03 Nov 2020
Medicare Advantage May See 2.8% Change in 2022 Revenue, 4.5% Growth
As CMS considers fully phasing in encounter data and making changes to Medicare Advantage Star Ratings, CMS policies could lead to a slight increase in Medicare Advantage revenue. Continue Reading
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29 Oct 2020
CMS Finalizes Price Transparency Rule with Self-Service Tool
The price transparency final rule, known as the “Transparency in Coverage” rule, incorporates two major approaches which will go into effect between 2022 and 2024. Continue Reading
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29 Oct 2020
CMS Releases Vaccine Coverage Plan, Medicare Reimbursement Rate
The true Medicare reimbursement rate for the vaccine will vary based on a couple of factors but the press release specifies that single-dose vaccines will cost $28.39. Continue Reading
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22 Oct 2020
CommonWell Mobilizes to Support Payer Interoperability Compliance
As payers prepare for interoperability compliance in 2021, CommonWell is leveraging its network of providers and technology vendors to help. Continue Reading
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19 Oct 2020
GA Individual Market Reform Approved Over Industry Objections
While industry leaders agree that the reinsurance phase will lower premiums, many oppose the individual market reform’s departure from both federal and state-based exchanges. Continue Reading
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14 Oct 2020
What Happens if SCOTUS Overturns ACA, Besides Coverage Loss?
In the event of an ACA overturn, which experts consider unlikely, the impacts would touch not only uninsurance rates, but also affordability, quality, and progress against disparities. Continue Reading
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08 Oct 2020
5 Challenges, 5 Policy Solutions for the Medicare Enrollment Process
Medicare enrollment continues to pose challenges for beneficiaries, but there are concrete steps that policymakers can take to reduce the burden according to Better Medicare Alliance. Continue Reading
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29 Sep 2020
How an Overturned Affordable Care Act Would Impact Payer Industry
Manatt Health experts predict that the Affordable Care Act will remain largely intact, in part because the alternative would be highly disruptive. Continue Reading
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28 Sep 2020
Overview of Federal Policy Around Pre-Existing Conditions Coverage
The order comes as the nation awaits the Supreme Court’s decision on the Affordable Care Act’s constitutionality, the law which originally secured pre-existing conditions coverage. Continue Reading
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23 Sep 2020
What Happens When Medicaid COVID-19 Flexibilities, Funding Expire?
Medicaid coronavirus flexibilities and funding timelines are largely tied to the public health emergency, which is currently set to expire on October 25, 2020. Continue Reading
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23 Sep 2020
House Amendment Imperils Payer Anti-Trust Exemption
The McCarron-Ferguson Act’s anti-trust exemption for payers is on the chopping block again, with payers defending it on the grounds of maintaining state’s rights to regulate the industry. Continue Reading
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16 Sep 2020
CMS Releases Risk Adjustment Advance Notice Early For MA Plans
The notice phases out RAPS data in favor of encounter data and finalizes risk adjustment changes. Continue Reading
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15 Sep 2020
CMS Rescinds Controversial Medicaid Fiscal Accountability Rule
CMS has decided to withdraw the controversial rule that would have led to significant cuts in Medicaid funding. Continue Reading
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20 Aug 2020
What the Interoperability Rule Will Mean for Payers in 2021
In addition to the technological adjustments, payers can expect further rulemaking from CMS in the fall of 2020 to clarify certain parts of the interoperability rule. Continue Reading
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17 Aug 2020
Court Affirms CSR Reimbursement, But Amount Still Questionable
A lower court will have to determine how much the government should pay in 2017 cost-sharing reduction reimbursement while accounting for 2018 premium tax credits. Continue Reading
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05 Aug 2020
CMS Temporarily Lowers Individual, Small Group Exchange Premiums
CMS urged states to follow suit in bringing down individual and small group exchange premiums by offering premium credits. Continue Reading
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03 Aug 2020
MA Senate Aims To Reduce Drug Spending With Step Therapy Reform
If the bill passes in the state’s House of Representatives, Massachusetts would be the twenty-ninth state to pass step therapy reform. Continue Reading
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31 Jul 2020
CMS Reveals Low Part D Premium, AHIP Warns of Rebate Rule Impact
Although the average basic Part D premium for 2021 is the second lowest in about seven years, AHIP warns the rebate rule could reverse this trend. Continue Reading
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20 Jul 2020
Appeals Court OKs 3-Year Short-Term Limited Duration Health Plans
The majority opinion argued that while short-term limited duration health plans may not be beneficial for consumers, the Departments had authority to reinterpret the plans’ duration. Continue Reading
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14 Jul 2020
Payers Recommend More Federal Funds for MA, Medicaid, Employers
Payers offered several suggestions regarding how to deliver more federal funds for these entities and called on Congress to ensure stable health insurance markets. Continue Reading
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09 Jul 2020
How Payers, Policymakers Can Help Small Business Health Coverage
Payers and stakeholders can increase healthcare savings for small businesses by sharing data on small business health coverage. Continue Reading
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01 Jul 2020
OK Becomes First State to Adopt Medicaid Expansion During COVID-19
After years of debate, a statewide ballot determined that Oklahoma would adopt Medicaid expansion by altering its state constitution. Continue Reading
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30 Jun 2020
Congress Considers Expanding ACA As Feds Move to Dismantle It
As unemployment soars, the House of Representatives voted on expanding the ACA while the Trump Administration filed a brief in favor of dismantling it. Continue Reading
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15 Jun 2020
Major Payers Find HHS Finalized Nondiscrimination Rule Too Narrow
Payers reacted negatively to the HHS finalized nondiscrimination rule, specifically regarding its lack of gender and sexual discrimination protections. Continue Reading
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09 Jun 2020
6 Fixes to Improve Medicaid Coverage Access Amid COVID-19
New York can draw from its experience during the Great Recession to improve its coronavirus Medicaid strategy. Continue Reading
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08 Jun 2020
Out-of-Network Healthcare Spending Spikes for Lab Tests, Pathology
Outsourcing lab testing and high rates of out-of-network pathology bills for in-network hospitals can cause out-of-network healthcare spending. Continue Reading
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27 May 2020
Medicare Advantage, Part D Plans Join CMS to Cut Insulin Costs
AHIP and Medicare Advantage and Part D plans applaud the Part D Senior Savings Model which seeks to lower insulin costs in the Medicare coverage gap. Continue Reading