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
26 Nov 2024
CMS suggests public payer weight loss drug coverage changes
Amid suggestions around prior authorizations and AI use, CMS introduces a policy that would expand weight loss drug coverage in Medicare Advantage, Medicaid and Part D plans. Continue Reading
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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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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
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26 May 2020
Audio-only Telehealth Coverage Essential During COVID-19 Outbreak
Telehealth exploded amidst the COVID-19 pandemic. But disparities in reimbursement for audio-only telehealth visits may have downstream implications for Medicare Advantage members. Continue Reading
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22 May 2020
CMS Expands Telehealth, Rural Plan Options for Medicare Advantage
CMS chose to finalize some proposals in advance, including measures that increase access to telehealth and rural plan options for Medicare Advantage beneficiaries. Continue Reading
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21 May 2020
Rate Setting During COVID-19: Risk Corridors and Reinsurance
Experts from Manatt Health and the Robert Wood Johnson Foundation share how risk corridors and reinsurance can alleviate coronavirus rate-setting uncertainties. Continue Reading
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15 May 2020
IRS Creates Cafeteria Plan, HDHP Flexibilities Due to COVID-19
The cafeteria plan and high deductible health plan flexibilities come as employees face high healthcare spending due to the coronavirus. Continue Reading
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08 May 2020
CMS Releases Final 2021 Payment Notice, Extends QHP Timeline
The CMS final 2021 payment notice is intended to lower premiums, enhance program integrity, and increase market stability among other goals. Continue Reading
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07 May 2020
ACA Battle Continues, States and Feds File Supreme Court Briefs
At the heart of the debate over the ACA lies the question of whether or not the individual mandate to purchase health insurance was a choice. Continue Reading
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06 May 2020
CO Public Option Bill Paused, Unemployment Rises Due To COVID-19
The impacts of coronavirus have delayed the public option bill which payers in the state have strongly opposed. Continue Reading
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29 Apr 2020
Medicaid, CHIP Amendments Help States Fight COVID-19 Outbreak
Recent CMS amendments and waivers allow state Medicaid and CHIP programs more flexibility in order to respond to the COVID-19 outbreak. Continue Reading
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28 Apr 2020
Supreme Court Rules Federal Government Must Pay $12B to ACA Insurers
The federal government must pay $12 billion to insurers who enrolled in an Affordable Care Act program meant to protect against financial risk. Continue Reading
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23 Apr 2020
CMS Delays Interoperability Final Rule Roll Out Due to COVID-19
Due to concerns over the coronavirus, CMS had pushed back the deadline for meeting the requirements of the recent Interoperability and Patient Access final rule. Continue Reading
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14 Apr 2020
Payers Recommend Actions To Promote Biosimilars, Drug Competition
In the hopes of bringing down healthcare spending, AHIP has recommended five steps that the FDA and FTC can take to support biosimilars. Continue Reading
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13 Apr 2020
An Overview of the FFCRA, CARES Act Coronavirus Testing Rules
The coronavirus testing rules, which will be in effect until the public health emergency lifts, are broad, but certain plans and benefits are exempt. Continue Reading
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07 Apr 2020
CMS Finalizes MA and Part D Rates, Leaves ESRD Rule Unchanged
CMS anticipates a bump in revenue of approximately 1.66 percent due to the rate changes. Continue Reading
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02 Apr 2020
COVID-19 Recession to Increase Uninsurance Rates, Test Medicaid
COVID-19 will lead to increased unemployment and pose serious challenges to Medicaid and coverage for uninsured individuals. Continue Reading
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19 Mar 2020
What The Families First Coronavirus Response Act Means for Payers
Private payers and Medicaid will offer free coronavirus testing, but patients continue to see out-of-pocket healthcare spending for treatment. Continue Reading
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18 Mar 2020
Fiscal, Health Challenges That Coronavirus Poses To The Uninsured
The uninsured—who often have chronic conditions and service jobs—are the most vulnerable to the coronavirus, but not solely for medical reasons. Continue Reading
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16 Mar 2020
CMS Urges Medicaid Expansion Amid Coronavirus Emergency
As the novel strain of coronavirus, COVID-19, escalates nationwide and is officially declared a national emergency, CMS looks to Medicaid expansion. Continue Reading
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12 Mar 2020
AHIP: 3 Factors to Consider for CMS Data Interoperability Rule
The interoperability rule should protect patients’ privacy, reduce healthcare costs, and focus on enabling patient information personalization. Continue Reading
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11 Mar 2020
CMS Targets Medicare Advantage Beneficiaries In COVID-19 Efforts
With the correlation between infection and age, CMS and AHIP are opening up new benefits and cost-sharing flexibilities to help Medicare beneficiaries access care. Continue Reading
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10 Mar 2020
How Will Health Literacy Affect Interoperability Rule Benefits?
While some patients will not benefit due to health literacy and technological barriers, the interoperability rule will increase options for others, CMS says. Continue Reading
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Feature
09 Mar 2020
How the Affordable Care Act Impacted the Individual Market
The passing of the Affordable Care Act in 2012 shook up the individual health insurance marketplace and eight years later, the market is still feeling its impact. Continue Reading
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09 Mar 2020
CMS Releases Finalized Rule on Interoperability
The CMS rule mandates that payers provide patients access to data through a Patient Access API and access to a list of in-network providers through a Provider Directory API. Continue Reading
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04 Mar 2020
Do Short-Term Limited Duration Plans Deserve Industry Skepticism?
From healthcare organizations to the courts, many have expressed skepticism about short-term limited duration plans’ ability to provide adequate healthcare coverage. Continue Reading
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02 Mar 2020
SCOTUS Will Review ACA Constitutionality, Decision Expected 2021
The court will review the questions posed in the Fifth Circuit Court regarding the individual mandate and ACA constitutionality. Continue Reading
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19 Feb 2020
Experts Lambast CMS MFAR as Detrimental to Employers, Patients
The Chamber of Commerce cited the increased burden for employers and restrictions on access to care as reasons to delay MFAR. Continue Reading
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12 Feb 2020
Bill on Surprise Medical Billing Moves Forward to Full House Vote
The Ban Surprise Billing Act centers on transparency and cost-sharing limits and shares some commonalities with the Ways and Means Committee proposal. Continue Reading
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06 Feb 2020
ESRD Proposal May Inadequately Reimburse Medicare Advantage Plans
Medicare Advantage proponents are concerned that the new CMS proposal may result in underpayment to Medicare Advantage plans for end-stage renal disease care. Continue Reading
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06 Feb 2020
Post-ACA Access to Care, Coverage Disparities Shifted in 2017
Starting in 2017, healthcare trends that started with the ACA including access to care, uninsurance rates, and care avoidance began to reverse in nonexpansion states. Continue Reading
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05 Feb 2020
Proposed Medicare Advantage Changes Address Drug Pricing, ESRD
The changes would adjust Medicare Advantage star ratings and mandate that Part D plans develop an online price comparison tool to address prescription drug pricing. Continue Reading
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04 Feb 2020
AHIP: HHS Proposed Price Transparency Rule Not Actionable, Secure
The new HHS proposed rule suggests a price transparency tool that would put beneficiary data at risk and not provide actionable information, AHIP says. Continue Reading
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30 Jan 2020
CMS Releases Medicaid Block Grant With Drug, Benefit Flexibilities
The Medicaid block grants aim to serve non-elderly adults by giving states flexibility on drug formularies and benefit packages. Continue Reading
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27 Jan 2020
CMS: Medicare Will Cover Genetic Diagnostics For Certain Cancers
CMS will cover Next Generation Sequencing, a genetic diagnostic tool for inherited ovarian or breast cancer. Continue Reading
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27 Jan 2020
Supreme Court OKs Public Charge, Immigrants On Medicaid May Be Denied Entry
The Supreme Court has approved the public charge rule by a vote of 5-4, denying entry to immigrants who were, are, or could be on Medicaid for healthcare coverage. Continue Reading
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23 Jan 2020
Centene, WellCare Finalize Major Health Payer Merger Deal
The health payer merger deal between Centene and WellCare further consolidates the healthcare industry and covers more than 24 million members across 50 states. Continue Reading
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23 Jan 2020
Tufts Health Expands Telehealth Solution, Boosts Access to Care
Tufts Health Plan expands its telehealth solution, offering members access to board-certified doctors and specialists at their fingertips for no cost. Continue Reading
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21 Jan 2020
Supreme Court Will Not Expedite ACA Constitutionality Review
The Supreme Court will not expedite the review and supporters of the court’s decision say that ACA constitutionality is not the issue at hand. Continue Reading
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14 Jan 2020
Opioid Overdose Mortality Decreased 6% in Medicaid Expansion States
Medicaid expansion was associated with a six-percent lower rate of total opioid overdose deaths. Continue Reading
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09 Jan 2020
CMS Addresses Duplicate Discounts, State Medicaid Rebate Requests
The new guidance helps states avoid submitting a state Medicaid rebate requests for drugs that already received a 340B discount from the manufacturer. Continue Reading
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08 Jan 2020
VHA Sees Better Medication Adherence Despite High Drug Costs
The VA sees better medication adherence than other payers, with cost-related nonadherence is 5.9 percentage points lower than its non-VHA counterparts. Continue Reading
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07 Jan 2020
Medicare Advantage Risk Adjustment Model Continues to Phase In
The Medicare Advantage risk adjustment model is in the midst of a three-year phase in and will be more reliant on encounter data, according to the advance notice from CMS. Continue Reading
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07 Jan 2020
ME Payers Cover Hearing Aids, Self-Insured Companies Exempt
While Maine payers will cover up to $3,000 per hearing aid per year every three years for eligible members, the law leaves self-insured companies exempt. Continue Reading
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06 Jan 2020
Tenth Circuit Court Upholds HHS Risk Adjustment Calculations
The decision to uphold the HHS risk adjustment calculations of 2014 through 2018 could have implications for future litigation regarding the entire ACA. Continue Reading
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31 Dec 2019
Hospital Price Transparency Rule Takes Effect January 1, 2019
The hospital price transparency rule takes effect on January 1, requiring providers to publicize their rates for all items and services. Continue Reading
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13 Nov 2019
Strategies for Addressing Opioid Use Disorder in Rural Areas
The opioid epidemic has disproportionately affected rural communities. To tackle this crisis, care models are gaining political buy-in, working with local communities, and maximizing small budgets to bring change. Continue Reading
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08 Aug 2019
Finalized CMS Rule Supports Medicare Coverage for Gene Therapy
The finalized rule resolved some major contentions with prior versions and provided Medicare coverage for CAR T-cell therapy in healthcare facilities. Continue Reading
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15 Jul 2019
A Comprehensive Review of the Latest Affordable Care Act Hearing
In the Affordable Care Act hearing on July 9, the defendants focused on TCJA to defend the bill’s constitutionality while the plaintiffs clarified the government’s position on a remedy. Continue Reading
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11 Jul 2019
White House Abandons Rebate Rule Due to Medicare Spending
The White House’s rebate rule could have caused a significant rise in seniors’ health insurance premiums and $200 billion in Medicare spending. Continue Reading
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03 Jul 2019
ACA Risk Adjustment Worked as Intended in 2018, CMS Reports
CMS found that the ACA risk adjustment program successfully distributed the financial risk. Continue Reading
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21 Jun 2019
CMS Defines New Medicaid Integrity Guidelines
CMS set new integrity guidelines and warned states of future audits on Medicaid eligibility determinations. Continue Reading
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07 Jun 2019
How Does the Health Payer, Insurance Industry Support the Economy?
Health payers generate economic growth by providing insurance coverage, creating jobs, and making tax contributions, according to AHIP. Continue Reading
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22 Apr 2019
How to Be More Efficient in HEDIS Reporting
By remediating gaps in data collection, health plans can immediately improve the efficiency of HEDIS reporting. Continue Reading
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13 Nov 2017
Top 5 Most Common Healthcare Provider Fraud Activities
The most common healthcare provider fraud activities drain public payer finances and promote unsafe care conditions for beneficiaries. Continue Reading
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20 Sep 2017
Top 10 Healthcare Spending Categories in the United States
Many of the highest healthcare pending categories in the US continued to climb as indicated by significant growth in expenditure amounts. Continue Reading
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15 Jun 2017
AMA, AHA Call for Stronger Patient Insurance Protections
The AMA joins other prominent health industry groups in calling on the Senate to address patient insurance protection concerns. Continue Reading
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18 May 2017
CMS to Shutter Small Business Health Options Program Website
CMS will close its portal allowing small business to enroll members on the health insurance exchanges due to low usage rates. Continue Reading
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Feature
04 Nov 2016
The Progress and Challenges of the Affordable Care Act
Various clauses of the Affordable Care Act brought obstacles for insurers to overcome. Continue Reading
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Answer
15 Jun 2016
How the Affordable Care Act Changed the Face of Health Insurance
Why have health insurance rates gone up after the Affordable Care Act was implemented? Continue Reading