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
26 Mar 2026
UnitedHealthcare launches AI chatbot for member care navigation
UnitedHealthcare said the AI chatbot will support customer advocates by handling simple care navigation tasks and referring members to advocates when needed. Continue Reading
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News
23 Mar 2026
CMS vows to ditch faxes for electronic claims attachments
A new final rule would establish standards for the electronic exchange of claim attachments for all HIPAA-covered entities by 2028. Continue Reading
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News
29 Feb 2024
MA Payment Reductions May Impact Value of Healthcare for Beneficiaries
The value of healthcare for beneficiaries, including supplemental benefits and premiums, could be negatively impacted if CMS finalizes the Advance Notice policies. Continue Reading
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26 Feb 2024
Care Access, Coverage Value Similar in Medicare Advantage and Medicare
Despite many similarities in care access, Medicare Advantage beneficiaries faced care delays due to prior approval requirements more often than those in traditional Medicare. Continue Reading
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21 Feb 2024
CareSource Partnership Boosts Access to Substance Use Disorder Treatment
The partnership will connect members in Kansas with transportation services to facilitate access to substance use disorder treatment. Continue Reading
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20 Feb 2024
Dental Coverage in Medicare Advantage Plans Varies by Demographic
Beneficiaries 64 or younger, dual-eligibles, and those in racial or ethnic minority groups were more likely to have Medicare Advantage plans with dental coverage. Continue Reading
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Feature
13 Feb 2024
Overcoming Tech Barriers to Achieve Prior Authorization Transparency
Payers can use the next couple of years to establish a solid technology strategy to ensure compliance with the prior authorization final rule. Continue Reading
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12 Feb 2024
HHS Will Provide Technical Assistance to States Addressing Homelessness
Participating states have implemented Medicaid section 1115 demonstrations or other state plan amendments to improve access to housing-related services for those facing homelessness. Continue Reading
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News
07 Feb 2024
How Do Payers Cover COVID-19 Vaccines, Treatments, and Tests Post-PHE?
Public and private payers generally offer some coverage of COVID-19 vaccines, treatments, and tests, but cost-sharing requirements vary. Continue Reading
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Answer
06 Feb 2024
What Is Behind Rampant Medicare Advantage Contract Terminations?
Health systems do not invest in the infrastructure needed to support Medicare Advantage, while health plans offer low reimbursement, leading to contract terminations. Continue Reading
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05 Feb 2024
Medicare Part D Low-Income Subsidy Loss Tied to Higher Out-of-Pocket Costs
Out-of-pocket costs increased by 700 percent for beneficiaries who experienced a temporary loss of their Medicare Part D low-income subsidy. Continue Reading
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02 Feb 2024
HCSC Announces $3.3B Cigna Medicare Business Acquisition
Barring regulatory or conditional challenges, the payer expects the acquisition to be finalized in early 2025. Continue Reading
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01 Feb 2024
Lawmakers Lobby for Payment and Policy Stability in Medicare Advantage
The group of senators called for payment and policy stability in Medicare Advantage in the wake of new marketing, competition, and prior authorization standards. Continue Reading
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31 Jan 2024
CMS Proposes 3.7% Increase in Medicare Advantage Plan Payments
In addition to an increase in Medicare Advantage plan payments, CMS proposed updates to the Part D risk adjustment model and star ratings. Continue Reading
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29 Jan 2024
HHS Seeks Stakeholder Input to Improve Medicare Advantage Transparency
The request for information seeks feedback on access to care, provider networks, and competition in the Medicare Advantage program. Continue Reading
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18 Jan 2024
Underserved MA Beneficiaries Opt for Plans with Supplemental Benefits
Black individuals were 11.2 percentage points more likely to enroll in a plan with a comprehensive dental benefit, highlighting the attraction of supplemental benefits for underserved beneficiaries. Continue Reading
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17 Jan 2024
CMS Finalizes Payer Requirements to Streamline Prior Authorization
Payers must send prior authorization decisions within 72 hours for urgent requests and seven calendar days for standard requests, CMS finalized. Continue Reading
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17 Jan 2024
States Leverage Waivers To Support Medicaid Redetermination
CMS has categorized the waivers for Medicaid redetermination into four buckets, of which ex parte renewals had the highest adoption rate among states. Continue Reading
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11 Jan 2024
NY Medicaid Section 1115 Waiver Amendment Improves Access to Care
The Medicaid section 1115 waiver allows New York to invest nearly $6 billion in its healthcare system to improve the workforce and access to care. Continue Reading
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09 Jan 2024
Elevance Health Lawsuit Slams Medicare Advantage Star Ratings Calculation
Elevance Health said the new Medicare Advantage star rating methodology led to inaccurate and lower scores for 2024. Continue Reading
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News
28 Dec 2023
Does Integrating Medicare and Medicaid Improve Care for Dual Eligibles?
UPMC’s fully integrated dual eligible special needs plan improved home- and community-based services use but fell short in other areas. Continue Reading
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Feature
26 Dec 2023
Key Regulations and Policies That Will Impact Payers in 2024
In 2024, payers must comply with Medicare Advantage marketing requirements, price transparency regulations, and prior authorization policies. Continue Reading
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21 Dec 2023
ACA Marketplace Enrollment Up By 33%, Surpassing 19M Enrollees
Around 15 million enrollees have selected an ACA marketplace plan through the HealthCare.gov platform. Continue Reading
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19 Dec 2023
HHS Urges States to Reduce Medicaid, CHIP Child Disenrollments
States that have not expanded Medicaid have higher child disenrollment rates than expansion states combined, new data indicated. Continue Reading
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18 Dec 2023
Leveraging Social Determinants for Medicare, Medicaid Engagement
Social determinants of health are a top barrier for Medicare and Medicaid populations, but health plans can tap into the data to optimize member engagement and outcomes. Continue Reading
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Feature
18 Dec 2023
What Health Plans Are Available For People With Disabilities?
Medicare and Medicaid are common health plan options for people with disabilities, though they must meet certain criteria before becoming eligible for coverage. Continue Reading
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14 Dec 2023
Lawsuit Alleges Humana Used AI to Deny Medically Necessary Claims
The AI model projections led Humana to deny medically necessary claims, resulting in beneficiaries paying costs out of pocket or forgoing care. Continue Reading
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13 Dec 2023
Lawmakers Urge CMS to Improve Data Collection in Medicare Advantage
CMS should improve data collection and reporting of prior authorization denials, encounter data, and supplemental benefit utilization. Continue Reading
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11 Dec 2023
Drug Price Negotiation Would’ve Reduced Prices, OOP Spending in 2021
Out-of-pocket spending reductions from drug price negotiation varied among demographic groups, highlighting disparities. Continue Reading
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11 Dec 2023
How to Tailor Member Engagement for Medicare, Medicaid Populations
Medicare and Medicaid spending is on the rise, so health plans need to optimize their member engagement strategies to align with specific population needs. Continue Reading
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News
11 Dec 2023
How Human and Artificial Intelligence Can Streamline Claims Reviews
Properly integrating artificial intelligence and human expertise helps payers generate savings from complex and high-cost claims. Continue Reading
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30 Nov 2023
Medicare Hospice Model Improved Quality of Life, Reduced Medicare Spending
The Medicare Care Choices Model increased hospice use and reduced net Medicare spending by 13 percent. Continue Reading
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27 Nov 2023
Preventive Care Visits Among Medicare Beneficiaries Grew, Study Finds
During preventive care visits, physicians were more likely to provide counseling provision and order screening labs than at problem-based visits. Continue Reading
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21 Nov 2023
Quality Outcomes Are Better When Medicaid MCOs Administer Pharmacy Benefits
In 33 of 34 comparative analyses, HEDIS scores were higher in states where Medicaid MCOs administered pharmacy benefits. Continue Reading
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17 Nov 2023
Cardiovascular Disease Utilization Grew After Medicaid Expansion
The two expansion states saw higher rates of cardiovascular care, medication, and hospitalization use after Medicaid expansion. Continue Reading
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14 Nov 2023
Avoidable Hospitalizations Less Common in Medicare Advantage, Study Finds
Medicare beneficiaries with ambulatory care-sensitive conditions visited clinicians with lower rates of avoidable hospitalizations. Continue Reading
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13 Nov 2023
Blending Human Expertise & Technology to Improve Claims Negotiations
Strategic partnerships that leverage both human expertise and technology can improve out-of-network claim negotiations and operational efficiency while maintaining payer-provider relationships. Continue Reading
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08 Nov 2023
An Overview of 2024 Coverage for Veterans Beyond Veterans Affairs
Better outreach, multiple coverage sources in addition to Veterans Affairs benefits, and Medicaid expansion may be key to lowering uninsurance among veterans. Continue Reading
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News
07 Nov 2023
CMS Proposals Address Anti-Competitive Practices in Medicare Advantage
The proposed rule includes a fixed compensation of $632 for agents and brokers helping Medicare Advantage beneficiaries choose a plan. Continue Reading
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06 Nov 2023
Care Quality, Health Outcomes Better in Medicare Advantage than FFS
There were fewer hospital readmissions and preventable hospitalizations in Medicare Advantage compared to Medicare fee-for-service. Continue Reading
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03 Nov 2023
7 Elements of Successful Community Health Worker Integration
Several Medicaid programs have taken various approaches to integrating community health workers into their coverage policies and services. Continue Reading
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News
01 Nov 2023
9 Trends To Watch During ACA Marketplace 2024 Open Enrollment
Policy changes and ripple effects from other markets will shape the Affordable Care Act marketplace’s 2024 open enrollment trends. Continue Reading
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Answer
24 Oct 2023
What Cigna’s FCA Settlement Means for Other Medicare Advantage Plans
Per its settlement, Cigna must conduct annual risk assessments, but all Medicare Advantage plans should be proactively monitoring their compliance actions. Continue Reading
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Feature
17 Oct 2023
What Technologies Support Payers With Claims Management Processes?
Claims processing software, adjudication software, and health IT systems can streamline the claims management process for payers. Continue Reading
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16 Oct 2023
HHS Patient Assistance Program Aims To Boost Access to COVID-19 Drug
The patient assistance program will maintain financial support for certain populations seeking to access Pfizer’s Paxlovid, starting in 2024. Continue Reading
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16 Oct 2023
Medicare Advantage Star Ratings Fall for Second Consecutive Year
Around 42 percent of Medicare Advantage plans received 2024 star ratings of four or higher, down from 51 percent in 2023. Continue Reading
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13 Oct 2023
Medicare Part B Premiums, Deductibles Will Increase in 2024
Medicare Part B premiums will be $174.70 per month in 2024 and the annual deductible will be $240, CMS shared. Continue Reading
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12 Oct 2023
Who is Challenging the Medicare Drug Price Negotiation Rule?
Drug companies and pharmaceutical groups are suing HHS, arguing that the Medicare drug price negotiation rule violates constitutional amendments. Continue Reading
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11 Oct 2023
Does Medicaid Managed Care Impact Specialty Care Access for Kids?
Medicaid managed care enrollment was tied to limited mental health professional visits but did not impact other specialty care access. Continue Reading
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06 Oct 2023
Medicaid Expansion Improved Health Equity for Redlined Areas
Uninsurance rates were worse in historically redlined areas in the seven states that have not adopted Medicaid expansion, leading to a lack of health equity. Continue Reading
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04 Oct 2023
CMS Orders States to Provide Continuous Coverage for Kids in Medicaid, CHIP
Enacting 12 months of continuous coverage for kids in Medicaid and CHIP can promote access to primary care and foster better patient-provider relationships, CMS said. Continue Reading
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27 Sep 2023
Total Adoption of Continuous Eligibility May Improve Coverage Rates
Continuous eligibility in Medicaid would heighten spending in some areas and lower spending in others for states and the federal government. Continue Reading
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26 Sep 2023
CMS: Medicare Advantage Premiums Will See Little Change in 2024
CMS projects that average Medicare Advantage premiums will rise by just $0.64 in 2024 to $18.50 per month. Continue Reading
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21 Sep 2023
CMS Pauses Medicaid Disenrollments, Reviving Coverage for 500K People
CMS has identified 30 states with system errors that impacted ex parte renewals and caused 500,000 disenrollments. Continue Reading
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Answer
21 Sep 2023
The Medicare Advantage Marketing Problem and Where It’s Headed
With new Medicare Advantage marketing regulations in place for 2024, payers must work with their marketing teams and establish proactive oversight programs to ensure compliance. Continue Reading
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Answer
19 Sep 2023
Medicare Advantage RADV Rule May Prompt More Legal Action from Payers
Humana’s lawsuit has created a roadmap for other payers who may want to take legal action against CMS and the Medicare Advantage RADV final rule. Continue Reading
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Answer
18 Sep 2023
Top Reasons Behind Retail, Medicare Advantage Plan Partnerships
Co-branded Medicare Advantage plans may address prescription drug spending and access to care among seniors but require significant alignment between payers and retailers. Continue Reading
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News
15 Sep 2023
Price May Drive Affordable Care Act Marketplace Plan Selection
Silver plan uptake has declined on the Affordable Care Act Marketplace, potentially due to higher costs. Continue Reading
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12 Sep 2023
Beneficiaries with Cancer Spend Less Out-of-Pocket in Medicare Advantage
In addition to lower out-of-pocket costs, Medicare Advantage beneficiaries with cancer have better access to care management and palliative care than those in fee-for-service. Continue Reading
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11 Sep 2023
How Do Rebates Impact Part D Spending for Plans, Beneficiaries?
After accounting for rebates, Part D spending totaled $21 billion for beneficiaries and $5.3 billion for plan sponsors. Continue Reading
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11 Sep 2023
Improving Payment Integrity with a Building Blocks Methodology
Payers need a proven framework for payment integrity to create financial value, handle change, and engage at the highest levels of organizational strategy. Continue Reading
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08 Sep 2023
High Switching Rates from FFS to Medicare Advantage Drove MA Enrollment
In 2021, the switching rate from Medicare FFS to Medicare Advantage was 6.5 times higher than the switching rate in the opposite direction. Continue Reading
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Feature
05 Sep 2023
How Quality Measures, Star Ratings Impact Healthcare Payers
High performance on standardized quality measures like HEDIS and Medicare Advantage Star Ratings help consumers determine how to choose between healthcare payers. Continue Reading
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01 Sep 2023
Half of Medicare Advantage Beneficiaries Left Plan After 5 Years
After five years, 53.4 percent of dual-eligible beneficiaries and 48.3 percent of non-dual-eligible beneficiaries disenrolled from their Medicare Advantage plan. Continue Reading
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31 Aug 2023
CMS: Ex Parte Systems May Disenroll Eligible Medicaid, CHIP Enrollees
States that do not take action to comply with CMS protocols and protect affected Medicaid and CHIP enrollees may face steep penalties like losing FMAP eligibility. Continue Reading
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29 Aug 2023
HHS Releases First 10 Drugs Eligible for Medicare Price Negotiation
Following through on the Inflation Reduction Act provisions, the Biden-Harris Administration will begin Medicare price negotiations with the drug companies this fall. Continue Reading
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25 Aug 2023
74% of Terminated Medicaid Enrollees Were Cut for Procedural Reasons
At least four out of ten Medicaid enrollees who completed the renewal process have been disenrolled. Continue Reading
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24 Aug 2023
Beneficiaries Are Satisfied With Medicare Advantage Plans, Coverage
Beneficiary satisfaction with problem resolution was higher among those likely to renew their Medicare Advantage plan. Continue Reading
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Answer
22 Aug 2023
How Can Medicare Advantage Organizations Prepare for RADV Audits?
Ahead of RADV audits, Medicare Advantage plans must internally review charts, invest in compliance programs, and monitor coding vendors. Continue Reading
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21 Aug 2023
CMS Announces Monthly Payment Option for Out-of-Pocket Part D Costs
Starting in 2025, beneficiaries can opt to pay out-of-pocket Part D costs monthly and owe $0 when picking up prescription drugs at the pharmacy. Continue Reading
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21 Aug 2023
Trends in Price Ratios Between Commercial, Medicare Advantage Plans
The difference in pricing depended on the size of the insurer, market consolidation, rural healthcare status, and other factors. Continue Reading
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21 Aug 2023
How Does Medicaid Cover Obesity Treatments for Children?
New guidelines from the American Academy of Pediatrics may help improve Medicaid coverage of obesity treatments for children. Continue Reading
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15 Aug 2023
KLAS: Payers Want Efficient Claims and Administration Platforms
Payers recognized claims and administration platforms Cognizant and HealthEdge for their efficiency and functionality. Continue Reading
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08 Aug 2023
ACA Marketplace Premiums Set to Rise Again, Inflation a Key Factor
Inflation-driven increases in medical care and prescription drug costs could make consumers pay more for 2024 Affordable Care Act Marketplace premiums Continue Reading
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Answer
01 Aug 2023
How One MA Plan Prioritized SDOH to Improve Diabetes Care Access
Zing Health facilitated access to diabetes care by providing continuous glucose monitors at pharmacies for no cost. Continue Reading
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News
01 Aug 2023
CMS Projects 2024 Medicare Part D Premiums Will Fall by 1.8%
The projected decrease in Medicare Part D premiums reflects premium stabilization and improved Part D benefits, both tied to the Inflation Reduction Act. Continue Reading
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31 Jul 2023
Medicare Coverage Associated with Higher Cancer Screening Rates
Breast cancer screenings increased by 50 percent and colorectal cancer screenings doubled after individuals started receiving Medicare coverage. Continue Reading
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27 Jul 2023
Why CMS Paused Medicaid Coverage Redeterminations in 6 States
In some states, Medicaid coverage redeterminations have led to improper disenrollments due to procedural reasons. Continue Reading
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24 Jul 2023
CA, KY Expand Behavioral Health Services Through Mobile Crisis Teams
The mobile crisis teams will offer Medicaid beneficiaries behavioral health services such as screenings, de-escalation support, and care coordination. Continue Reading
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18 Jul 2023
Medicare Advantage Plans Have Narrow Psychiatrist Networks, Study Finds
Almost 65 percent of psychiatrist networks were narrow in Medicare Advantage plans, compared to around 40 percent in Medicaid managed care and ACA plans. Continue Reading
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17 Jul 2023
10 Top-Selling Drugs Accounted for 22% of Medicare Part D Spending
Medicare Part D spending reached $216 billion in 2021, with the top ten drugs accounting for $48 billion. Continue Reading
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13 Jul 2023
Medicaid Expansion Improved Palliative Care Access for Cancer Patients
Although access improved, utilization of these services remained low in states with and without Medicaid expansion. Continue Reading
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11 Jul 2023
Medicare Advantage Quality Bonus Program Needs Reform, Report Finds
A reformed Medicare Advantage quality bonus program should penalize contracts for poor performance and determine plan quality at the local level. Continue Reading
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11 Jul 2023
English Proficiency Can Impact Care Disparities, Coverage Rates
Limited English proficiency puts individuals at risk of care disparities, but Medicaid agencies can take steps to secure beneficiaries’ access to coverage. Continue Reading
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10 Jul 2023
ARPA Reduced Fiscal Challenges on CA Affordable Care Act Marketplace
Affordable Care Act marketplace enrollees may have had lower costs in 2021, but affordability barriers persisted. Continue Reading
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06 Jul 2023
Healthcare Spending Lower in MA for Beneficiaries with Chronic Conditions
Total monthly healthcare spending ranged up to $1,532 for Medicare Advantage beneficiaries with chronic conditions compared to $2,204 for fee-for-service beneficiaries. Continue Reading
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30 Jun 2023
High-Risk Medication Use Lower Among Medicare Advantage Beneficiaries
Medicare Advantage beneficiaries received 24.3 fewer high-risk medications per 1,000 beneficiaries compared to those in traditional Medicare. Continue Reading
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28 Jun 2023
Beneficiaries’ Chronic Conditions Did Not Drive MA to FFS Switching Rates
Among beneficiaries with multiple chronic conditions, the rate of switching from Medicare Advantage to fee-for-service was low, ranging from 2.8 percent to 4.0 percent. Continue Reading
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27 Jun 2023
Medicare Advantage Plan Payment Cuts Did Not Impact Enrollment Growth
Counties that faced large Medicare Advantage plan payment cuts from the ACA and those that had smaller cuts saw similar enrollment growth. Continue Reading
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News
27 Jun 2023
How Medicaid Network Adequacy Rules Affect Children with Special Needs
Children with special needs may struggle to access specialty care with the new Medicaid network adequacy standards. Continue Reading
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News
23 Jun 2023
Judge Blocks FL Ban on Medicaid Coverage for Gender-Affirming Care
Following the ruling, all transgender beneficiaries in Florida can seek Medicaid coverage for gender-affirming care. Continue Reading
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22 Jun 2023
Cash Payments Could Help Medicaid Beneficiaries Obtain Better Coverage
Medicaid beneficiaries have worse care than private payer enrollees; cash payments may offer access to higher-quality care. Continue Reading
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21 Jun 2023
MedPAC Offers Changes to Medicare Advantage Benefits, Payment Policies
In addition to recommending standardized benefits and payment policy reform in Medicare Advantage, MedPAC addressed high drug prices in Medicare Part B. Continue Reading
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16 Jun 2023
New York Extends Medicaid Postpartum Coverage to 12 Months After Birth
The state joins 34 others that have extended Medicaid postpartum coverage from 60 days to one year following childbirth. Continue Reading
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15 Jun 2023
Medicare Advantage Overpayments Expected to Surpass $75B in 2023
The estimation of Medicare Advantage overpayments is more than twice as high as MedPAC’s prediction of $27 billion. Continue Reading
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14 Jun 2023
Inflationary Rebates for Generic Drugs Offset Medicaid Spending
Inflationary rebates for generic drugs totaled between 2 and 12 percent of the $53.6 billion Medicaid spent on the drugs between 2017 and 2020. Continue Reading
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14 Jun 2023
How COVID-19 Policies Impacted Medicaid Enrollment Among Children
Some states experienced an increase in children’s Medicaid enrollment of more than 14 percent. Continue Reading
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13 Jun 2023
Lawmakers Request More Info on Medicaid Redetermination Compliance
Florida and Arkansas have seen high disenrollment numbers due to procedural reasons, generating concerns about Medicaid redetermination compliance. Continue Reading
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News
13 Jun 2023
Coronavirus Pandemic Policies May Have Improved Care Affordability
Coronavirus pandemic policies such as continuous Medicaid enrollment may have reduced unaffordability barriers. Continue Reading
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12 Jun 2023
Rising Enrollment, Higher Costs Spur Medicare Spending Growth
Total Medicare spending is projected to increase from $744 billion in 2022 to $1.7 trillion in 2033. Continue Reading
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09 Jun 2023
5 Strategies for Designing a Medicaid Family Planning Program
Medicaid family planning programs provide critical services to beneficiaries who experience access to care barriers. Continue Reading
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05 Jun 2023
Medicare Coverage of Alzheimer’s Drugs Relies on FDA Traditional Approval
In addition to the Alzheimer’s drugs receiving FDA traditional approval, Medicare coverage hinges on clinicians collecting evidence on how the drugs work. Continue Reading