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
06 Dec 2024
Lawmakers promote access to direct primary care in Medicaid
While Medicaid programs can use waivers to implement direct primary care, a law that is under consideration in the Senate would make it easier for states to take this approach. Continue Reading
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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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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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26 Aug 2024
How enhanced premium tax credits could affect health equity
If the Inflation Reduction Act's enhanced premium tax cuts are renewed in 2025, they could increase enrollment among populations with higher uninsurance rates. Continue Reading
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10 Apr 2024
Payers react to 2025 Medicare Advantage, Part D Final Rates
The Medicare Advantage and Part D final rate notice drew negative reactions from the payer community, as the growth rate dipped to 2.33 percent. Continue Reading
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29 Mar 2024
CMS chops short-term, limited duration plan length to 4 months
A new CMS policy significantly reduces the maximum amount of time that a consumer can receive coverage from a short-term, limited duration plan. Continue Reading
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22 Mar 2024
Medicaid Health Plan Will Reimburse Health Equity Certification
The health plan aims to improve health equity among its in-network hospitals by reducing certification costs. Continue Reading
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20 Sep 2023
Hospital Outpatient Department Costs Consistently Outpace Offices, ASCs
By billing technical services separately, hospital outpatient department costs for coloscopy screenings were 47 percent higher than in the ASC or provider settings. Continue Reading
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11 Sep 2023
Medicare Part D Patients with HIV May See Lower Drug Costs Under IRA
Medicare Part D beneficiaries with HIV will benefit from the out-of-pocket healthcare spending cap and the expansion of low-income subsidy coverage. Continue Reading
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Feature
06 Sep 2023
An Overview of the CMS AHEAD Model for Health Equity Advancement
Participating states could receive as much as $12 million through the AHEAD model to align various payers on health equity goals. Continue Reading
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30 Aug 2023
OIG Strengthens Oversight Strategy for Managed Care Organizations
The four-phase managed care life cycle reinforces OIG’s goals of ensuring access to care, providing financial oversight, and promoting data accuracy. Continue Reading
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07 Aug 2023
HHS Attributes Record Low Uninsurance Rate to ACA Enrollment
The US uninsured rate dropped to 7.7 percent in 2023 after Affordable Care Act marketplace enrollment soared to 16 million enrollees. Continue Reading
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03 Aug 2023
Payers, Employers Support the No Surprises Act IDR Process in Court
While providers disapprove of basing out-of-network payment rates on the qualifying payment amount, payers and employers have defended the No Surprises Act policy. Continue Reading
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31 Jul 2023
AHIP, BCBSA Voice Concerns About Proposed Prior Authorization Rule
The rule might conflict with prior authorization standards and may be aligned with outdated policies, the payers argued. Continue Reading
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28 Jul 2023
VA Benefit Unawareness Leaves Vets Vulnerable to Healthcare Fraud
Healthcare fraud could catch any patient, but veterans who are unaware of their benefits are particularly at risk. Continue Reading
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25 Jul 2023
Biden Admin Proposes Mental Health Parity in Private Health Plans
Private health plans would have to evaluate provider networks and prior authorization requirements to ensure mental health parity for members. Continue Reading
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17 Jul 2023
Generic Insulin Drug Pricing, Access Still Pose Problems for Uninsured
While some progress has been made, drug pricing, availability, and confusion among consumers prevent uninsured Americans from gaining easy access to insulin. Continue Reading
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07 Jul 2023
HHS Proposed Rule Aims to Distinguish STLDI from Comprehensive Plans
Short-term, limited-duration insurance (STLDI) plans are too difficult for consumers to differentiate from traditional plans which can lead to underinsurance, HHS stated. Continue Reading
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23 Jun 2023
Slow but Steady: Experts Report on 2023 Mergers and Acquisitions Trends
Policy changes, portfolio renewals, and regulatory reviews will impact mergers and acquisitions in 2023. Continue Reading
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19 Jun 2023
Employer Sponsored Health Plan Enrollment Will Hit 159M in 2033
As employer-sponsored health plan coverage grows, uninsurance will rise but will not attain 2019 levels. Continue Reading
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13 Jun 2023
Health Plans Must Continue Covering Preventive Care Services
The preventive care services mandate does not apply to the plaintiffs in Braidwood v Becerra, per the joint stipulation. Continue Reading
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12 Jun 2023
AHIP Urges 4 Types of Policies to Reduce Healthcare Spending
AHIP suggested stemming provider consolidation and private equity involvement to reduce healthcare spending. Continue Reading
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24 May 2023
What Employers Need to Know About ERISA Compliance for Health Plans
ERISA compliance involves understanding the fiduciary role and the key health plan obligations that the law requires of employers. Continue Reading
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News
18 May 2023
4 Categories of Preventive Care Services Covered Under the ACA
ACA requires coverage of preventive care services without cost-sharing, but some services have sparked litigation. Continue Reading
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16 May 2023
Court Upholds ACA Preventive Care Compliance Amid Legal Proceedings
Health insurers and employers must cover ACA preventive care services as they await the oral hearing expected in the summer. Continue Reading
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05 May 2023
Uninsured Immigrants Face Significant Regulatory Barriers to Coverage
Uninsured immigrants make up over 30 percent of the US uninsured population, despite accounting for only eight percent of the country’s residents due to legislative hurdles. Continue Reading
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24 Apr 2023
AHIP Marketing Campaign Targets Pharma’s Prescription Drug Pricing
The payer organization stated that prescription drug pricing is out of control and explained health insurance's role in reducing the impact. Continue Reading
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20 Apr 2023
Public-Private Program Boosts Uninsured Access to COVID-19 Vaccines
Uninsured Americans have had access to free coronavirus treatments and vaccines during the pandemic and an HHS program seeks to extend this trend beyond the public health emergency. Continue Reading
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19 Apr 2023
Experts Assess the Effects of the No Surprises Act on Surprise Billing
Lawmakers passed the No Surprises Act in an attempt to eradicate surprise billing, but providers warn about the effect the law may have on provider networks. Continue Reading
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17 Apr 2023
HHS Finalizes Notice of Benefit and Payment Parameters for 2024
The Notice of Benefit and Payment Parameters for 2024 final rule finalized network adequacy standards and standardized health plan policies, but not the meaningful difference standard. Continue Reading
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31 Mar 2023
HHS Finalizes 3.32% Increase in 2024 Medicare Advantage Payments
In addition to boosting Medicare Advantage payments by $13.8 billion, HHS finalized technical changes to the risk adjustment model. Continue Reading
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30 Mar 2023
Judge Rules That Employers Do Not Have to Cover Certain Preventive Care Services
Employers may not have to cover preventive care services that have been recommended by the US Preventive Services Task Force. Continue Reading
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News
29 Mar 2023
AHIP Argues In Favor of the Copay Coupon Accumulator Rule
The payer organization supported the copay coupon accumulator rule arguing that it would prevent pharmaceutical manufacturers from using coupons as marketing tools. Continue Reading
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News
24 Feb 2023
What the Prior Authorization Proposed Rule Means for Payers
If finalized, the rule will establish new data exchange and prior authorization requirements that payers must comply with starting January 1, 2026. Continue Reading
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23 Feb 2023
How to Fix ERISA Waivers to Pursue Employer Sponsored Health Plan Reform
Certain aspects of ERISA present a roadblock to states seeking healthcare reform across public and private payers, including employer sponsored health plans. Continue Reading
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10 Feb 2023
HHS Shares COVID-19 Public Health Emergency End Date, What to Expect
The US Department of Health and Human Services gave states 90 days to prepare for the end of the coronavirus public health emergency, which will conclude on May 11, 2023. Continue Reading
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31 Jan 2023
Proposed Rule Adds Contraceptive Coverage Pathway, Cuts Moral Exemption
The proposed rule would implement a contraceptive coverage pathway for individuals whose payers have a religious exemption and do not opt into an accommodation. Continue Reading
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27 Jan 2023
BCBSA: 6 Policy Changes Could Save $767B in Healthcare Spending
Blue Cross Blue Shield Association’s policy proposals to reduce healthcare spending included expanding site-neutral payment policies, bolstering prescription drug competition, and more. Continue Reading
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20 Jan 2023
Most Impactful USPSTF Preventive Care Final Recommendations of 2022
The task force introduced two new topics for preventive care and assigned new grades to two sets of preventive care strategies. Continue Reading
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09 Jan 2023
Tracking the Results of Medicare Advantage Marketing Policies Remains a Challenge
Medicare Advantage marketing practices are under scrutiny, but more research is required to assess the source of the problems. Continue Reading
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06 Jan 2023
HHS, CMS Aim to Improve Medicaid Social Determinants of Health ILOS Efforts
The federal agencies outlined six principles that states can use to ensure that their Medicaid social determinants of health efforts are effective. Continue Reading
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14 Dec 2022
7 Key Changes to ACA Enrollment, Plan Selection in 2024 Proposed Rule
Affordable Care Act enrollment and plan selection may look different in 2024, particularly related to standardized plans. Continue Reading
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09 Dec 2022
7 Challenges, Opportunities for All-Payer Claims Databases
States, payers, and other healthcare stakeholders rely on all-payer claims databases to inform their strategies, so it is essential to maximize the efficiency of these resources. Continue Reading
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07 Dec 2022
Payer, Provider Orgs React to Prior Authorization Proposed Rule
The proposed prior authorization rule aims to speed up the process through electronic prior authorization, a move that appeals to major payer and provider organizations alike. Continue Reading
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02 Dec 2022
AMA Defends Affordable Care Act’s Preventive Care Coverage Requirement
The American Medical Association reminded the Court of the national progress that resulted from the preventive care coverage requirement, asking that the requirement remain intact. Continue Reading
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21 Nov 2022
No Surprises Act Leads to 9M Averted Surprise Bills, 275K Arbitration Claims
Although the No Surprises Act has successfully averted surprise bills, the law also resulted in significantly more dependence on the federal resolution process than anticipated. Continue Reading
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25 Oct 2022
AHIP Envisions Race, Ethnicity Data Collection Standardization Improvements
The payer organization urged federal organizations to consider adopting AHIP’s race and ethnicity data standardization recommendations to facilitate health equity progress. Continue Reading
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19 Oct 2022
How End of PHE Will Impact Consumer COVID-19 Healthcare Spending By Coverage Type
The end of the public health emergency and the depletion of federal treatment, testing, and vaccine supplies will influence consumer healthcare spending depending on the coverage type. Continue Reading
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13 Oct 2022
HHS Finalizes Rule That Aims to Fix the Affordable Care Act Family Glitch
The fix is expected to expand access to affordable healthcare coverage by ending the Affordable Care Act family glitch. Continue Reading
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11 Oct 2022
AHA: CBO Report Inaccurately Assessed Commercial Insurance Premium Drivers
AHA argued that the CBO report is based on a false assumption that hospital prices are driving health insurance premiums. Continue Reading
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04 Oct 2022
Inflation Reduction Act Takes Effect: Biosimilar Payment Boost for Medicare
Amidst concerns about Medicare negotiating drug prices, another part of the Inflation Reduction Act related to drug costs goes into effect. Continue Reading
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29 Sep 2022
Problems with Medicare Advantage Payment System Contribute to Overpayment
Medicare Advantage plans are overpaid and do not exhibit the quality of care improvements to justify their payments. Continue Reading
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26 Sep 2022
HHS Procures Federally-Covered COVID-19 Treatment Doses For Uninsured
As coronavirus treatments enter commercial markets, HHS has secured 60,000 coronavirus treatment doses for the uninsured, a store which is intended to last through September 2023. Continue Reading
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14 Sep 2022
40% of Americans Blame Deductibles for High Out-of-Pocket Healthcare Costs
High out-of-pocket healthcare costs are the result of a convergence of factors, but chief among them are challenges around prescription drug coverage. Continue Reading
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13 Sep 2022
OR Introduces Coverage for Mental Health Mobile Crisis Intervention Services
The mental health mobile crisis intervention services aim to improve access to care and boost health equity in the state. Continue Reading
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13 Sep 2022
Consumers Seek Transparency Around Treatment Costs, Healthcare Deals
Respondents across the political spectrum supported transparency and accountability regarding healthcare costs. Continue Reading
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18 Aug 2022
How the Inflation Reduction Act Will Impact Employers, Health Plans
The Inflation Reduction Act has generated concerns that Medicare drug price negotiations could lead to additional costs for employers and employer-sponsored health plan members. Continue Reading
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09 Aug 2022
Total Medicaid Expansion Could Improve Uninsurance, Heath Equity
Total Medicaid expansion may prove most beneficial for Black women of reproductive age who could see a 53.7 percent drop in uninsurance. Continue Reading
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09 Aug 2022
Payers Praise Inflation Reduction Act, Warn About Pharmaceutical Loopholes
Payers supported the Inflation Reduction Act primarily due to its extension of the American Rescue Plan Act’s subsidies for the next three years. Continue Reading
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03 Aug 2022
Uninsurance Rate Drops to Record Low of 8%, Pointing to ACA Enrollment Boom
Experts found that uninsurance dropped for every income bracket between 2020 and 2022, reaching a historic low. Continue Reading
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26 Jul 2022
Cementing ARPA Enhanced Subsidies May Boost Deficit, Lower Uninsurance
American Rescue Plan Act’s enhanced subsidies would lead to higher enrollment in the Affordable Care Act marketplace, which would have implications for uninsurance and costs. Continue Reading
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26 Jul 2022
Key Factors in 2023 Individual Health Insurance Market Premiums
AHIP outlined several influences on the 2023 individual health insurance market premiums including risk pool factors and overall cost drivers. Continue Reading
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14 Jul 2022
NY Anticipates the Impact of Ending the American Rescue Plan Act Flexibilities
The American Rescue Plan Act has significantly impacted New York’s healthcare coverage and could leave a large number of uninsured individuals if the law’s enhanced tax credits end. Continue Reading
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06 Jul 2022
Reducing Premiums Can Lead to Improved Insurance Coverage
Considering the fact that the majority of low-income consumers owe small premiums, researchers suggested that lowering premiums by a few dollars monthly could improve insurance coverage. Continue Reading
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29 Jun 2022
GAO: Gaps Remain in Medicaid Managed Care Direct Payments Oversight
CMS has made changes to its data collection processes for Medicaid managed care direct payments, but there is still room for improvement, according to GAO. Continue Reading
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24 Jun 2022
Payers Respond to SCOTUS Overturning Abortion Rights Case
The decision to overturn the federal abortion rights case is likely to have downstream impacts on healthcare coverage as the right to abortions becomes a states issue. Continue Reading
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23 Jun 2022
Colorado Implements Section 1332 Waiver to Advance Health Equity
Colorado’s waiver seeks to reduce premiums and expand access to care in order to advance health equity. Continue Reading
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15 Jun 2022
Key Steps to Improve Coverage Integration for Dually Eligible Individuals
As a follow-up to its 2021 mid-year report which outlined the challenges that dually eligible individuals face, MACPAC offered steps states can take to integrate this population’s coverage. Continue Reading
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03 Jun 2022
HHS, CMS Extend American Rescue Plan Funding For HCBS Another Year
States have another year to leverage federal funds from the American Rescue Plan to support HCBS initiatives. Continue Reading
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27 May 2022
BMA Supports Bill on Medicare Advantage Prior Authorizations
The bill would aim to standardize processes and require greater oversight on Medicare Advantage plans’ utilization and denial of prior authorizations. Continue Reading
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24 May 2022
NQF Opens Comment Period on Federal Program Quality Measures
Stakeholders are invited to assess quality measures from six federal programs, weighing factors such as patient outcomes and alignment with programmatic goals. Continue Reading
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28 Apr 2022
CMS, HHS Finalize 2023 Notice of Benefits, Payment Parameters
CMS and HHS released the 2023 Notice of Benefits and Payment Parameters Final Rule, finalizing many of the proposed changes. Continue Reading
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26 Apr 2022
Part D Out-of-Pocket Spending Cap Could Promote Health Equity
Imposing an out-of-pocket spending cap on Medicare Part D is not a new concept, but new research reveals that it may be important for advancing equity. Continue Reading
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12 Apr 2022
AHIP Responds to Proposed CDC Opioid Prescribing Guidelines
AHIP agreed with the aims of the centers’ proposed opioid prescribing guidelines, but listed six recommendations such as improving alignment with quality measure organizations. Continue Reading
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12 Apr 2022
Top Challenges, Benefits of At-Home Coronavirus Testing Coverage
Changes in at-home coronavirus testing coverage have created opportunities and challenges for payers as the pandemic reshapes preventive care services. Continue Reading
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08 Apr 2022
CMS Releases Alzheimer’s Treatment National Coverage Determination
With the finalization of its national coverage determination, the agency shared that it would cover the treatment under coverage with evidence development. Continue Reading
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07 Apr 2022
How The No Surprises Act Seeks to Change Surprise Billing
The act seeks to reduce surprise billing through independent dispute resolution and incentives for providers to join health plan networks. Continue Reading
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05 Apr 2022
CAQH Shares Interoperability and Patient Access Rule Compliance
The organization found that, while 64 percent of payers have made patient access points, not all payers have made their endpoints public. Continue Reading
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05 Apr 2022
CMS: 2023 Medicare Advantage, Part D Rate Sees 8.5% Revenue Boost
CMS also shared in the final 2023 Medicare Advantage and Part D Rate announcement that Medicare Advantage star ratings would increase by 0.54 percent on average. Continue Reading
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30 Mar 2022
Uninsured May Lose Access to COVID-19 Services Without Federal Funds
Without additional federal funds, providers will not receive reimbursement for administering COVID-19 services to uninsured individuals, which may boost out-of-pocket costs. Continue Reading
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09 Mar 2022
MACPAC Highlights Dual Eligible Challenges in CMS Proposed Rule
The 2023 proposed rule fails to address technical and resource challenges that states may face in integrating benefits for dual eligibles using dual eligibles special needs plans. Continue Reading
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08 Mar 2022
How Eliminating Individual Mandate Impacted the Latino Community
The elimination of the individual mandate coincided with a rise in uninsurance and decreased ability to afford care within the Latino population. Continue Reading
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03 Mar 2022
Payers React to State of the Union 2022 on ARPA, Drug Costs
Payers applauded the marketplace premium tax credit enhancements and other efforts to control healthcare costs noted in the State of the Union but renewed calls for drug pricing reform. Continue Reading
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16 Feb 2022
BBBA, Medicaid Expansion Could Expand Coverage For HIV Community
Medicaid expansion has been shown to improve early diagnosis of HIV, but it may also improve affordability and access to care. Continue Reading
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11 Feb 2022
CMS Updates Medicare Coverage for Certain Lung Cancer Screenings
The agency has expanded the population of beneficiaries that qualify for low dose CT scan lung cancer screenings, following the USPSTF’s B recommendation in 2021. Continue Reading
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11 Feb 2022
AHIP Comments on Alzheimer’s Drug National Coverage Determination
The national coverage determination for a hotly debated Alzheimer’s treatment received support from AHIP, although the large payer organization requested some clarification. Continue Reading
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07 Feb 2022
CMS Issues Over-the-Counter Coronavirus Testing Guidance
The over-the-counter coronavirus testing guidance addresses questions that payers may have regarding compliance, shortages, fraud, and more. Continue Reading
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03 Feb 2022
AHIP Calls On Congress to Address Price Gouging of COVID-19 Tests
AHIP recommended that Congress amend the CARES Act, allow for additional testing codes, and create a better system for tracking at-home tests to eliminate price gouging of COVID-19 tests. Continue Reading
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03 Feb 2022
Medicare Will Cover OTC Coronavirus Tests At The Counter
According to CMS, at no other time has Medicare covered over-the-counter tests for free, but the public payer will begin to cover over-the-counter coronavirus tests starting in spring 2022. Continue Reading
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03 Feb 2022
CMS Seeks Input on Medicare Advantage, Part D Health Equity Index
In addition to introducing the potential health equity index, CMS announced that it anticipates a 7.98 percent increase in revenue for Medicare Advantage plans. Continue Reading
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01 Feb 2022
Industry Reacts to Report on Payer Mental Health Parity Compliance
A recent report has stirred up debate among payer and provider groups about what needs to change in mental health parity compliance. Continue Reading
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28 Jan 2022
Key Payer Concerns in Proposed 2023 Benefit, Payment Parameters
Payers expressed concerns about changes to the risk adjustment process, plan standardization, and network adequacy deadlines. Continue Reading
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27 Jan 2022
Record-Breaking ACA Open Enrollment Gains 5.8M New Enrollees
CMS and HHS leaders attributed the record-breaking outcomes for the 2022 Affordable Care Act marketplace open enrollment season to outreach efforts and the 2021 special enrollment period. Continue Reading
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26 Jan 2022
Top Reasons Why Health Plans Fail Mental Health Parity Compliance
Historically, payers have often failed mental health parity compliance analyses and the Department of Labor’s report illuminates the reasons behind trend. Continue Reading
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26 Jan 2022
Consumers Face Struggles with COVID-19 Testing Access, Coverage
Consumers struggled with finding available COVID-19 testing and had trouble receiving health insurance coverage for the tests they could access. Continue Reading
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24 Jan 2022
AHIP, BCBSA Back HHS, Interim Final Rule in Surprise Billing Lawsuit
AHIP and BCBSA have sided with HHS in a surprise billing lawsuit and stated that the interim final rule helps protect patients against high out-of-network costs and does not negatively impact provider networks. Continue Reading
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21 Jan 2022
How Private Payers, Medicaid Cover At-Home COVID-19 Testing
In the early days of mandatory coverage for at-home COVID-19 tests, major payers are fairly split on whether to provide direct coverage for at-home COVID-19 testing. Continue Reading
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12 Jan 2022
Industry Reacts to CMS Medicare Coverage Determination Proposal
Two major payer organizations have released statements applauding the proposal’s approach, but patient advocates and provider organizations are divided. Continue Reading
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11 Jan 2022
CMS Requires Payers to Cover At-Home Coronavirus Testing
CMS included incentives for covering at-home coronavirus testing costs at the counter instead of through claims reimbursements. Continue Reading
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10 Jan 2022
CMS Releases 2023 Medicare Advantage, Part D Proposed Rule
The calendar year 2023 Medicare Advantage and Part D proposed rule adjusts medical loss ratio reporting, network adequacy metrics, star ratings, and other important standards. Continue Reading
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29 Dec 2021
HHS Releases 2023 Payment Notice, Medicaid Waiver Guidance
The Notice of Benefit and Payment Parameters 2023 proposed rule supports plan option standardization and the Medicaid waiver guidance addresses mobile crisis intervention waivers. Continue Reading