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
10 Jun 2026
ACA tax credit lapse led to fewer signups, more plan drop-off
Following the lapse of the ACA enhanced premium tax credits, there was a signup shortfall of 1.5 million, but more plan drop-off is expected, according to the Commonwealth Fund. Continue Reading
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09 Jun 2026
CMS received nearly 15K NSA complaints, mostly against providers
Most complaints alleging PHS Act violations are related to the No Surprises Act, with tens of thousands of allegations made against providers, CMS reports. 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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News
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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News
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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News
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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News
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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News
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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News
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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News
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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News
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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News
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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News
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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News
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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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