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
13 Apr 2026
Payers face faster prior authorization approvals under CMS proposal
Under the proposed rule, affected payers would need to respond to urgent prior authorization requests for drugs within 24 hours and to standard requests within 72 hours. Continue Reading
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News
13 Apr 2026
CMS proposes 2.4% IPPS bump, joint replacement model expansion
A proposed rule would increase inpatient reimbursement by $1.9B next year, while expanding the Comprehensive Care for Joint Replacement Model nationwide. Continue Reading
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News
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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News
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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News
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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News
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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News
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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News
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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News
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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News
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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News
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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News
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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News
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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News
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