Medicare, Medicaid and CHIP
Government programs ensure access to healthcare for vulnerable populations. Medicare covers people 65 and older and younger individuals with specific disabilities. Medicaid and the Children's Health Insurance Program (CHIP) are joint federal-state initiatives offering health coverage to low-income families, children, pregnant women, the elderly and people with disabilities.
Top Stories
-
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
-
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
-
News
25 Nov 2024
Top 5 Medicare Advantage payers by footprint in 2025
The five Medicare Advantage payers with the largest footprint in 2025 made their case to beneficiaries by positioning themselves on affordability, quality and access to care. Continue Reading
-
Feature
13 Nov 2024
Understanding Medicare vs. Medicaid vs. CHIP
Medicare, Medicaid and CHIP are very influential in the healthcare industry at large, often steering trends in value-based care, social determinants of health and health equity. Continue Reading
-
News
17 Oct 2024
Medicare Advantage growth persists ahead of open enrollment
Medicare Advantage growth continues, spurred on by high quality of care, lower costs and better access to care. Continue Reading
-
News
04 Oct 2024
CMS, HHS update Medicare drug price negotiation process
The next Medicare drug price negotiation cycle might see new parameters around the negotiation platform and more talks around patient experience and pharmacy concerns. Continue Reading
-
Feature
12 Aug 2024
Key MA quality bonus payment program outcomes, concerns
Understanding the quality bonus payment program is critical to appreciating Medicare Advantage and discussing the calls for reform. Continue Reading
-
Feature
22 Jul 2024
Data, technology strategies boost payer patient education
Analytics platforms, omnichannel engagement tools, telehealth, and other technological and data advancements have been pivotal to successful payer patient education. Continue Reading
-
News
08 Jul 2024
Medicare Advantage, individual markets did well financially in 2023
As plans continue to recover from the pandemic, Medicare Advantage plans continued their strong performance, financially, in 2023. Continue Reading
-
News
19 Jun 2024
Improving LTPAC Management Interventions Using Real-Time Analytics
Real-time analytics improves care management in long-term care by enabling timely interventions and enhancing outcomes under value-based care models. Continue Reading
-
News
10 Jun 2024
Enhancing Transparency and Trust in Healthcare with Smart Contract Management
Managing health plan provider contracts is complex, but next-generation technological solutions can increase transparency and streamline the process across stakeholders. Continue Reading
-
News
05 Jun 2024
A Spotlight on Food Is Medicine: Creating Sustainable Programs
Food-is-medicine programs are popular, but health plans need to overcome challenges related to scalability and ROI to generate sustainable positive outcomes. Continue Reading
-
News
03 Jun 2024
Economic Wellness for Seniors Worsened from 2020 to 2022
Seniors scored poorly on categories such as food insecurity and housing costs, although they did experience positive trends in other areas. Continue Reading
-
News
29 May 2024
3 Key Metrics that Determine Member Satisfaction for Health Plans
Nearly every payer in the survey was stumped by two factors of member satisfaction: digital customer experience and provider wait times. Continue Reading
-
Feature
20 May 2024
What to expect in the NSA’s independent dispute resolution process
The No Surprises Act's independent dispute resolution process provides a channel for payers and providers to negotiate payments without affecting patient spending. Continue Reading
-
News
20 May 2024
Using Member Engagement to Balance Personalization, Participation
Health plans need to balance widespread participation and personalization for incentive programs to be successful; technology and meaningful communications are key. Continue Reading
-
News
09 May 2024
Concerns about mental health are higher than during COVID-19
Technology’s influence on mental health in America has been mixed, with social media being a key driver for wellness concerns. Continue Reading
-
News
06 May 2024
CVS Health acquires Hella+Health amid Medicare Advantage troubles
The Medicare Advantage broker, Hella+Health, has stated that it receives commissions but does not accept rewards from carriers. Continue Reading
-
News
02 May 2024
Health savings accounts come with unexpected fees, CFPB reports
In many instances, consumers with health savings accounts may spend more on unexpected fees than they earn in interest. Continue Reading
-
News
01 May 2024
Employers want cost-effective partners for contracted healthcare services
The KLAS report sheds light on employers’ feelings towards firms offering employer-sponsored healthcare services, including Marathon Health, Premise Health, and Proactive MD. Continue Reading
-
Feature
30 Apr 2024
How do Medicare Advantage insurers craft population-specific health plans?
Medicare Advantage insurers should prioritize data collection and provider collaboration when establishing population-specific health plans. Continue Reading
-
News
29 Apr 2024
Key Elements of Effective Member Incentive Programs
Incentive programs can motivate member behaviors as long as health plans design meaningful and strategic rewards. Continue Reading
-
News
25 Apr 2024
Humana reports Medicare Advantage growth, income gains in Q1 2024
Full-year consolidated revenues are expected to be $113 billion and individual Medicare Advantage membership is projected to grow by 150,000. Continue Reading
-
News
22 Apr 2024
Provider markups on specialty drugs increased commercial premiums
The average provider markup on specialty drugs was 42 percent and represented 0.7 percent of total healthcare spending. Continue Reading
-
News
18 Apr 2024
UnitedHealth Group lost $1.4B in Q1 2024 following cyberattack
The total impact of the Change Healthcare cyberattack on UnitedHealth Group amounted to $0.74 per share in the first quarter of the year. Continue Reading
-
News
17 Apr 2024
GAO: states enact own regulations to address pharmacy benefit managers
State regulations aim to boost transparency around pharmacy benefit manager practices and regulate pharmacy reimbursement. Continue Reading
-
News
15 Apr 2024
Health savings accounts have mixed effects on healthcare spending, use
Among health savings account members, healthcare spending was higher for inpatient services but lower for emergency department visits than PPO members. Continue Reading
-
News
01 Apr 2024
Biosimilar competition did not reduce out-of-pocket spending, study finds
Compared with the year before biosimilar availability, mean out-of-pocket spending was 12 percent higher in the second year after competition entered the market. Continue Reading
-
Feature
26 Mar 2024
How can payers be prepared to manage third-party security incidents?
Payers should implement vendor management programs, incident response plans, and training processes to prepare for third-party security incidents. Continue Reading
-
News
21 Mar 2024
Massachusetts residents delay services due to high healthcare costs
Nearly 70 percent of Massachusetts residents are worried about high healthcare costs, with co-pays and hospital bills topping the list of concerns. Continue Reading
-
News
20 Mar 2024
HHS, payers meet to address Change Healthcare cyberattack response
HHS called on payers to improve support for small, rural, safety-net providers but acknowledged progress on Change Healthcare cyberattack response. Continue Reading
-
News
18 Mar 2024
Humana and Baptist Health reach contract agreement for in-network coverage
Starting April 1, Humana beneficiaries can receive in-network coverage again at Baptist Health hospitals, physicians, clinics, and outpatient facilities. Continue Reading
-
News
14 Mar 2024
Wellcare partners with tech company to improve value-based primary care
The partnership will allow Wellcare to share increased financial risk and advance value-based primary care. Continue Reading
-
News
01 Mar 2024
Health Insurance Costs Are Growing Too Expensive for Small Businesses
Even small businesses that currently can afford health insurance face a steep cost cliff if premiums increase. Continue Reading
-
News
28 Feb 2024
UnitedHealth Group Scrutinized for Alleged Antitrust Practices
The antitrust practices may have not only squashed competition with competitors, but also allowed the major payer to skirt around certain regulations. Continue Reading
-
News
27 Feb 2024
Privately Insured Adults Are Satisfied With Health Plan Coverage
Privately insured adults in traditional plans were more satisfied with their health plan coverage than those in high-deductible plans. Continue Reading
-
News
16 Feb 2024
Elevance Health’s $2.5B Acquisition of BCBSLA Paused a Second Time
The acquisition attempt, which started in January 2023, has been called off again after pushback from regulators and lawmakers. Continue Reading
-
Feature
14 Feb 2024
How Payers and Pharmacy Benefit Managers Work Together to Lower Costs
Pharmacy benefit managers negotiate prescription drug prices with drug manufacturers and pharmacies on behalf of payers. Continue Reading
-
News
09 Feb 2024
Medicare Advantage Intake Surveys May Draw Insights, But Not Always
Some questions are better suited for telephonic surveys than others during the Medicare Advantage enrollment process. Continue Reading
-
News
08 Feb 2024
KLAS Report Reveals Top-Performing Vendors for Payer Services
The top-performing vendors varied across payer services, with Zelis ranking high for payment accuracy and integrity and ZeOmega succeeding in care management. Continue Reading
-
News
31 Jan 2024
How Affordability Challenges Reveal Care Disparities for ESI Members
Although some populations were more likely to utilize services like mental healthcare or preventive care, care disparities showed up in their affordability challenges. Continue Reading
-
News
30 Jan 2024
No Surprises Act Prevented 10M Surprise Medical Bills, But IDR Use Grows
An estimated 670,000 commercial claims were submitted to the No Surprises Act’s independent dispute resolution process last year. Continue Reading
-
News
24 Jan 2024
UnitedHealth Group Saw Revenue and Enrollment Growth in 2023
UnitedHealth Group’s revenue increased by more than $47 billion, with UnitedHealthcare and Optum both seeing growth. Continue Reading
-
News
23 Jan 2024
OOP Costs Greater for Cancer Patients in High-Deductible Health Plans
After switching to a high-deductible health plan, out-of-pocket costs increased by 68.1 percent for patients with cancer relative to those in traditional plans. Continue Reading
-
News
22 Jan 2024
UnitedHealthcare Platform Improves Member Access to Well-being Programs
The platform can connect members with well-being programs that are specific to their healthcare needs. Continue Reading
-
Feature
16 Jan 2024
What Utilization Management Strategies Do Payers Use to Lower Costs?
Utilization management strategies aim to lower healthcare costs and prevent low-value care but can have unintended consequences for patients. Continue Reading
-
Answer
10 Jan 2024
How One Payer Tackled the No Surprises Act Provider Directory Rule
Since the No Surprises Act went into effect, payers and providers have struggled to keep up with certain provisions and many wonder if automation can fill the gaps. Continue Reading
-
News
08 Jan 2024
Elevance Health Plans to Acquire TX-Based Infusion Therapy Provider
Elevance Health aims to expand the infusion therapy provider’s geographical footprint and improve therapeutic coverage. Continue Reading
-
News
05 Jan 2024
US Drug Prices Are 8x the Cost in Peer Countries for Some Drugs
For nine out of ten Medicare-negotiated drug prices, the US still faced higher costs than peer countries even with rebates. Continue Reading
-
News
04 Jan 2024
Centene Pays South Carolina $25M to Settle Overcharging Allegations
The settlement resolved allegations that Centene overcharged for and misrepresented costs of pharmacy services. Continue Reading
-
News
03 Jan 2024
2024 Employer Sponsored Health Plan Predictions: GLP-1s, Vendors, Data
In 2024, healthcare costs will drive decision-making in employer sponsored health plans as they reassess their point solutions and benefits. Continue Reading
-
Answer
02 Jan 2024
2024 Payer Strategies: Population-Based Plans, MA Differentiation
In 2024, payer strategies will include improving health equity partnerships, differentiating their Medicare Advantage plans, and offering care navigation. Continue Reading
-
News
27 Dec 2023
Humana Awards $169K in Health Equity Grants to Community-Based Orgs
The health equity grant recipients align with Humana’s goals to improve access to care and address social determinants of health. Continue Reading
-
News
20 Dec 2023
Most Employers Offering Retiree Health Plans Use Medicare Advantage
For many retirees, a Medicare Advantage plan may be the only option they have for receiving retiree health benefits. Continue Reading
-
News
15 Dec 2023
2022 National Healthcare Spending Growth Slowed to Pre-COVID Levels
National healthcare spending grew 4.1 percent in 2022 and Medicare and private payers experienced a slightly slower growth rate than the previous year. Continue Reading
-
Answer
12 Dec 2023
How Healthcare Leaders Can Weigh Pros, Cons of Payer Megamergers
Payer megamergers can have mixed results and the overall impact largely hinges on the companies' commitment to value-based care principles. Continue Reading
-
News
07 Dec 2023
Humana Foundation Grants $1M to Address Food Insecurity, Mental Health
The grants will help researchers analyze various interventions and their impacts on food security and mental health. Continue Reading
-
News
06 Dec 2023
How Employers Can Promote Cardiovascular Care, Women’s Health
Employers can implement a number of strategies to raise awareness and promote access to cardiovascular care to support women’s health. Continue Reading
-
Feature
05 Dec 2023
How Do Payers Cover Prenatal, Postpartum Care for Pregnant People?
Public and private payers cover essential prenatal care for pregnant people, but coverage levels and costs may vary by plan. Continue Reading
-
News
04 Dec 2023
Payers Embrace Healthcare IT for Cost Optimization, Member Engagement
Payers expect to increase their spending on healthcare IT resources by 3 to 5 percent in the next two years. Continue Reading
-
News
04 Dec 2023
Setting the Foundation for Member Engagement Across Populations
Health payers need a solid member engagement foundation in order to tailor their strategies to optimize outcomes and costs for specific populations. Continue Reading
-
Answer
29 Nov 2023
Blue Cross Blue Shield of MA Eliminates More Prior Authorizations
The payer focused on prior authorizations that may slow down the transition from hospital care to home care. Continue Reading
-
Feature
16 Nov 2023
How Can Payers Support Providers Through Workforce Challenges?
Payers can implement value-based payment models and invest in training programs to support providers through workforce challenges. Continue Reading
-
News
15 Nov 2023
How Much Members Spend on Diabetes Chronic Disease Management
It is well known that diabetes is a costly disease, but even members with insurance may pay thousands of dollars per year for chronic disease management. Continue Reading
-
News
13 Nov 2023
KLAS: Epic’s Payer Platform Generates High User Satisfaction
Epic’s payer platform helped improve cost savings around users’ clinical data acquisition efforts. Continue Reading
-
News
09 Nov 2023
What Non-Medical Supplemental Benefits Will MA Plans Offer in 2024?
Food and produce, transportation, and social needs services top the list of non-medical supplemental benefits from Medicare Advantage plans in 2024. Continue Reading
-
Feature
02 Nov 2023
How Public, Private Payers Cover Care for the LGBTQ+ Population
Healthcare coverage for the LGBTQ+ population differs depending on a member’s state, health plan, and service needed. Continue Reading
-
News
31 Oct 2023
Study Finds Geographic Variation in Payer Prices for Office Visits
The county-level price for patient office visits from Humana ranged from $69 to $144 nationwide. Continue Reading
-
Feature
30 Oct 2023
Top Payer Concerns, Opportunities Around Generative AI Integration
Payers should create a unified approach to AI overall, thoroughly document generative AI integration, and ensure the explainability of their generative AI tools. Continue Reading
-
News
27 Oct 2023
Finances, Mental Health Concerns Impact Adults’ Wellbeing, Cigna Finds
Almost a third of adults who reported needing mental health counseling did not receive care, primarily due to high costs. Continue Reading
-
Feature
26 Oct 2023
4 Key Strategies to Promote Effective Payer, Provider Alignment
Data-sharing, value-based contracts, and standardized quality measures are critical to improving payer-provider alignment. Continue Reading
-
Answer
25 Oct 2023
3 Steps One Medicaid MCO Took to Boost Its Patient Experience Score
Patient experience is a key measure in the NCQA health plan rating system, but two components—ease and speed of access to care—can be hard to achieve. Continue Reading
-
News
23 Oct 2023
Humana Ranks High for Experience, Affordability Among MA Plans
Humana earned 3.9 stars for member experience and an overall rating of 4.3 stars. Continue Reading
-
Feature
20 Oct 2023
Demystifying Medicaid Managed Care, Its Role in the Future of VBC
Medicaid managed care plans have gained traction as the dominant form of coverage in the Medicaid space with millions of beneficiaries in managed care organizations. Continue Reading
-
News
19 Oct 2023
Employer Sponsored Health Insurance Premiums Grew by 7% in 2023
The average annual premium for employer-sponsored health insurance is $8,435 for single coverage and $23,968 for family coverage. Continue Reading
-
Feature
18 Oct 2023
3 Ways That Large Employers Influence Health Insurance Costs, Coverage
Large employers can impact health benefit design, access to chronic disease management programs, and affordability of care. Continue Reading
-
News
10 Oct 2023
What Are Major Payers Offering Medicare Advantage Members in 2024?
UnitedHealthcare, Humana, Cigna, and Aetna are aiming to keep premiums and prescription drug costs low for Medicare Advantage beneficiaries in 2024. Continue Reading
-
News
09 Oct 2023
UHC Commercial Plan Focuses on Price Transparency, Preventive Care
The payer’s emphasis on preventive care may have contributed to its and strong re-enrollment rate. Continue Reading
-
News
05 Oct 2023
Mortality Rates Among Women and Children Are Rising, UHG Report Finds
Between 2018 and 2021, the maternal mortality rate increased by 29 percent, from 17.3 to 22.4 deaths per 100,000 live births. Continue Reading
-
News
03 Oct 2023
Alignment Health to Offer Medicare Advantage Plans That Address SDOH
The Medicare Advantage plans will address food insecurity by offering benefits like quarterly grocery allowances. Continue Reading
-
News
02 Oct 2023
How API Marketplaces and Strategic Partnerships Drive Payer Innovation
API marketplaces are pivotal for enhancing innovation by streamlining operations, improving member experiences, and strengthening provider relationships. Continue Reading
-
News
28 Sep 2023
AMA: Commercial Coverage of Digital Medicine Services is Inconsistent
Transparency on commercial coverage policies for digital medicine services was also lacking, with some plans having no coverage information publicly available. Continue Reading
-
News
26 Sep 2023
Cigna Healthcare Invests $1M to Reduce Food Insecurity for Seniors
The funding will support programs that address food insecurity, such as food pantries, mobile food deliveries, and nutritional meal boxes. Continue Reading
-
News
25 Sep 2023
Anthem Blue Cross Grants CA Orgs $1.2M to Address Mental Health
The grants are a part of Elevance Health Foundation’s $30 million commitment to improve equity for people with mental health disorders. Continue Reading
-
News
25 Sep 2023
How APIs Transform Payer Approaches to Member, Provider Experience
APIs are reshaping healthcare by improving member and provider interactions, driving digital maturity in health plans, and offering real-time information access, cost transparency, and streamlined processes Continue Reading
-
News
22 Sep 2023
Employers Expect Highest Health Plan Benefits Cost Growth in 10 Years
Employees are expected to cover 22 percent of total premiums in 2024, a factor of health plan benefits costs that has not changed since 2022. Continue Reading
-
News
20 Sep 2023
How Payers Unlock Healthcare Efficiency Through the Power of APIs
Healthcare payers are harnessing the power of APIs to create seamless member experiences, streamline operations, and stay competitive in the digital healthcare landscape. Continue Reading
-
News
18 Sep 2023
Blue Shield of CA Technology Partnership Improves Care Management
Through a new care management platform, care managers can access members’ health data in one location. Continue Reading
-
Feature
13 Sep 2023
How the Top 4 Disruptive Insurtechs Have Evolved Since Their IPOs
In a health insurance landscape that is consolidating into a few major players, four insurtechs sought to change the system. Continue Reading
-
Feature
07 Sep 2023
Exploring the History of the Blue Cross Blue Shield Association
The Blue Cross Blue Shield Association boasts 34 independent companies that provide healthcare coverage to people across the United States. Continue Reading
-
News
28 Aug 2023
Cigna Removes Prior Authorization for 25% of Medical Services
The payer has removed prior authorization requirements for over 1,100 medical services since 2020. Continue Reading
-
Feature
28 Aug 2023
Top 5 Largest Health Insurance Payers in the United States
These top five health insurance payers hold the largest net revenue and members. Continue Reading
-
Answer
16 Aug 2023
Payer Turns to PBM Coupon Program to Lower Prescription Drug Spending
In the first quarter of 2023, the program resulted in $4.5 million in reduced prescription drug spending for participating employer groups. Continue Reading
-
News
15 Aug 2023
How Payers Are Reducing Prior Authorizations, Limiting Care Disruptions
To limit patient care disruptions, payers have reduced prior authorization requirements for genetic testing, cataract surgeries, and physical therapy. Continue Reading
-
Answer
14 Aug 2023
Key Strategies for Transitioning a Health Plan into Cloud Computing
Cloud computing technology adoption is on the rise worldwide, but how can health plans shift their complex processes into this new platform? Continue Reading
-
News
11 Aug 2023
Blue Cross of Idaho Invests in Digital Platform, Improving Senior Care
Blue Cross of Idaho’s investment will help Endear Health expand its digital platform and facilitate access to healthcare programs for seniors. Continue Reading
-
Feature
10 Aug 2023
Unpacking What Price Transparency Looks Like for Health Plans
Health plans must sort through heaps of data to publish useful, accurate price transparency information for consumers. Continue Reading
-
Feature
04 Aug 2023
Top Member Education Strategies for High Performance Network Benefits
Member education strategies might vary based on whether the network is narrow or tiered, but clear communication is always necessary. Continue Reading
-
Answer
26 Jul 2023
First Impressions Count: How Onboarding Affects Member Engagement
From the first point of contact to tracking the results on welcome package touchpoints, onboarding strategies are key to forming a strong payer-member relationship. Continue Reading
-
News
24 Jul 2023
Consumers Blame Payers, Utilization Management for Delays in Care
Utilization management barriers were particularly high for individuals with neurological disorders and mental healthcare needs. Continue Reading
-
News
21 Jul 2023
Humira Price for Commercial Plans Remained Steep Despite High Rebates
The net price of Humira for commercial health plans in 2020 was $1,812, significantly higher than its initial launch price of $522. Continue Reading
-
News
19 Jul 2023
How Mental and Behavioral Health Disparities Impact Adults, Youth
American Indian/Alaska Native adults faced higher rates of substance use disorder and drug deaths, highlighting mental and behavioral health disparities. Continue Reading