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HealthPayerIntelligence News

CMS Adds Flexibility to Medicare Part D Formulary Strategies

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CMS is encouraging Medicare Part D health plans to adopt new formulary design strategies that are geared towards lowering drug prices and improving consumer choice. A memo from the agency highlights a major upcoming change to the...

ACA Health Insurance Tax to Cost $16B, Lead to Higher Premiums

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The Affordable Care Act’s health insurance tax (HIT) is expected to levy $16 billion in fees for health insurers by 2020, leading payers to increase premiums by an anticipated 2.2 percent, according to a Oliver-Wyman report...

How Capitated Payments Prompt Payer, Provider Innovation

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The challenges of lowering care costs and improving healthcare quality may lead payers to consider the use of capitated payments as part of their value-based payment model strategies. Capitated payments are pre-arranged payments for...

Payers See Cost, Quality Gains with Value-Based Payment Models

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Payers and providers participating in value-based payment models are seeing reduced costs and improvements in care quality.   Value-based payment, which is expected to account for 59 percent of all healthcare payments by 2020, helps...

Next Generation ACO Model Saved Medicare $62M in 2016

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Next Generation Accountable Care Organizations (ACO) saved the Medicare program $62 million during their first year of operation in 2016, encouraging CMS to expand downside risk models across Medicare. Next Generation ACOs accept the...

GOP Senators Propose to Reinforce Pre-Existing Condition Protections

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Half a dozen Republican Senators have introduced a bill that would ensure the Affordable Care Act’s pre-existing condition protections would remain a federal law despite upcoming legal challenges. The Ensuring Coverage for Patients...

Value-Based Care Slashes Per Member Per Month Costs in Kansas

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BlueCross BlueShield of Kansas has seen significantly lower per member per month costs for beneficiaries participating in value-based care arrangements, including accountable care organizations (ACOs) and patient-centered medical homes...

Payers, Providers Create New Medicare Advantage Partnerships

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New Medicare Advantage plans, many born of innovative partnerships between payers and providers, are creating more options for beneficiaries to supplement their existing coverage with high-value offerings. Commercial payers operating in...

GAO Critiques HHS Actions on ACA Navigator Program Funding

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The Government Accountability Office (GAO) has questioned the data-driven methodology behind significant reductions in funding for the ACA navigator program and subsequent declines in new enrollment in health insurance plans.   In a...

1115 Medicaid Demonstrations Should be Budget-Neutral, CMS Says

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CMS has issued new guidelines for state officials around creating budget-neutral 1115 Medicaid demonstrations. CMS informed state governments that the agency will use a formalized methodology to determine if 1115 demonstrations are a...

How Employers Can Design High-Quality Cancer Care Benefits

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Designing meaningful and high-quality cancer care benefits is a challenge for employer-sponsored health plans.   Cancer, a costly and complex condition that takes many different forms, requires coordination across the entire...

Anthem, Walmart Partner for Over-the-Counter Drug Allowance

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A new partnership between Anthem and Walmart will allow Medicare Advantage beneficiaries to purchase over-the-counter drugs and other drug store necessities with a plan allowance. Starting in January of 2019, Anthem beneficiaries will be...

CMS Tells States to Curb Silver-Loading with Off-Exchange Plans

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CMS is asking state insurance departments to offer more off-exchange health plans in order to reduce silver-loading of qualified health plans (QHP). Silver-loading is the practice of raising premiums so that payers can earn larger federal...

CMS Provides $8.4M to Stabilize State Insurance Markets

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CMS has awarded $8.4 million to 31 states in an effort to stabilize state insurance markets and increase the number of affordable health plan options for beneficiaries. Recipients are allowed to use the ACA-funded State Flexibility Grant...

New Jersey Gains CMS Approval for Reinsurance Program

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New Jersey has received approval from CMS to implement a five-year reinsurance program that aims to lower individual health plan premiums by 15 percent. The program will operate from 2019 to 2023 and provide $218 million in reinsurance...

CMS Processes State Medicaid Requests, Approvals 23% Faster

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CMS has announced that an agency initiative to streamline state Medicaid approvals and state plan amendments (SPAs) has increased approval processing speed by 23 percent. In 2017, CMS sent a bulletin to state Medicaid programs informing...

Top 10 Highest Performing Medicare Advantage Health Plans

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Medicare Advantage (MA) plans are growing in popularity as an aging consumer population seeks comprehensive coverage for acute and chronic care needs. A competitive, lucrative market for high-performing plans has emerged, giving payers an...

Google Invests $375M in Oscar Health for Medicare Advantage

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Google’s parent company, Alphabet, has invested $375 million in Oscar Health to help the tech-focused payer enter into Medicare Advantage markets by 2020, according to multiple news outlets, including Reuters. Oscar Health said in...

OH Medicaid Adopts Pass-Through Model for Managed Care Drugs

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Ohio’s Medicaid program has issued a mandate that requires managed care health plans to re-negotiate pharmacy benefit manager (PBM) contracts to transition from a spread-pricing drug purchasing model to a pass-through model. The...

Commercial Payers See Promise in Diabetes Prevention Program

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The Diabetes Prevention Program could offer commercial payers an impactful way to prevent chronic disease for beneficiaries, according to a new report from AHIP.   In 2012, AHIP recruited seven large payers to a pilot program which...

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