Policy and Regulation

How One Payer Tackled the No Surprises Act Provider Directory Rule

January 10, 2024 - Brian Marsella, president of Health Payment Systems (HPS) and Paymedix, was accustomed to the challenges of maintaining provider directories when he joined HPS and Paymedix in 2022. But two years into his tenure and two years after the No Surprises Act went into effect, it was clear the payer’s provider directory processes needed to...


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Top Payer Concerns, Opportunities Around Generative AI Integration

by Kelsey Waddill

Generative AI may become a fixture of the health insurance landscape, seamlessly integrated into common payer processes, reducing timelines from hours or days to minutes. But for now, the tool’s future is fraught with...

AHIP, BCBSA Voice Concerns About Proposed Prior Authorization Rule

by Kelsey Waddill

AHIP joined the American Hospital Association (AHA), American Medical Association (AMA), and Blue Cross Blue Shield Association (BCBSA) in opposing the prior authorization reformation efforts from CMS...

How Medicaid Network Adequacy Rules Affect Children with Special Needs

by Kelsey Waddill

Children with special health care needs (CSHCN) may experience access to care barriers as a result of new quantitative Medicaid network adequacy standards, a study published in Health Affairs...

Judge Blocks FL Ban on Medicaid Coverage for Gender-Affirming Care

by Victoria Bailey

A federal judge has blocked Florida’s ban on Medicaid coverage for gender-affirming care, stating that the rule violated federal law and was politically motivated. The ban’s inception...

Slow but Steady: Experts Report on 2023 Mergers and Acquisitions Trends

by Kelsey Waddill

What will happen to the volume and value of mergers and acquisitions in 2023? This is a question at the forefront of payers’ minds as the healthcare industry emerges from the uncertainties of the coronavirus pandemic. The twelve...

How COVID-19 Policies Impacted Medicaid Enrollment Among Children

by Kelsey Waddill

Medicaid enrollment among children surged during the coronavirus pandemic, fueled in certain states by policies in the Families First Coronavirus Response Act (FFCRA) that helped maintain coverage, a...

Coronavirus Pandemic Policies May Have Improved Care Affordability

by Kelsey Waddill

Coronavirus pandemic policies may have helped curb unmet care, unaffordability in care, and certain care disparities, but these trends could also reflect lower overall care utilization due to...

Extending Medicaid Postpartum Coverage May Reduce Disenrollment

by Kelsey Waddill

States that have extended their Medicaid postpartum coverage periods may be better positioned to protect residents from widespread coverage loss in the wake of the public health emergency’s...

What Employers Need to Know About ERISA Compliance for Health Plans

by Kelsey Waddill

The Employee Retirement Income Security Act of 1974 (ERISA) dominates the health insurance industry and regulates coverage for around 139 million Americans in 2.5 million health plans, making familiarity with ERISA compliance critical for...

Court Upholds ACA Preventive Care Compliance Amid Legal Proceedings

by Kelsey Waddill

The US Court of Appeals for the Fifth Circuit determined that employers and health insurers must maintain compliance with Affordable Care Act (ACA) preventive care services provision while the law...

Uninsured Immigrants Face Significant Regulatory Barriers to Coverage

by Kelsey Waddill

Regulatory barriers present significant hurdles for uninsured immigrants seeking healthcare coverage, a report from the Urban Institute and the Robert Wood Johnson Foundation (RWJF) found. The...

Experts Assess the Effects of the No Surprises Act on Surprise Billing

by Kelsey Waddill

The No Surprises Act may have successfully defended consumers from surprise billing but requires reworking in other areas, an issue brief from Urban Institute and the Robert Wood Johnson Foundation...

HHS Finalizes Notice of Benefit and Payment Parameters for 2024

by Kelsey Waddill

The Department of Health and Human Services (HHS) has released the HHS Notice of Benefit and Payment Parameters for 2024 final rule which addressed network adequacy, plan selection, special enrollment...

HHS Finalizes 3.32% Increase in 2024 Medicare Advantage Payments

by Victoria Bailey

HHS has finalized the 2024 Medicare Advantage and Part D rate announcement, which includes a 3.32 percent increase in Medicare Advantage payments. “Medicare should be providing equitable,...

Stakeholder Groups Oppose Medicare Advantage Risk Adjustment Changes

by Victoria Bailey

Since CMS released the 2024 Medicare Advantage Advance Notice in February, healthcare stakeholders have not been silent about their concerns with the proposed risk adjustment model changes. CMS...

AHIP Asks CMS to Reconsider Proposed Medicare Advantage Policy Changes

by Victoria Bailey

AHIP is urging CMS to consider the potential adverse impacts of its proposed rule for Medicare Advantage policy and technical changes, specifically raising concerns about the star rating changes, new...

The Future of Medicare Advantage Risk Adjustment Data Validation

by Kelsey Waddill

Around four years passed between when CMS proposed the new rule on Medicare Advantage risk adjustment and when the Medicare Advantage Risk Adjustment Data Validation final rule was published. As stakeholders review the long-awaited final...

BCBSA: 6 Policy Changes Could Save $767B in Healthcare Spending

by Kelsey Waddill

In a report and briefing, Blue Cross Blue Shield Association (BCBSA) recommended policy solutions that could help bring runaway healthcare spending under control, saving $767 billion across 10...

HHS Posts Timeline for Medicare 2026 Drug Price Negotiations

by Kelsey Waddill

In accordance with the Inflation Reduction Act, the US Department of Health and Human Services (HHS) announced that Medicare will begin drug price negotiations for prices going into effect in 2026 and...