Policy and Regulation

CMS Grants NC 1115 Medicaid Waiver to Implement Managed Care System

by Thomas Beaton

North Carolina has received a 1115 waiver from CMS allowing the state to implement a Medicaid managed care system administered through private payers. The state’s Department of Health and Human...

New Drug Pricing Model Could Save Medicare Part B $17.2 Billion

by Thomas Beaton

A new drug pricing model with an international component could save Medicare Part B approximately $17.2 billion over five years, CMS says.   The International Pricing Index (IPI) will test if...

Proposed Rule Alters HRAs to Allow Direct Reimbursement to Employees

by Thomas Beaton

The Departments of Labor, Treasury, and HHS have proposed a new rule that would allow employers to directly reimburse employees’ care costs through health reimbursement arrangements (HRAs) as an...

CMS Broadens ACA Waiver Scope for State Insurance Programs

by Thomas Beaton

CMS has issued federal guidance intended to expand the scope and availability of state-level waiver programs.   State governments can now apply for State Relief and Empowerment Waivers that may...

BCBS of TN Defrauded $2M in $2B Telemedicine Insurance Scheme

by Thomas Beaton

BlueCross BlueShield (BCBS) of Tennessee has been named a damaged party after it was defrauded $2 million as part of a larger $2 billion telemedicine insurance scheme, according to the Department of...

IL Payers File Pharma Lawsuit Over Opioid Prescription Costs, Safety

by Thomas Beaton

A coalition of Illinois payers has sued prominent pharmaceutical companies in a lawsuit that argues the companies are responsible for a spike in opioid prescription costs and patient safety risks. The...

$36.9M in Medicare Fraud Leads to Federal Convictions, Sentencing

by Thomas Beaton

New high-profile Medicare fraud cases have led to convictions and lengthy prison sentences for providers that attempted to defraud Medicare of $36.9 million. Federal agencies including HHS, the FBI,...

CMS Proposes Drug Price Transparency in Television Ads

by Thomas Beaton

CMS has proposed a new rule that would enhance drug price transparency by requiring drug manufacturers to publish wholesale prices of Medicaid and Medicare prescription drugs during television...

CMS: ACA Premiums to Decline in 2019 for Silver Plan Consumers

by Thomas Beaton

CMS has announced it expects the average ACA health plan premium to drop by 1.5 percent for healthy consumers that purchase low-cost silver tier plans. The agency stated that it is the first time...

AMA, Industry Orgs Object to Short-Term Health Plan Expansion

by Thomas Beaton

The American Medical Association and other industry trade groups have filed amici curiae in support of a lawsuit contesting the legality of short-term health plans. The Association for Community...

Montana Reinsurance Program May Cut Premiums Up to 20%

by Thomas Beaton

Montana is moving ahead with the idea of creating a reinsurance program for the state’s health insurance market.  The program may reduce premiums between 10 and 20 percent, said Governor...

Senators Propose Limits on Surprise Healthcare Billing

by Thomas Beaton

A bipartisan group of Senators has introduced legislation that aims to end surprise healthcare billing, a practice which can lead to extremely high out-of-pocket costs for consumers. The Protecting...

Medicare-Medicaid Dual Eligible Care Models Aim to Coordinate Care

by Thomas Beaton

Medicare and Medicaid dual-eligible care models provide extensive care coordination to ensure beneficiaries with multiple chronic conditions can access healthcare services, according to a new AHIP...

FDA Recruits Payers to Submit Quality Feedback on Medical Devices

by Thomas Beaton

FDA has launched a new quality assurance program that leverages feedback from commercial payers about medical device coverage requirements in order to expedite approvals. The Private Payor Program...

MedPAC to Explore if Hospital Consolidation Impacts Medicare Costs

by Thomas Beaton

The House Committee on Energy and Commerce has asked the Medicare Payment Advisory Commission (MedPAC) to investigate whether or not hospital consolidation increases Medicare spending. In a letter to...

CA Plans Medical Loss Ratio Guidelines for Dental Insurance Plans

by Thomas Beaton

Consumers of dental plans may benefit from more transparency around the medical loss ratio (MLR) of dental insurance options, asserts the California Dental Association (CDA). In a recent research...

Handful of States Propose Lower ACA Premium Rates for 2019

by Thomas Beaton

Several states have announced lower ACA premium rates for 2019, bucking a national trend brought on by unstable markets and regulatory changes.   While early proposals from a number of states,...

Payers Sue to Collect 2017 Cost Sharing Reduction Payments

by Thomas Beaton

Payer organizations are exercising their right to use the court system to collect cost sharing reduction (CSR) payments that were not provided in the last quarter of 2017. A number of lawsuits are...

How to Curb Adverse Selection in the Individual Health Plan Market

by Thomas Beaton

Maintaining a profitable individual health plan product is already challenging, but adverse selection can create additional problems that impede a payer’s ability to control health plan...

CMS Adds Flexibility to Medicare Part D Formulary Strategies

by Thomas Beaton

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...