Policy & Regulation

GAO: states enact own regulations to address pharmacy benefit managers

April 17, 2024 - States have implemented their own regulations to address pharmacy benefit manager (PBM) operations, some of which may prove better routes than national legislation, according to a report from the Government Accountability Office (GAO). Partnering with PBMs is one way health plans can try to minimize prescription drug spending. PBMs process claims,...

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PHE unwinding work may aid Medicaid, CHIP final rule compliance

by Victoria Bailey

The eligibility and enrollment processes for Medicaid and the Children’s Health Insurance Program (CHIP) have been riddled with inefficiencies. Policies like annual coverage limits and waiting periods have created barriers for...

Medicare Advantage final rule addresses competition and marketing practices

by Victoria Bailey

CMS has finalized policies to promote competition in Medicare Advantage and Part D plans, boost access to behavioral healthcare services, and reduce deceptive marketing practices. The Contract Year...

CMS final rule improves access to Affordable Care Act marketplace coverage

by Victoria Bailey

CMS has finalized policies to increase access to marketplace coverage and expand essential health benefits (EHBs) in the HHS 2025 Notice of Benefit and Payment Parameters final rule. “Access to...

Overcoming Tech Barriers to Achieve Prior Authorization Transparency

by Victoria Bailey

Prior authorization has posed problems for nearly all healthcare stakeholders. The CMS Interoperability and Prior Authorization Final Rule aims to streamline the utilization management process and improve data-sharing between payers,...

Lawmakers Lobby for Payment and Policy Stability in Medicare Advantage

by Victoria Bailey

A bipartisan group of United States Senators has urged CMS to ensure payment and policy stability in Medicare Advantage as the agency considers program updates for 2025. The letter to CMS...

CMS Proposes 3.7% Increase in Medicare Advantage Plan Payments

by Victoria Bailey

Medicare Advantage plan payments will increase by 3.7 percent or $16 billion in 2025, CMS proposed in the Calendar Year (CY) 2025 Advance Notice for the Medicare Advantage and Medicare Part D...

No Surprises Act Prevented 10M Surprise Medical Bills, But IDR Use Grows

by Victoria Bailey

The No Surprises Act (NSA) helped prevent 10.1 million surprise medical bills in the first nine months of 2023, according to a survey from AHIP and the Blue Cross Blue Shield Association (BCBSA). The...

Centene Pays South Carolina $25M to Settle Overcharging Allegations

by Victoria Bailey

Centene Corporation has reached a $25.89 million settlement after allegedly overcharging South Carolina’s Medicaid program for pharmacy services. Per the settlement, Centene must pay South...

Key Regulations and Policies That Will Impact Payers in 2024

by Victoria Bailey

As healthcare stakeholders and the federal government work to make healthcare more accessible and affordable for consumers, CMS and HHS are frequently introducing and finalizing new rules and regulations. There were a couple of key...

Lawsuit Alleges Humana Used AI to Deny Medically Necessary Claims

by Victoria Bailey

Humana is facing a class action lawsuit alleging that the payer used an artificial intelligence (AI) tool to deny Medicare Advantage beneficiaries’ claims for medically necessary care. In a...

CMS Proposals Address Anti-Competitive Practices in Medicare Advantage

by Victoria Bailey

CMS has proposed provisions to improve protections for Medicare Advantage beneficiaries, prevent anti-competitive practices, and strengthen access to behavioral healthcare services. The Contract Year...

What Cigna’s FCA Settlement Means for Other Medicare Advantage Plans

by Victoria Bailey

Cigna’s recent brush with False Claims Act violations serves as a reminder that Medicare Advantage organizations should be routinely assessing their risk and compliance activities. The Department of Justice (DOJ) announced in...

Who is Challenging the Medicare Drug Price Negotiation Rule?

by Victoria Bailey

The Medicare drug price negotiation provisions in the Inflation Reduction Act hold promising spending reductions for beneficiaries, but drug companies are not backing down without a fight. In August...

The Medicare Advantage Marketing Problem and Where It’s Headed

by Victoria Bailey

Each year, Medicare’s open enrollment period starts mid-October and is preceded by an influx of marketing materials advertising private Medicare Advantage, Medicare Part D, and Medigap plans. While marketing practices are intended to...

HHS Releases First 10 Drugs Eligible for Medicare Price Negotiation

by Victoria Bailey

Updated 10/3/2023: This article has been updated to include the drug companies' decisions to participate in the negotiation process. HHS has announced the first ten drugs that will be available...

CMS Announces Monthly Payment Option for Out-of-Pocket Part D Costs

by Victoria Bailey

CMS has released draft guidance detailing a new program allowing Medicare beneficiaries to pay out-of-pocket Part D costs in monthly installments. The Medicare Prescription Payment Plan is required...

Payers, Employers Support the No Surprises Act IDR Process in Court

by Victoria Bailey

The provisions of the No Surprises Act rule that detail the independent dispute resolution (IDR) process for out-of-network claims have been making waves in the healthcare space. The No Surprises Act...

Biden Admin Proposes Mental Health Parity in Private Health Plans

by Victoria Bailey

The Biden-Harris Administration has proposed a rule to improve access to mental healthcare for privately insured Americans by establishing mental health parity requirements. The rule supports the...

CMS Proposed Rule Addresses Drug Cost Transparency in Medicaid

by Victoria Bailey

The Centers for Medicare and Medicaid Services (CMS) has issued a proposed rule that aims to increase the transparency of prescription drug costs in Medicaid. “This proposed rule prioritizes...

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