Policy and Regulation News

AHIP: HHS Proposed Price Transparency Rule Not Actionable, Secure

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The HHS Transparency in Coverage proposed rule is not an actionable or secure method to achieving price transparency, nor is it an authorized exercise of HHS authority, AHIP argues in its comments on...

Centene, WellCare Finalize Major Health Payer Merger Deal

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Centene and WellCare announced they have finalized a major health payer merger deal that will combine the two organizations into the largest health insurer by membership with more than 24 million...

Tufts Health Expands Telehealth Solution, Boosts Access to Care

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Commercial members of Tufts Health Plan can now access US-based, board-certified providers for medical needs and diagnoses through the expansion of its telehealth virtual healthcare solution, according...

Supreme Court Will Not Expedite ACA Constitutionality Review

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The Supreme Court will not expedite a review of the Affordable Care Act’s (ACA’s) constitutionality. The Fifth Circuit Court of Appeals declared the individual mandate void in December...

Opioid Overdose Mortality Decreased 6% in Medicaid Expansion States

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Medicaid expansion states saw a six percent decreased rate in total opioid overdose deaths compared to states that did not expand Medicaid eligibility, according to researchers from the University of...

CMS Addresses Duplicate Discounts, State Medicaid Rebate Requests

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CMS has issued guidance that will help states avoid pursuing a duplicate discount from manufacturers when submitting state Medicaid rebate requests. “Manufacturers are not required to both...

VHA Sees Better Medication Adherence Despite High Drug Costs

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The drug pricing and coverage plan at Veterans Health Administration (VHA) is poised to improve medication adherence, with the payer boasting a 5.9 percentage point lower rate of cost-related...

Medicare Advantage Risk Adjustment Model Continues to Phase In

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Update 1/13/20: This article has been updated to reflect that the American Academy of Actuaries’ paper and the Tenth Circuit Court decision were in regards to the Affordable Care Act’s...

ME Payers Cover Hearing Aids, Self-Insured Companies Exempt

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Maine law now requires payers to provide hearing aid coverage, but leaves self-insured companies exempt from covering them. Representative Jim Handy (D-ME) has noted both social and professional...

Tenth Circuit Court Upholds HHS Risk Adjustment Calculations

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The Tenth Circuit Court of Appeals determined that the rules HHS used to calculate 2014 through 2018 risk adjustments were neither arbitrary nor capricious. In order to help healthcare payers predict...

Individual Mandate Void, ACA Constitutionality Still In Question

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The Fifth Circuit Court found the individual mandate to be unconstitutional but sidestepped making a decision on the rest of the Affordable Care Act (ACA). “The law has been a focal point of our...

Chart Reviews Without Service Records May Cause Improper Payments

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The Office of the Inspector General’s (OIG’s) recent study on Medicare Advantage (MA) payments analyzed whether MA organizations are raising their risk-adjusted payment rates in reaction to...

AHIP Lobbies for Medicaid Managed Care Orgs, Alzheimer’s Patients

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America’s Health Insurance Plans (AHIP) recently issued an amicus brief in support of states covering MMCO’s health insurance tax. The national payer organization has also been lobbying...

Senators Oppose CMS Promoting Short Term, Limited Duration Plans

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Twenty-three senators are concerned about the administration's promotion of short term, limited duration plans that may not meet the ACA’s coverage and pre-existing condition protection...

Rising Premiums, Deductibles Boost Urgency of Healthcare Reform

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The average annual growth in premium and deductible costs for workers outpaced their median income growth from 2008 to 2018, a Commonwealth Fund study discovered. “Over the last decade, employer...

Strategies for Addressing Opioid Use Disorder in Rural Areas

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The opioid epidemic has affected rural and urban areas alike. According to research from the American Academy of Family Physicians, those in rural areas had an 87 percent higher chance of receiving an...

CMS Finalizes Home Health PPS, Expands Infusion Medicare Benefits

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CMS has announced the finalization of changes to the home health payment model, known as the home health prospective payment system (HH PPS), which includes a home infusion benefit and offers an...

Verma Testifies to House on ACA Repeal, ACA Replacement Unknown

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When the House Committee on Energy and Commerce brought in CMS Administrator Seema Verma to testify regarding the White House’s attempts to repeal the Affordable Care Act, the hearing covered...

Proposed Bill Permits HHS to Negotiate Drug Prices, Saves $345 B

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By allowing the HHS to negotiate drug prices tied to international standards, Title I of the Lower Drug Costs Now Act of 2019 (HR-3) would save the federal government $345 billion from 2023 to 2029,...

MI Medicaid Plans to Cut PBMs and Use Fee for Service Drug Payments

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Update 10/11/2019: This article has been updated to include a statement from the Michigan Association of Health Plans.  Michigan is the latest among state Medicaid programs to back away from...