Coverage and Payment
Coverage and reimbursement shapes patient access and affordability. Life sciences companies rely on favorable coverage decisions to ensure market access and adoption of their products, while health plans need effective reimbursement strategies to manage costs and provide comprehensive benefits to their members.
CMS Site-Neutral Payments Affect Small Share of Spending
Payments to off-campus hospital sites affected by site-neutral payment policy amount to only 2.3% of Medicare outpatient spending.
How the Transitional Drug Add-On Payment Adjustment Works
The TDAPA supports payment and patient access to new therapies introduced to the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS). CMS has continued to refine the payment designation through rulemaking. Stakeholders should continue to monitor this payment-adjustment policy, as it has evolved since its introduction and may continue to change in future rulemaking cycles.
Physician Payment for Some Services Lags Behind Inflation
Physician reimbursement for some services under Medicare FFS has declined, while payment increased for the same services in the hospital outpatient setting.
IRA Question of the Week: How Will Negotiation Affect Reimbursement?
The introduction of the maximum fair price through the Medicare drug price negotiation process is expected to lower provider reimbursement.
Coding, Billing, and Reimbursement Barriers to Obesity Care
Assessing barriers that impact patient access to obesity care and educating stakeholders on how to mitigate them can advance solutions toward improving care.
340B Reimbursement Proposal Could Reduce Payments for 80% of Hospitals
To assess how changes in OPPS payment for reimbursement of drugs under the 340B program would affect hospital reimbursement and Medicare Part B beneficiary cost sharing, Avalere estimated the impact of increasing reimbursement for 340B drugs in Medicare Part B to ASP + 6%. The analysis finds that most hospitals would see overall payment decreases, while payments would be subject to higher cost sharing.
Final CMS Alzheimer’s Coverage Memo Will Impact Access Beyond Medicare
The final CMS NCD for amyloid beta-targeting monoclonal antibodies for Alzheimer’s Disease establishes a dual pathway to Medicare coverage based on FDA approval and likely creates access and operational challenges for stakeholders.
Medicare Draft Coverage for Alzheimer’s Drugs May Challenge Access
Thirty-one percent of rural Medicare fee-for-service beneficiaries with early-onset Alzheimer’s disease or a mild cognitive impairment diagnosis do not have access to a hospital outpatient department in their county, and fewer than 1% live near an Alzheimer’s disease research center.
Video: The Coverage Gap and Medicaid Expansion
Tune into another episode of Avalere Health Essential Voice. In this segment, our experts discuss the forthcoming debate around the coverage gap in non-Medicaid expansion states, potential policy options, and the impact on key stakeholders.
PACHA Highlights Need to Address HIV PrEP Coverage Disparities
On March 8–9, the Presidential Advisory Council on HIV/AIDS (PACHA) discussed avenues to achieving equitable access to HIV prevention products for at-risk populations as well as next steps in revising the National Strategic Plan to End the HIV Epidemic.
Measuring Scope of COVID-19 Relief Coverage Expansion Provisions
Avalere analysis finds that Congress's healthcare reforms under the COVID-19 relief bill could expand exchange coverage subsidies for up to 18.3 million individuals.
Measuring the Scope of Presidential Candidates’ Coverage Proposals
Avalere analysis finds that the candidates’ healthcare coverage reform proposals could impact a range of 23M to 153M individuals across insurance markets.
SCOTUS Ruling on ACA Could Impact Coverage and Policy Outlook
With the US Supreme Court set to hear arguments starting November 10 on California v. Texas, and Judge Amy Coney Barrett’s nomination under consideration in the Senate, questions remain regarding the future of the law.
COVID-19 Therapies Could Benefit from NTAP Reimbursement Opportunity
Therapies currently being developed to treat COVID-19 in the inpatient setting have opportunity for additional Medicare reimbursement.
Will Your Organization Be Ready for the MA-ESRD Coverage Expansion?
With the release of the 2021 Medicare Advantage (MA) and Part D Final Rule, the details of the upcoming policy change that allows beneficiaries with end-stage renal disease (ESRD) to enroll in MA are set. Stakeholders need to adapt quickly to be prepared.
Prostate Cancer Patients in Employer Part D Plans Stay in the Coverage Gap Longer Than Those in Non-Employer Part D Plans
New Avalere analysis finds that Medicare Part D patients taking brand prostate cancer drugs enrolled in Employer Group Waiver Plans (EGWPs) have more prescriptions in the coverage gap than patients in non-employer plans.
States Act to Ensure Coverage Protections in Advance of ACA Decision
The majority of 2020 state legislative sessions are either approaching crossover deadlines or adjournment. In 2019 and 2020, at least 15 states (CT, DE, FL, HI, IN, LA, MD, ME, NH, NJ, NM, NV, OR, VT, and WA) have enacted laws to create or study coverage protections against pre-existing condition exclusions or coverage of all essential health benefits (EHB) provided for in the Affordable Care Act (ACA).
SCOTUS Decision to Review ACA Case Could Undermine Coverage and Access
On March 2, the Supreme Court (SCOTUS) announced that it will review an appeal of the 5th Circuit Court of Appeal’s decision in Texas v. Azar regarding the legality of the Affordable Care Act’s (ACA’s) individual mandate and other provisions.
2020 Election: Healthcare Coverage Landscape Varies in Super Tuesday States
Ahead of the Super Tuesday primaries on March 3, healthcare remains a top issue among voters. According to January 2020 polling from Bipartisan Policy Center, 56% of individuals ranked healthcare as one of their top 3 issues when determining how to vote in the upcoming election, above the economy (44%), immigration (33%), taxes (31%), gun control (30%), and environmental policy (23%).
The Administration Provides Employers and Employees with Enhanced Flexibility in Connection with Health Reimbursement Arrangements
Final rule by the Treasury Department, Department of Labor, and the Department of Health and Human Services reverses previous Treasury Department guidance blocking tax-advantaged HRAs that were not integrated with a comprehensive employer-sponsored plan.