Health plans and TPAs
Health plans are insurance policies that private companies or government programs offer to cover healthcare costs for enrolled individuals. Third-party administrators manage and process insurance claims for these health and employee benefit plans, often serving as intermediaries among healthcare providers, payers and beneficiaries.
Top Stories
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News
10 Sep 2024
Employer strategies to address factors driving healthcare costs
High healthcare costs have motivated employers to think creatively about their benefits and strategies, from rethinking their partnerships with PBMs to finding ways to limit GLP-1 utilization. Continue Reading
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Feature
29 Jul 2024
What are the differences between Medicare Parts A, B, C, D?
Medicare includes four different segments that each insure a wide variety of services and supplies for enrollees. Continue Reading
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News
15 Jul 2024
CMS shares Medicaid, CHIP data on children with ASD, autism
CMS found that half of the children with these conditions in public payer programs were diagnosed early, which could positively impact outcomes. Continue Reading
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News
26 Jun 2024
5 Ways to Modernize the Healthcare Payments Experience
Modernizing the healthcare payments experience can improve efficiency, compliance and satisfaction among health plans, providers, and members. Continue Reading
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News
17 Jun 2024
3 Tips to Reduce Provider Abrasion and Enhance Payment Integrity
Enhancing payment integrity and reducing provider abrasion require clear communication, human expertise in complex billing, and customized solutions to ensure effective relationships between providers and payers. Continue Reading
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News
13 May 2024
CMS extends waivers for the Medicaid unwinding process again
States can use waivers for the Medicaid unwinding through June 30, 2025 so that more Americans can maintain Medicaid coverage. Continue Reading
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News
07 May 2024
AHIP shares how enrollment in Medicare Supplement coverage has evolved
Beneficiaries with Medicare Supplement coverage were less likely to have problems paying medical bills, AHIP found. Continue Reading
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News
03 May 2024
HHS final rule boosts ACA coverage access for DACA recipients
With this final rule, around 100,000 previously uninsured DACA recipients may gain coverage access through the ACA marketplace. Continue Reading
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News
29 Apr 2024
Elevance Health Medicaid plan improves housing stability for NV beneficiaries
The Nevada Medicaid plan provided short-term financial assistance to beneficiaries and partnered with a community-based organization to boost housing stability. Continue Reading
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News
24 Apr 2024
FDA approval of Wegovy expands coverage access for Medicare beneficiaries
Medicare beneficiaries eligible for Wegovy coverage may still face cost barriers due to the high list price of the drug. Continue Reading
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News
23 Apr 2024
Medicaid final rules improve care access for managed care, FFS beneficiaries
The rules address payment rates, care quality, and home- and community-based services in Medicaid managed care and fee-for-service plans. Continue Reading
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News
22 Apr 2024
Can AI Manage High-cost Claims? Not Without Humans
AI and human expertise play crucial roles in managing the growing complexity and volume of high-cost healthcare claims. Continue Reading
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News
16 Apr 2024
23% of disenrolled Medicaid beneficiaries remain uninsured, KFF finds
Over half of disenrolled Medicaid beneficiaries who remain uninsured have not enrolled in another health insurance plan due to costs. Continue Reading
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Answer
11 Apr 2024
PHE unwinding work may aid Medicaid, CHIP final rule compliance
Some states have already cut in-person interviews and limited renewals to once a year, aligning with Medicaid and CHIP final rule policies. Continue Reading
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Feature
09 Apr 2024
How are Medicare plans lowering drug costs for beneficiaries?
Medicare and Medicare Advantage plans help lower drug costs for beneficiaries by establishing preferred pharmacy networks, promoting generic drug utilization, and working with PBMs. Continue Reading
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News
08 Apr 2024
Medicare Advantage final rule addresses competition and marketing practices
In addition, the Medicare Advantage final rule requires plans to review prior authorization policies with a health equity perspective. Continue Reading
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News
04 Apr 2024
Expanding Medicaid eligibility in GA would reduce uninsurance by 28%
Around 173,000 young adults between 19 and 34 would gain health insurance coverage if Georgia expanded Medicaid eligibility. Continue Reading
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News
03 Apr 2024
CMS final rule improves access to Affordable Care Act marketplace coverage
The rule expanded the special enrollment period to allow consumers with household incomes at or below 150 percent of the federal poverty level to apply for marketplace coverage outside open enrollment. Continue Reading
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News
02 Apr 2024
HHS extends special enrollment period for former Medicaid beneficiaries
Former Medicaid beneficiaries now have until November 30 to apply for marketplace coverage during the special enrollment period. Continue Reading
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News
28 Mar 2024
Medicare spending on GLP-1 drugs reached $5.7 billion in 2022
Medicare spending on GLP-1 drugs may continue rising as demand surges and coverage expands. Continue Reading
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27 Mar 2024
CMS final rule aims to simplify Medicaid, CHIP enrollment, coverage
The CMS final rule updated renewal and enrollment policies and sought to eliminate practices that cause coverage disruptions. Continue Reading
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News
25 Mar 2024
Medicaid disenrollments surpass 18M, exceeding HHS projections
Most Medicaid disenrollments occurred due to procedural reasons, meaning beneficiaries did not complete the required renewal process. Continue Reading
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News
19 Mar 2024
Healthcare spending is higher in Medicare households, study finds
Healthcare spending accounted for 13.6 percent of total household spending for Medicare households compared to 6.5 percent for non-Medicare households. Continue Reading
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News
13 Mar 2024
Continuous Medicaid eligibility during PHE improved postpartum coverage
After the continuous Medicaid eligibility requirement was implemented, postpartum Medicaid enrollment rose from 63.1 percent to 72.8 percent. Continue Reading
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News
12 Mar 2024
2024 Medicare Advantage premiums remain low and stable
For beneficiaries selecting plans through eHealth, the average Medicare Advantage premium is $9 per month—the same as in 2023. Continue Reading
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News
11 Mar 2024
Medicare Advantage enrollment increased by 1.7 million beneficiaries
For-profit health plans accounted for 73.5 percent of all Medicare Advantage enrollment in 2024. Continue Reading
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07 Mar 2024
Few Physicians Participate in Both Medicaid and Marketplace Plans
The share of Medicaid-participating primary care physicians participating in marketplace plans ranged from 8.5 percent in South Carolina to 59.6 percent in Iowa. Continue Reading
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News
06 Mar 2024
Utilization Restrictions on Medicare Part D Drugs Increased, Study Finds
Utilization restrictions were more common among brand-name-only drugs and in standalone prescription drug plans. Continue Reading
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Answer
05 Mar 2024
With Proper Use, Artificial Intelligence Improves Health Plan Operations
Health plans must fully understand artificial intelligence tools before using them to assist with coverage determinations or administrative tasks. Continue Reading
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News
04 Mar 2024
Medicare Advantage Beneficiaries Receive Less Home Healthcare Services
Medicare Advantage beneficiaries had shorter home healthcare lengths of stay and fewer visits from nurses, therapy clinicians, and home health aides than traditional Medicare beneficiaries. Continue Reading
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29 Feb 2024
MA Payment Reductions May Impact Value of Healthcare for Beneficiaries
The value of healthcare for beneficiaries, including supplemental benefits and premiums, could be negatively impacted if CMS finalizes the Advance Notice policies. Continue Reading
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26 Feb 2024
Care Access, Coverage Value Similar in Medicare Advantage and Medicare
Despite many similarities in care access, Medicare Advantage beneficiaries faced care delays due to prior approval requirements more often than those in traditional Medicare. Continue Reading
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News
21 Feb 2024
CareSource Partnership Boosts Access to Substance Use Disorder Treatment
The partnership will connect members in Kansas with transportation services to facilitate access to substance use disorder treatment. Continue Reading
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20 Feb 2024
Dental Coverage in Medicare Advantage Plans Varies by Demographic
Beneficiaries 64 or younger, dual-eligibles, and those in racial or ethnic minority groups were more likely to have Medicare Advantage plans with dental coverage. Continue Reading
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Feature
13 Feb 2024
Overcoming Tech Barriers to Achieve Prior Authorization Transparency
Payers can use the next couple of years to establish a solid technology strategy to ensure compliance with the prior authorization final rule. Continue Reading
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News
12 Feb 2024
HHS Will Provide Technical Assistance to States Addressing Homelessness
Participating states have implemented Medicaid section 1115 demonstrations or other state plan amendments to improve access to housing-related services for those facing homelessness. Continue Reading
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News
07 Feb 2024
How Do Payers Cover COVID-19 Vaccines, Treatments, and Tests Post-PHE?
Public and private payers generally offer some coverage of COVID-19 vaccines, treatments, and tests, but cost-sharing requirements vary. Continue Reading
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Answer
06 Feb 2024
What Is Behind Rampant Medicare Advantage Contract Terminations?
Health systems do not invest in the infrastructure needed to support Medicare Advantage, while health plans offer low reimbursement, leading to contract terminations. Continue Reading
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News
05 Feb 2024
Medicare Part D Low-Income Subsidy Loss Tied to Higher Out-of-Pocket Costs
Out-of-pocket costs increased by 700 percent for beneficiaries who experienced a temporary loss of their Medicare Part D low-income subsidy. Continue Reading
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02 Feb 2024
HCSC Announces $3.3B Cigna Medicare Business Acquisition
Barring regulatory or conditional challenges, the payer expects the acquisition to be finalized in early 2025. Continue Reading
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News
01 Feb 2024
Lawmakers Lobby for Payment and Policy Stability in Medicare Advantage
The group of senators called for payment and policy stability in Medicare Advantage in the wake of new marketing, competition, and prior authorization standards. Continue Reading
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31 Jan 2024
CMS Proposes 3.7% Increase in Medicare Advantage Plan Payments
In addition to an increase in Medicare Advantage plan payments, CMS proposed updates to the Part D risk adjustment model and star ratings. Continue Reading
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29 Jan 2024
HHS Seeks Stakeholder Input to Improve Medicare Advantage Transparency
The request for information seeks feedback on access to care, provider networks, and competition in the Medicare Advantage program. Continue Reading
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18 Jan 2024
Underserved MA Beneficiaries Opt for Plans with Supplemental Benefits
Black individuals were 11.2 percentage points more likely to enroll in a plan with a comprehensive dental benefit, highlighting the attraction of supplemental benefits for underserved beneficiaries. Continue Reading
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17 Jan 2024
CMS Finalizes Payer Requirements to Streamline Prior Authorization
Payers must send prior authorization decisions within 72 hours for urgent requests and seven calendar days for standard requests, CMS finalized. Continue Reading
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17 Jan 2024
States Leverage Waivers To Support Medicaid Redetermination
CMS has categorized the waivers for Medicaid redetermination into four buckets, of which ex parte renewals had the highest adoption rate among states. Continue Reading
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News
11 Jan 2024
NY Medicaid Section 1115 Waiver Amendment Improves Access to Care
The Medicaid section 1115 waiver allows New York to invest nearly $6 billion in its healthcare system to improve the workforce and access to care. Continue Reading
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09 Jan 2024
Elevance Health Lawsuit Slams Medicare Advantage Star Ratings Calculation
Elevance Health said the new Medicare Advantage star rating methodology led to inaccurate and lower scores for 2024. Continue Reading
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28 Dec 2023
Does Integrating Medicare and Medicaid Improve Care for Dual Eligibles?
UPMC’s fully integrated dual eligible special needs plan improved home- and community-based services use but fell short in other areas. Continue Reading
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Feature
26 Dec 2023
Key Regulations and Policies That Will Impact Payers in 2024
In 2024, payers must comply with Medicare Advantage marketing requirements, price transparency regulations, and prior authorization policies. Continue Reading
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News
21 Dec 2023
ACA Marketplace Enrollment Up By 33%, Surpassing 19M Enrollees
Around 15 million enrollees have selected an ACA marketplace plan through the HealthCare.gov platform. Continue Reading
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19 Dec 2023
HHS Urges States to Reduce Medicaid, CHIP Child Disenrollments
States that have not expanded Medicaid have higher child disenrollment rates than expansion states combined, new data indicated. Continue Reading
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18 Dec 2023
Leveraging Social Determinants for Medicare, Medicaid Engagement
Social determinants of health are a top barrier for Medicare and Medicaid populations, but health plans can tap into the data to optimize member engagement and outcomes. Continue Reading
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Feature
18 Dec 2023
What Health Plans Are Available For People With Disabilities?
Medicare and Medicaid are common health plan options for people with disabilities, though they must meet certain criteria before becoming eligible for coverage. Continue Reading
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14 Dec 2023
Lawsuit Alleges Humana Used AI to Deny Medically Necessary Claims
The AI model projections led Humana to deny medically necessary claims, resulting in beneficiaries paying costs out of pocket or forgoing care. Continue Reading
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13 Dec 2023
Lawmakers Urge CMS to Improve Data Collection in Medicare Advantage
CMS should improve data collection and reporting of prior authorization denials, encounter data, and supplemental benefit utilization. Continue Reading
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11 Dec 2023
Drug Price Negotiation Would’ve Reduced Prices, OOP Spending in 2021
Out-of-pocket spending reductions from drug price negotiation varied among demographic groups, highlighting disparities. Continue Reading
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11 Dec 2023
How to Tailor Member Engagement for Medicare, Medicaid Populations
Medicare and Medicaid spending is on the rise, so health plans need to optimize their member engagement strategies to align with specific population needs. Continue Reading
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11 Dec 2023
How Human and Artificial Intelligence Can Streamline Claims Reviews
Properly integrating artificial intelligence and human expertise helps payers generate savings from complex and high-cost claims. Continue Reading
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30 Nov 2023
Medicare Hospice Model Improved Quality of Life, Reduced Medicare Spending
The Medicare Care Choices Model increased hospice use and reduced net Medicare spending by 13 percent. Continue Reading
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27 Nov 2023
Preventive Care Visits Among Medicare Beneficiaries Grew, Study Finds
During preventive care visits, physicians were more likely to provide counseling provision and order screening labs than at problem-based visits. Continue Reading
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21 Nov 2023
Quality Outcomes Are Better When Medicaid MCOs Administer Pharmacy Benefits
In 33 of 34 comparative analyses, HEDIS scores were higher in states where Medicaid MCOs administered pharmacy benefits. Continue Reading
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17 Nov 2023
Cardiovascular Disease Utilization Grew After Medicaid Expansion
The two expansion states saw higher rates of cardiovascular care, medication, and hospitalization use after Medicaid expansion. Continue Reading
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14 Nov 2023
Avoidable Hospitalizations Less Common in Medicare Advantage, Study Finds
Medicare beneficiaries with ambulatory care-sensitive conditions visited clinicians with lower rates of avoidable hospitalizations. Continue Reading
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13 Nov 2023
Blending Human Expertise & Technology to Improve Claims Negotiations
Strategic partnerships that leverage both human expertise and technology can improve out-of-network claim negotiations and operational efficiency while maintaining payer-provider relationships. Continue Reading
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08 Nov 2023
An Overview of 2024 Coverage for Veterans Beyond Veterans Affairs
Better outreach, multiple coverage sources in addition to Veterans Affairs benefits, and Medicaid expansion may be key to lowering uninsurance among veterans. Continue Reading
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News
07 Nov 2023
CMS Proposals Address Anti-Competitive Practices in Medicare Advantage
The proposed rule includes a fixed compensation of $632 for agents and brokers helping Medicare Advantage beneficiaries choose a plan. Continue Reading
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06 Nov 2023
Care Quality, Health Outcomes Better in Medicare Advantage than FFS
There were fewer hospital readmissions and preventable hospitalizations in Medicare Advantage compared to Medicare fee-for-service. Continue Reading
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03 Nov 2023
7 Elements of Successful Community Health Worker Integration
Several Medicaid programs have taken various approaches to integrating community health workers into their coverage policies and services. Continue Reading
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News
01 Nov 2023
9 Trends To Watch During ACA Marketplace 2024 Open Enrollment
Policy changes and ripple effects from other markets will shape the Affordable Care Act marketplace’s 2024 open enrollment trends. Continue Reading
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Answer
24 Oct 2023
What Cigna’s FCA Settlement Means for Other Medicare Advantage Plans
Per its settlement, Cigna must conduct annual risk assessments, but all Medicare Advantage plans should be proactively monitoring their compliance actions. Continue Reading
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Feature
17 Oct 2023
What Technologies Support Payers With Claims Management Processes?
Claims processing software, adjudication software, and health IT systems can streamline the claims management process for payers. Continue Reading
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16 Oct 2023
HHS Patient Assistance Program Aims To Boost Access to COVID-19 Drug
The patient assistance program will maintain financial support for certain populations seeking to access Pfizer’s Paxlovid, starting in 2024. Continue Reading
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16 Oct 2023
Medicare Advantage Star Ratings Fall for Second Consecutive Year
Around 42 percent of Medicare Advantage plans received 2024 star ratings of four or higher, down from 51 percent in 2023. Continue Reading
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13 Oct 2023
Medicare Part B Premiums, Deductibles Will Increase in 2024
Medicare Part B premiums will be $174.70 per month in 2024 and the annual deductible will be $240, CMS shared. Continue Reading
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12 Oct 2023
Who is Challenging the Medicare Drug Price Negotiation Rule?
Drug companies and pharmaceutical groups are suing HHS, arguing that the Medicare drug price negotiation rule violates constitutional amendments. Continue Reading
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11 Oct 2023
Does Medicaid Managed Care Impact Specialty Care Access for Kids?
Medicaid managed care enrollment was tied to limited mental health professional visits but did not impact other specialty care access. Continue Reading
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06 Oct 2023
Medicaid Expansion Improved Health Equity for Redlined Areas
Uninsurance rates were worse in historically redlined areas in the seven states that have not adopted Medicaid expansion, leading to a lack of health equity. Continue Reading
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04 Oct 2023
CMS Orders States to Provide Continuous Coverage for Kids in Medicaid, CHIP
Enacting 12 months of continuous coverage for kids in Medicaid and CHIP can promote access to primary care and foster better patient-provider relationships, CMS said. Continue Reading
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27 Sep 2023
Total Adoption of Continuous Eligibility May Improve Coverage Rates
Continuous eligibility in Medicaid would heighten spending in some areas and lower spending in others for states and the federal government. Continue Reading
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26 Sep 2023
CMS: Medicare Advantage Premiums Will See Little Change in 2024
CMS projects that average Medicare Advantage premiums will rise by just $0.64 in 2024 to $18.50 per month. Continue Reading
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21 Sep 2023
CMS Pauses Medicaid Disenrollments, Reviving Coverage for 500K People
CMS has identified 30 states with system errors that impacted ex parte renewals and caused 500,000 disenrollments. Continue Reading
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Answer
21 Sep 2023
The Medicare Advantage Marketing Problem and Where It’s Headed
With new Medicare Advantage marketing regulations in place for 2024, payers must work with their marketing teams and establish proactive oversight programs to ensure compliance. Continue Reading
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Answer
19 Sep 2023
Medicare Advantage RADV Rule May Prompt More Legal Action from Payers
Humana’s lawsuit has created a roadmap for other payers who may want to take legal action against CMS and the Medicare Advantage RADV final rule. Continue Reading
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Answer
18 Sep 2023
Top Reasons Behind Retail, Medicare Advantage Plan Partnerships
Co-branded Medicare Advantage plans may address prescription drug spending and access to care among seniors but require significant alignment between payers and retailers. Continue Reading
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News
15 Sep 2023
Price May Drive Affordable Care Act Marketplace Plan Selection
Silver plan uptake has declined on the Affordable Care Act Marketplace, potentially due to higher costs. Continue Reading
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12 Sep 2023
Beneficiaries with Cancer Spend Less Out-of-Pocket in Medicare Advantage
In addition to lower out-of-pocket costs, Medicare Advantage beneficiaries with cancer have better access to care management and palliative care than those in fee-for-service. Continue Reading
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11 Sep 2023
How Do Rebates Impact Part D Spending for Plans, Beneficiaries?
After accounting for rebates, Part D spending totaled $21 billion for beneficiaries and $5.3 billion for plan sponsors. Continue Reading
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News
11 Sep 2023
Improving Payment Integrity with a Building Blocks Methodology
Payers need a proven framework for payment integrity to create financial value, handle change, and engage at the highest levels of organizational strategy. Continue Reading
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08 Sep 2023
High Switching Rates from FFS to Medicare Advantage Drove MA Enrollment
In 2021, the switching rate from Medicare FFS to Medicare Advantage was 6.5 times higher than the switching rate in the opposite direction. Continue Reading
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Feature
05 Sep 2023
How Quality Measures, Star Ratings Impact Healthcare Payers
High performance on standardized quality measures like HEDIS and Medicare Advantage Star Ratings help consumers determine how to choose between healthcare payers. Continue Reading
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01 Sep 2023
Half of Medicare Advantage Beneficiaries Left Plan After 5 Years
After five years, 53.4 percent of dual-eligible beneficiaries and 48.3 percent of non-dual-eligible beneficiaries disenrolled from their Medicare Advantage plan. Continue Reading
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31 Aug 2023
CMS: Ex Parte Systems May Disenroll Eligible Medicaid, CHIP Enrollees
States that do not take action to comply with CMS protocols and protect affected Medicaid and CHIP enrollees may face steep penalties like losing FMAP eligibility. Continue Reading
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29 Aug 2023
HHS Releases First 10 Drugs Eligible for Medicare Price Negotiation
Following through on the Inflation Reduction Act provisions, the Biden-Harris Administration will begin Medicare price negotiations with the drug companies this fall. Continue Reading
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25 Aug 2023
74% of Terminated Medicaid Enrollees Were Cut for Procedural Reasons
At least four out of ten Medicaid enrollees who completed the renewal process have been disenrolled. Continue Reading
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24 Aug 2023
Beneficiaries Are Satisfied With Medicare Advantage Plans, Coverage
Beneficiary satisfaction with problem resolution was higher among those likely to renew their Medicare Advantage plan. Continue Reading
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Answer
22 Aug 2023
How Can Medicare Advantage Organizations Prepare for RADV Audits?
Ahead of RADV audits, Medicare Advantage plans must internally review charts, invest in compliance programs, and monitor coding vendors. Continue Reading
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21 Aug 2023
CMS Announces Monthly Payment Option for Out-of-Pocket Part D Costs
Starting in 2025, beneficiaries can opt to pay out-of-pocket Part D costs monthly and owe $0 when picking up prescription drugs at the pharmacy. Continue Reading
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21 Aug 2023
Trends in Price Ratios Between Commercial, Medicare Advantage Plans
The difference in pricing depended on the size of the insurer, market consolidation, rural healthcare status, and other factors. Continue Reading
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News
21 Aug 2023
How Does Medicaid Cover Obesity Treatments for Children?
New guidelines from the American Academy of Pediatrics may help improve Medicaid coverage of obesity treatments for children. Continue Reading
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News
15 Aug 2023
KLAS: Payers Want Efficient Claims and Administration Platforms
Payers recognized claims and administration platforms Cognizant and HealthEdge for their efficiency and functionality. Continue Reading
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08 Aug 2023
ACA Marketplace Premiums Set to Rise Again, Inflation a Key Factor
Inflation-driven increases in medical care and prescription drug costs could make consumers pay more for 2024 Affordable Care Act Marketplace premiums Continue Reading