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Archive Author: Stephanie Lomas

Senior Health Policy Manager

CMS Releases Final Rule for 2026 for Health Insurance Marketplaces, Aimed at Safeguarding Consumers, and Improving Transparency and Health Equity

On January 13, 2025, the U.S. Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS) issued the final Notice of Benefit and Payment Parameters for 2026 (CMS-9888-F) with a fact sheet. This rule includes the following changes: Policies related to CMS’s authority to undertake compliance reviews and enforcement […]

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CMS Finalizes CY 2025 Policy Changes for Medicare Advantage and Part D Plans Impacting Patient Protections, Utilization Management, and Formularies

On April 4, 2024, the Centers for Medicare & Medicaid Services (CMS) released its Medicare Program; Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Program for Contract Year 2024--Remaining Provisions and Contract Year 2025 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, [...] Read More

CMS Releases Final Rule for 2025 Qualified Health Plans, Aimed at Strengthening Network Adequacy, Patient Access and Protections and Improving Plan Selection and Enrollment

On April 2, 2024, the U.S. Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS) issued the final Notice of Benefit and Payment Parameters for 2025 (CMS-9895-F) with a press release and fact sheet. This rule makes the following changes: Changes certain EHB prescription drug benefit requirements, Strengthens [...] Read More

For 2025, CMS Finalizes Changes Resulting in a 3.7% Increase in Plan Payments and Implements Inflation Reduction Act Provisions on Part D Benefit Redesign

On April 1, 2024, the Centers for Medicare & Medicaid Services (CMS) released its Announcement of Calendar Year (CY) 2025 Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies that would update program policies for Medicare Advantage and Medicare Part D beginning in 2025. CMS also issued its Final Calendar Year [...] Read More

For 2025, CMS Proposes Changes Resulting in a 3.7% Increase in Plan Payments and Implements Inflation Reduction Act Provisions on Part D Benefit Redesign

The Centers for Medicare & Medicaid Services (CMS) has released its Advance Notice of Methodological Changes for Calendar Year (CY) 2025 for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies that would update program policies for Medicare Advantage and Medicare Part D beginning in 2025, if finalized. CMS also issued [...] Read More

CMS Proposes CY 2025 Policy Changes for Medicare Advantage and Part D Plans Impacting Patient Protections, Utilization Management, and Formularies

On November 6, 2023, the Centers for Medicare & Medicaid Services (CMS) released its Medicare Program: Contract Year 2025 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly; Health Information Technology Standards and Implementation Specifications (CMS-4205-P)  with a [...] Read More

Discarded drug policy moves forward

As Applied Policy reported in January, under Section 90004 of Infrastructure Investment and Jobs Act (Infrastructure Act) which was passed in November 2021, manufacturers of drugs, including biosimilar biologic products, in single dose container or single use packages which are separately payable under Medicare Part B are required to provide the Centers for Medicare & Medicaid Services [...] Read More

The Debate over Step Therapy

Step therapy is the process under which a health insurance plan requires a patient to try one or more alternative—typically lower cost— drugs or treatment options before they can access the prescription which their physician has identified as the optimal treatment option for their diagnosis. For AHIP, the association representing America’s health plans, the stepwise [...] Read More

CMS Finalizes CY 2024 Policy Changes for Medicare Advantage and Part D Plans Impacting Plan Utilization Management, Patient Protections, and Health Equity

On April 5, 2023, the Centers for Medicare & Medicaid Services (CMS) released its Medicare Program; Contract Year 2024 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly (CMS-4201-F)  with a fact sheet and press release. The final [...] Read More

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