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.
Part D Policy Change Lowers Max OOP Costs for Many Enrollees
Cost-sharing reductions from enhanced plans and EGWPs allow beneficiaries to reach the catastrophic phase with lower OOP spending than those in basic plans.
Part D Choices Continue to Shrink with Fewer PDPs in 2026
The Part D market will contract even further in 2026, with a 22% decrease in standalone PDP options and a 9% decrease in non-SNP MA-PDs.
ICD-10 C&M Committee 2025 Fall Meeting: Proposed ICD-10-CM Code Revisions
On September 9-10, NCHS discussed proposals for 300+ new ICD-10-CM codes designed to improve accuracy, address emerging health issues, and strengthen disease reporting.
Health Plans 2030: Responding to OBBBA Medicaid Provisions
The OBBBA brings sweeping Medicaid changes, reshaping eligibility, funding, and access, impacting millions of enrollees, providers, and health plans.
The Role of Payer Mix in Access Strategies for Complex Therapeutic Areas
With IRA, MFN, and OBBBA pressures, manufacturers must assess coverage shifts, demographics, and payer mix to refine channel strategy and improve patient access.
The Evolving Role of Global Value Communication
As national reimbursement is no longer the only priority for global teams, value communication materials may evolve to enable meaningful, timely patient access.
340B Cuts Could Increase Other Payments for Most Hospitals
Reducing 340B reimbursement to ASP-28.7%, as previously proposed, may increase other payments, especially to small rural and urban hospitals.
Anti-Obesity Medication Coverage Varies Across Markets and Payers
Limited access to AOMs across markets and a growing AOM pipeline will necessitate collaboration across manufacturers, payers, and the state/federal government.
FY 2026 ICD-10-CM Codes Released
In June, CMS and the CDC announced over 400 new FY 2026 ICD-10-CM codes for patient encounters and discharges. These will address emerging health concerns, enhance clinical specificity, support accurate reporting, and reflect advances in medical knowledge and terminology.
Chronic Care Management in Medicare: Optimizing Utilization
CCM services remain underutilized, but a subset of claims lacking supporting diagnoses suggests opportunities to improve utilization via coding accuracy.
White Paper: Policy Considerations for Refining MA Star Ratings
This paper presents several proposed changes to the MA Stars Rating program and offers insight into how each proposal would impact federal entities, payers, and members.
Research on Opioid Use Reveals States, Local Governments Spend $94 Billion Annually
“The Cost of Addiction: Opioid Use Disorder in the U.S.” is the first-of-its-kind study that reveals state and local governments shoulder a significant financial burden on taxpayers, businesses, and communities.
Commercial Step Therapy May Include Steps Beyond FDA Label
Across three therapeutic areas, an Avalere Health analysis identified commercial plan coverage policies with more steps than indicated by drugs’ FDA labels.
White Paper: Medicaid Reforms’ Impact on Funding for Children’s Healthcare
Avalere Health estimated how three possible changes to federal Medicaid funding could impact national- and state-level funding in total and for children’s services.
USPSTF at a Crossroads: Preventive Care Coverage Mandate at SCOTUS
The Supreme Court weighs a case that could reshape access to no-cost preventive services under the ACA and redefine USPSTF's legal authority
Site of Care Optimization Offers Savings for Specialty Services
Across physician specialties, Medicare utilization and reimbursement data shows that site-of-care optimization can reduce expenditures for certain healthcare services.
How a New Technology Add-On Payment (NTAP) Works
Additional Medicare payment in the inpatient setting may be available to certain qualifying new technologies, but requires successful navigation of application processes.
New Resource: Commercial Payers’ Use of Oncology Compendia
Avalere’s dashboard provides insights into commercial payer trends for use of clinical drug compendia for off label coverage decisions in oncology.
Expiration of Enhanced Tax Credits Would Impact 18M Americans
If the ACA marketplace enhanced premium tax credits are made permanent, nearly 5 million people ages 50–64 will be eligible to receive premium subsidies in 2026.
State Copay Accumulator Bans Now Affect 16% of Commercial Lives
Over 16% of people enrolled in the US commercial insurance market belong to a health plan that must count copay assistance toward patient cost sharing.