Any of these six criteria under the health reform law
If any one of the following changes were made to a policy at any time since the Patient Protection and Affordable Care Act became law on March 23, 2010, the plan will lose its grandfathered status:
• coverage for a particular condition or illness is eliminated,
• an annual dollar limit on benefits is imposed or an existing limit is reduced,
• a coinsurance percentage is increased to any extent,
• a dollar co-payment is increased by more than the greater of $5.00 indexed for medical inflation or 15% (one-time allowance) plus medical inflation beyond what was in effect at the time the law was enacted,
• deductibles or out-of-pocket maximums are increased by more than 15% (one-time allowance) plus medical inflation beyond what was in effect at the time the law was enacted, or
• the employer changes eligibility requirements in certain ways or increases its employees’ contributions to premium by more than 5% plus medical inflation.
Upended: Can PBM Transparency Succeed?
March 6th 2024Simmering tensions in the pharmacy benefit management (PBM) industry have turned into fault lines. The PBMs challenging the "big three" have formed a trade association. Purchaser coalitions want change. The head of the industry's trade group says inherent marketplace friction has spilled over into political friction.
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In this episode of the "Meet the Board" podcast series, Briana Contreras, Managed Healthcare Executive editor, speaks with Ateev Mehrotra, a member of the MHE editorial advisory board and a professor of healthcare policy and medicine at Harvard Medical School. Mehtrotra is also a hospitalist at the Beth Israel Deaconess Medical Center in Boston. In the discussion, Contreras gets to know Mehrotra more on a personal level and picks his brain on some of his research interests including telehealth, alternative payment models and price transparency.
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Inflation Reduction Act: Reforms to Patient Cost-Sharing
September 18th 2023Lower out-of-pocket costs for patients might put upward pressure on drug prices, as manufacturers face less price sensitivity, note Matthew Majewski and Rhett Johnson of Charles River Associates. But they also note that upward pressure on price is likely to be limited to the inflation rate as any additional price increase would need to be paid back to CMS in the form of inflation rebates.
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Spending climbed by 2.7% in 2021. In 2020, it soared by 10.3%, fueled by federal government spending in response to the pandemic. The blizzard of calculations of 2021 healthcare spending by CMS’ actuaries also provides further evidence that utilization of healthcare services bounced back in 2021.
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