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Background and Objectives: The Affordable Care Act required private insurers to cover a set of recommended preventive services without cost-sharing. This included coverage of fluoride varnish (FV) applications without cost-sharing for children aged 1 through 5 during medical visits, an evidence-based treatment that prevents tooth decay. We examined if this coverage mandate was associated with more young children receiving FV., Methods: Using the Massachusetts All-Payer Claims Database (2014-2018), we examined the likelihood that a privately insured child received FV during a medical visit in a month. We used a difference-in-differences approach, comparing those included in the coverage mandate (aged 1-5) to those excluded from the mandate (aged 6-9), before and after the mandate was enacted (January 2015). We repeated analyses in children with Medicaid because this mandate may have had spillover effects for this population., Results: Among children aged 1 through 5 years with private insurance, 1-year postmandate the probability of FV receipt in a month increased 0.16 percentage points more relative to December 2014 (premandate) compared with the change among children aged 6 to 9 years (P < .001; 95% confidence interval = 0.1-0.22). When examining spillover to children with Medicaid, the mandate was not associated with a significant increase in the probability of monthly FV receipt 1-year postmandate., Conclusions: This Affordable Care Act mandate requiring coverage of FV without cost-sharing was associated with higher rates of young children receiving FV in medical settings, with the largest result observed among children with private insurance., (Copyright © 2024 by the American Academy of Pediatrics.)

Objective: To examine the temporal relationship between the anti-discrimination rules of the Affordable Care Act, which took full effect in 2017, and the incidence of commercial claims for gender-affirming care, as well as cost sharing for these services., Methods: We used a previously described algorithm to define a cohort of gender-diverse adults in the MarketScan Commercial Claims and Encounters Database. Claims for gender-affirming medical and surgical care were identified using International Classification of Diseases and Current Procedural Terminology codes plus pharmacy data; the annual incidence of surgical claims was calculated. Interrupted time series analyses were used to evaluate the temporal relationship between claims and anti-discrimination legislation. Claims data were also used to evaluate the patient contribution towards services., Results: There were 70,733 gender-diverse adults included in the study and 36,702 (51.9%) of them filed claims for gender-affirming care. The incidence of persons with claims for gender-affirming surgery increased from 0.002% in 2009 to 0.012% in 2021. Interrupted time series analyses demonstrated a greater year-to-year increase in claims after anti-discrimination policy influences took effect. This change was greatest for transmasculine chest procedures. The median lifetime net payment for gender-affirming surgery was $12,429.10 and cost sharing was $1019.20 (8.6%)., Conclusion: Commercial claims for gender-affirming surgery increased temporally with respect to implementation of anti-discrimination legislation and cost-sharing was reasonably low. However, many gender-diverse persons did not have claims for gender-affirming care, which may indicate continued out-of-pocket payment for these services., Competing Interests: Declaration of Competing Interest The authors declare that they have no conflict of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Abstract: To examine the impact of inadequate health insurance coverage on physician utilization among older adults using a novel quasi-experimental design in the time period following the elimination of cost sharing for most preventative services under the US Affordable Care Act of 2010.The Medical Expenditure Panel Survey full year consolidated data files for the period 2010 to 2017 were used to construct a pooled cross-sectional dataset of adults aged 60 to 70. Regression discontinuity design was used to estimate the impact of transitioning between non-Medicare and Medicare plans on use of routine office-based physician visits and emergency room visits.For the overall population, gaining access to Medicare at age 65 is associated with a higher propensity to make routine office-based visits (2.94 percentage points [pp]; P < .01) and lower out-of-pocket costs (-23.86 pp; P < .01) Similarly, disenrollment from non-Medicare insurance plans at age 66 was associated with more routine office-based visits (3.01 pp; P < .01) and less out-of-pocket costs (-8.09 pp; P < .10). However, some minority groups reported no changes in visits and out-of-pocket costs or reported an increased propensity to make emergency department visits.Enrollment into Medicare from non-Medicare insurance plans was associated with increased use of routine office-based services and lower out-of-pocket costs. However, some subgroups reported no changes in routine visits or costs or an increased propensity to make emergency department visits. These findings suggest other nonfinancial, structural barriers may exist that limit patient's ability to access routine services., Competing Interests: The authors have no funding and conflicts of interests to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Introduction: Although many Medicare Advantage plans have waived cost sharing for COVID-19 hospitalizations, these waivers are voluntary and may be temporary. To estimate the magnitude of potential patient cost sharing if waivers are not implemented or are allowed to expire, this study assesses the level and predictors of out-of-pocket spending for influenza hospitalizations in 2018 among elderly Medicare Advantage patients., Methods: Using the Optum De-Identified Clinformatics DataMart, investigators identified Medicare Advantage patients aged ≥65 years hospitalized for influenza in 2018. For each hospitalization, out-of-pocket spending was calculated by summing deductibles, coinsurance, and copays. The mean out-of-pocket spending and the proportion of hospitalizations with out-of-pocket spending exceeding $2,500 were calculated. A 1-part generalized linear model with a log link and Poisson variance function was fitted to model out-of-pocket spending as a function of patient demographic characteristics, plan type, and hospitalization characteristics. Coefficients were converted to absolute changes in out-of-pocket spending by calculating average marginal effects., Results: Among 14,278 influenza hospitalizations, the mean out-of-pocket spending was $987 (SD=$799). Out-of-pocket spending exceeded $2,500 for 3.0% of hospitalizations. The factors associated with higher out-of-pocket spending included intensive care use, greater length of stay, and enrollment in a preferred provider organization plan (average marginal effect=$634, 95% CI=$631, $636) compared with enrollment in an HMO plan., Conclusions: In this analysis of elderly Medicare Advantage patients, the mean out-of-pocket spending for influenza hospitalizations was almost $1,000. Federal policymakers should consider passing legislation mandating insurers to eliminate cost sharing for COVID-19 hospitalizations. Insurers with existing cost-sharing waivers should consider extending them indefinitely, and those without such waivers should consider implementing them immediately., (Copyright © 2021 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Intérêts concurrents: Aucun déclaré.

Importance: Reducing out-of-pocket costs is associated with improved patterns of contraception use. It is unknown whether reducing out-of-pocket costs is associated with fewer births., Objective: To evaluate changes in birth rates by income level among commercially insured women before (2008-2013) and after (2014-2018) the elimination of cost sharing for contraception under the Patient Protection and Affordable Care Act (ACA)., Design, Setting, and Participants: This cross-sectional study used data from Clinformatics Data Mart database from January 1, 2008, to December 31, 2018, for women aged 15 to 45 years who were enrolled in an employer-based health plan and had pregnancy benefits for at least 1 year. Women without household income information and women with evidence of having undergone a hysterectomy were excluded., Exposure: Section 2713 of the ACA., Main Outcomes and Measures: The primary outcome was the proportion of reproductive-aged women with a live birth by year (measured yearly from 2008 to 2018 [11 time points]) within 3 income categories. The secondary outcome was the distribution of contraceptive method fills in 3 categories by year: (1) most effective methods (long-acting reversible contraception or sterilization), (2) moderately effective methods (pill, patch, ring, and injectable), and (3) no prescription or surgical method., Results: The analytic sample included 4 590 989 women (mean [SD] age; 30.8 [9.1] years in 2013; 3 069 053 White [66.9%]) enrolled in 47 721 health plans. A total of 500 898 participants (40.8%) resided in households with incomes less than 400% of the federal poverty level in 2013. In all 3 years (2008, 2013, and 2018), women in the lowest income category were younger than women in the other income groups (median range, 21-22 years vs 30-34 years) and in households with a higher median number of dependents (9-10 vs 2-4). There was an associated decrease in births in all income groups in the period after the elimination of out-of-pocket costs. The estimated probability of birth decreased most precipitously among women in the lowest income group from 8.0% (95% CI, 7.4%-8.5%) in 2014 to 6.2% (95% CI, 5.7%-6.7%) in 2018, representing a 22.2% decrease (P < .001). The estimated probability decreased in the middle income group by 9.4%, from 6.4% (95% CI, 6.3%-6.4%) to 5.8% (95% CI, 5.7%-5.8%) (P < .001), and in the highest income group by 1.8%, from 5.6% (95% CI, 5.6%-5.7%) to 5.5% (95% CI, 5.4%-5.5%) (P < .001) in the period after the elimination of cost sharing., Conclusions and Relevance: In this cross-sectional study, the elimination of cost sharing for contraception under the ACA was associated with improvements in contraceptive method prescription fills and a decrease in births among commercially insured women. Women with low income had more precipitous decreases than women with higher income, suggesting that enhanced access to contraception may address well-documented income-related disparities in unintended birth rates.

Background: Specialty drugs are used to treat complex or life-threatening conditions, often at high financial costs to both patients and health plans. Three states - Delaware, Louisiana, and Maryland - passed legislation to cap out-of-pocket payments for specialty drugs at $150 per prescription. A concern is that these caps could shift costs to health plans, increasing insurance premiums. Estimates of the effect of the caps on patient and health-plan spending could inform future policies., Methods: We analyzed a sample that included 27,161 persons under 65 years of age who had rheumatoid arthritis, multiple sclerosis, hepatitis C, psoriasis, psoriatic arthritis, Crohn's disease, or ulcerative colitis and who were in commercial health plans from 2011 through 2016 that were administered by three large nationwide insurers. The primary outcome was the change in out-of-pocket spending among specialty-drug users who were in the 95th percentile for spending on specialty drugs. Other outcomes were changes in mean out-of-pocket and health-plan spending for specialty drugs, nonspecialty drugs, and nondrug health care and utilization of specialty drugs. We compared outcomes in the three states that enacted caps with neighboring control states that did not, 3 years before and up to 3 years after enactment of the spending cap., Results: Caps were associated with an adjusted change in out-of-pocket costs of -$351 (95% confidence interval, -554 to -148) per specialty-drug user per month, representing a 32% reduction in spending, among users in the 95th percentile of spending on specialty drugs. This finding was supported by multiple sensitivity analyses. Caps were not associated with changes in other outcomes., Conclusions: Caps for spending on specialty drugs were associated with substantial reductions in spending on specialty drugs among patients with the highest out-of-pocket costs, without detectable increases in health-plan spending, a proxy for future insurance premiums. (Funded by the Robert Wood Johnson Foundation Health Data for Action Program.)., (Copyright © 2020 Massachusetts Medical Society.)

Background: Health insurance reimbursement structure has evolved, with patients becoming increasingly responsible for their health care costs through rising out-of-pocket expenses. High levels of cost sharing can lead to delays in access to care, influence treatment decisions, and cause financial distress for patients., Methods: Patients undergoing the most common outpatient reconstructive plastic surgery operations were identified using Truven MarketScan databases from 2009 to 2017. Total cost of the surgery paid to the insurer and out-of-pocket expenses, including deductible, copayment, and coinsurance, were calculated. Multivariable generalized linear modeling with log link and gamma distribution was used to predict adjusted total and out-of-pocket expenses. All costs were inflation-adjusted to 2017 dollars., Results: The authors evaluated 3,165,913 outpatient plastic and reconstructive surgical procedures between 2009 and 2017. From 2009 to 2017, total costs had a significant increase of 25 percent, and out-of-pocket expenses had a significant increase of 54 percent. Using generalized linear modeling, procedures performed in outpatient hospitals conferred an additional $1999 in total costs (95 percent CI, $1978 to $2020) and $259 in out-of-pocket expenses (95 percent CI, $254 to $264) compared with office procedures. Ambulatory surgical center procedures conferred an additional $1698 in total costs (95 percent CI, $1677 to $1718) and $279 in out-of-pocket expenses (95 percent CI, $273 to $285) compared with office procedures., Conclusions: For outpatient plastic surgery procedures, out-of-pocket expenses are increasing at a faster rate than total costs, which may have implications for access to care and timing of surgery. Providers should realize the increasing burden of out-of-pocket expenses and the effect of surgical location on patients' costs when possible.

The Supreme Court holds that the government owes insurers the full risk corridors payments due under the Affordable Care Act.

Objective: The study aimed to analyse the financial burden that co-payments for prescribed and reimbursed medicines pose on patients in European countries., Methods: Five medicines used in acute conditions (antibiotic, analgesic) and in chronic care (hypertension, asthma, diabetes) were selected. Co-payments (standard and five defined population groups, e.g. low-income people, patients with high consumption) were surveyed based on information retrieved from national price lists (September 2017) and co-payment regulation in nine countries (Albania, Austria, England, France, Germany, Greece, Hungary, Kyrgyzstan and Sweden). The financial burden of the selected medicines (originator and lowest-priced generic) was described as the percentage of patients' payments for 1 month's therapy or treatment of one episode in comparison to the national minimum monthly wage., Results: The study showed large variation in co-payments between the countries. Financial burden resulting from co-payments for reimbursed medicines tended to be higher in lower-income countries (Kyrgyzstan: 9% of minimum monthly wage for generic amlodipine; 2-4% for generic and originator salbutamol; Albania: approximately 3% for originator amoxicillin/clavulanic acid and metformin). Most studied countries applied reduction or exemption mechanisms (children were exempt in five countries, no or lower co-payments for low-income people in five countries, exemptions from co-payments upon reaching a threshold of expenses in six countries)., Conclusions: Co-payments for prescribed medicines can pose a substantial financial burden for outpatients, particularly in lower-income countries. The price of a medicine, availability of lower-priced medicines and the design of co-payments, including exemptions and reductions for specific groups, can considerably impact patients' expenses for medicines.

Objective: To investigate how changes in insurer participation and composition as well as state policies affect health plan affordability for individual market enrollees., Data Sources: 2014-2019 Qualified Health Plan Landscape Files augmented with supplementary insurer-level information., Study Design: We measured plan affordability for subsidized enrollees using premium spreads, the difference between the benchmark plan and the lowest cost plan, and premium levels for unsubsidized enrollees. We estimated how premium spreads and levels varied with insurer participation, insurer composition, and state policies using log-linear models for 15 222 county-years., Principal Findings: Increased insurer participation reduces premium levels, which is beneficial for unsubsidized enrollees. However, it also reduces premium spreads, leading to lower plan affordability for subsidized enrollees. States responding to cost-sharing reduction subsidy payment cuts by increasing only silver plans' premiums increase premium spreads, particularly when premium increases are restricted to on-Marketplace silver plans. The latter approach also protects unsubsidized, off-Marketplace enrollees from experiencing premium shocks., Conclusions: Insurer participation and insurer composition affect subsidized and unsubsidized enrollees' health plan affordability in different ways. Decisions by state regulators regarding health plan pricing can significantly affect health plan affordability for each enrollee segment., (© Health Research and Educational Trust.)

Background: Adherence to endocrine therapy for breast cancer is often inadequate, in part because of out-of-pocket costs for medication. Numerous states have enacted parity laws to limit patient cost-sharing for oral anticancer drugs. The objective of this study was to estimate the impact of these laws on patient copayments for and adherence to oral endocrine therapy for breast cancer., Methods: Administrative health insurance claims data from 2007 to 2014 derived from a US health care database were used to identify female patients aged 18 to 64 years with invasive cancer or ductal carcinoma in situ of the breast who initiated endocrine therapy and were enrolled in fully insured health plans in states that either enacted parity legislation between 2008 and 2013 or had not yet enacted such legislation by 2015. Differences-in-differences analysis was used to compare copayments for and adherence to endocrine therapy during the 1-year period before and after each year of legislation enactment., Results: In total, 6900 individuals who received 7778 unique drug therapy courses were identified. Parity legislation was associated with significant decreases in the 25th percentile of copayments for anastrozole of $4.39 (95% confidence interval [CI], -$4.52 to -$4.26; P < .001) and for exemestane of $3.08 (95% CI, -$4.80 to -$1.35; P < .001). The median copayment for exemestane decreased by $10.25 (95% CI, -$12.61 to -$7.89; P < .001). A higher median monthly copayment was significantly associated with a greater risk of medication nonadherence (adjusted risk ratio, 1.006 per dollar increase; P < .001)., Conclusions: Parity laws had a modest effect on lowering the cost of anastrozole and exemestane, but more focused efforts to limit out-of-pocket costs for endocrine therapy may have a greater impact on medication adherence., (© 2018 American Cancer Society.)

In 2018, the Medicare Part D catastrophic threshold is $5000 in out-of-pocket total drug spending incurred by the beneficiary. Above this, Medicare pays 80%, prescription drug plans (PDPs) pay 15%, and beneficiaries pay a 5% copay. However, recent growth in catastrophic spending is caused by expensive specialty drugs. The 5% copay, on top of out-of-pocket spending, could result in beneficiaries not accessing specialty drugs. To assist beneficiaries, the Medicare Payment Advisory Commission (MedPAC) proposes to eliminate beneficiary catastrophic cost sharing, while PDPs pay 80% and Medicare pays 20%. Our objective was to assess other government cost-sharing approaches and consider how they would affect pharmaceutical access, PDP Part D incentives, and pharmaceutical innovation. We reviewed published literature and government reports on cost sharing between US government divisions or between government and private commercial entities. We discussed their cost-sharing applicability to Part D. We found that the US government has utilized numerous cost-sharing approaches to enhance public-private partnerships. We reviewed four cost-sharing arrangements and their applicability to Medicare: the Byrd-Bond Amendment to the Clean Air Act-Medicare bulk purchases drugs costing $8000 + ; North Atlantic Treaty Organization (NATO)-cost sharing based on high-risk markets; the Ryan White Ryan White Comprehensive AIDS Resources Emergency (CARE) Act-grants to PDPs in high-risk markets and grants to beneficiaries who cannot afford drugs; and the Department of Veterans Affairs-drug price negotiation for expensive drugs. In conclusion, a variety of federal cost-sharing approaches provide precedent for altering PDP cost sharing. The government tends to prefer options that have been tried elsewhere.

Background: To assess whether implementation of the Mental Health Parity and Addiction Equity Act (MHPAEA) was associated with: 1. Reduced differences in financial requirements (i.e., copayments and coinsurance) for substance use disorder (SUD) versus specialty mental health (MH) care and 2. Reductions in the level of cost-sharing for SUD-specific services., Methods: MH and SUD copayments and coinsurance, 2008-2013, were obtained from benefits databases for carve-in and carve-out plans from Optum ® . Linear regression was used to estimate the association of MHPAEA with differences between MH and SUD care financial requirements among carve-in and carve-out plans. A two-part regression model investigated whether MHPAEA was associated with changes in the use or level of financial requirements for SUD-specific services among carve-out plans., Results: MHPAEA was not associated with significant changes in the difference between SUD and MH copayments or coinsurance levels among either carve-in or carve-out plans. MHPAEA was associated with decreases in the levels of inpatient (in-network: -$51.17; out-of-network: -$34.39) and outpatient (in-network: -$10.26) detox copayments, but increases in the levels of in-network outpatient detox coinsurance (6 percentage points) among all carve-out plans., Conclusion: Even if SUD benefits had been historically less generous than MH benefits, SUD financial requirements were already at parity with MH financial requirements by the time MHPAEA was passed, among Optum ® plans. MHPAEA's SUD parity mandate reduced cost-sharing for detox services via copayments, but, for outpatient detox, the law simultaneously increased cost-sharing via coinsurance., (Copyright © 2018. Published by Elsevier B.V.)

Background: We sought to describe the relationship between the elimination of out-of-pocket costs and women's use of preventive care office visits and long-acting reversible contraception after accounting for baseline levels of cost sharing., Objectives: The objective of this analysis was to describe the relationship between the elimination of out-of-pocket costs and utilization of preventive care visits and long-acting reversible contraception insertion while taking baseline cost sharing levels under consideration., Study Design: In 2017, we used administrative health plan data to examine changes in out-of-pocket costs and service utilization among 2,172,065 women enrolled in 15,118 employer-based health plans between 2008 and 2015. We used generalized estimating equations to examine utilization patterns., Results: Women in this sample generally had low costs at baseline ($24 and $29 for preventive care visits and long-acting reversible contraception insertion, respectively). The elimination of baseline out-of-pocket costs were related to changes in the utilization of both services but more consistently for contraceptive device placement. Women whose low/moderate out-of-pocket costs were eliminated were more likely to use a preventive care office visit than women with persistent low/moderate costs (odds ratio, 1.05; 95% confidence interval, 1.04-1.05), but women with high out-of-pocket costs had lower utilization rates, even after their costs were eliminated. In contrast, the odds of having a contraceptive device placed was higher among all groups of women when out-of-pocket costs were zero, as compared with women with low/moderate costs. For instance, when compared with women with low/moderate costs, women were less likely to have a contraceptive device inserted (odds ratio, 0.92; 95% confidence interval, 0.86-0.97) when they had high costs but more likely after their costs were eliminated (odds ratio, 1.15; 95% confidence interval, 1.09-1.20)., Conclusion: Out-of-pocket costs were low prior to the Affordable Care Act. Eliminating costs was associated with increases in preventive service use among those with high levels of cost, but effect sizes were low, suggesting that cost is only 1 barrier. Failing to recognize that cost sharing was already low could cause us to falsely conclude that the elimination of cost sharing was ineffective., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Despite standardization, advocates for various industries and certain patient needs continue to propose changes in coverage rules. Much of the advocacy is occurring at the state level with a focus on pharmaceutical coverage, such as equalizing cost sharing between oral and infused oncology drugs or setting limits on cost sharing for prescriptions.

This final rule sets forth payment parameters and provisions related to the risk adjustment and risk adjustment data validation programs; cost-sharing parameters; and user fees for Federally-facilitated Exchanges and State Exchanges on the Federal platform. It finalizes changes that provide additional flexibility to States to apply the definition of essential health benefits (EHB) to their markets, enhance the role of States regarding the certification of qualified health plans (QHPs); and provide States with additional flexibility in the operation and establishment of Exchanges, including the Small Business Health Options Program (SHOP) Exchanges. It includes changes to standards related to Exchanges; the required functions of the SHOPs; actuarial value for stand-alone dental plans; the rate review program; the medical loss ratio program; eligibility and enrollment; exemptions; and other related topics.

Eliminating the cost-sharing payments (CSRs) to insurers to hold down out-of-pocket costs for low-income people who purchase individual health plans may wind up actually increasing overall federal spending by driving up premium subsidies to cover higher price plans.

With the industry in flux as federal healthcare reform legislation debates continue, leaders are preparing for what the post-Affordable Care Act world might look like. Predictions include patients assuming more responsibility for healthcare costs and therefore behaving like consumers, including choosing providers based on perceived value. What actions should chief nurse executives take to ensure the nursing enterprise responds to rising consumerism in healthcare?

This final rule sets forth payment parameters and provisions related to the risk adjustment program; cost-sharing parameters and cost-sharing reductions; and user fees for Federally-facilitated Exchanges and State-based Exchanges on the Federal platform. It also provides additional guidance relating to standardized options; qualified health plans; consumer assistance tools; network adequacy; the Small Business Health Options Programs; stand-alone dental plans; fair health insurance premiums; guaranteed availability and guaranteed renewability; the medical loss ratio program; eligibility and enrollment; appeals; consumer-operated and oriented plans; special enrollment periods; and other related topics.

Background: Starting in September of 2010, the Patient Protection and Affordable Care Act required most health insurance policies to cover evidence-based preventive care with no cost-sharing (no copays, coinsurance, or deductibles). It is unknown, however, whether declines in out-of-pocket costs for preventive services are large enough to prompt increases in utilization, the ultimate goal of the policy., Methods: In this study, we use a nationally representative sample of ambulatory care visits to estimate the impact of the zero cost-sharing mandate on out-of-pocket expenditures on well-child and screening mammography visits. Estimates are made using 2-part interrupted time-series models, with well-woman visits serving as the control group because they were not covered under the zero cost-sharing mandate until after our study period., Results: Results indicate a substantial reduction in out-of-pocket costs attributable to the Affordable Care Act. Between January 2011 and September 2012, the zero cost-sharing mandate reduced per-visit out-of-pocket costs for well-child visits from $18.46 to $8.08 (56%) and out-of-pocket costs for screening mammography visits from $25.43 to $6.50 (74%). No reduction was apparent for well-woman visits., Conclusions: The Affordable Care Act's zero cost-sharing mandate for preventive care has had a large impact on out-of-pocket expenditures for well-child and mammography visits. To increase preventive service use, research is needed to better understand barriers to obtaining preventive care that are not directly related to cost.

Competing Interests: of potential conflicts of interest may be found at the end of this article.

This final rule modifies the TRICARE regulation to reduce administrative barriers to access to mental health benefit coverage and to improve access to substance use disorder (SUD) treatment for TRICARE beneficiaries, consistent with earlier Department of Defense and Institute of Medicine recommendations, current standards of practice in mental health and addiction medicine, and governing laws. This rule seeks to eliminate unnecessary quantitative and non-quantitative treatment limitations on SUD and mental health benefit coverage and align beneficiary cost-sharing for mental health and SUD benefits with those applicable to medical/surgical benefits, expand covered mental health and SUD treatment under TRICARE to include coverage of intensive outpatient programs and treatment of opioid use disorder and to streamline the requirements for mental health and SUD institutional providers to become TRICARE authorized providers, and to develop TRICARE reimbursement methodologies for newly recognized mental health and SUD intensive outpatient programs and opioid treatment programs.

Background: The Affordable Care Act (ACA) required most private insurance plans to cover contraceptive services without patient cost-sharing as of January 2013 for most plans. Whether the ACA's mandate has impacted long-acting reversible contraceptives (LARC) use is unknown., Objective: The aim of this article is to assess trends in LARC cost-sharing and uptake before and one year after implementation of the ACA's contraceptive mandate., Design: A retrospective cohort study using Truven Health MarketScan claims data from January 2010 to December 2013., Subjects: Women aged 18-45 years with continuous insurance coverage with claims for oral contraceptive pills, patches, rings, injections, or LARC during 2010-2013 (N=3,794,793)., Measures: Descriptive statistics were used to assess trends in LARC cost-sharing and uptake from 2010 through 2013. Interrupted time series models were used to assess the association of time, ACA, and time after the ACA on LARC cost-sharing and initiation rates, adjusting for patient and plan characteristics., Results: The proportion of claims with $0 cost-sharing for intrauterine devices and implants, respectively, rose from 36.6% and 9.3% in 2010 to 87.6% and 80.5% in 2013. The ACA was associated with a significant increase in these proportions and in their rate of increase (level and slope change both P<0.001). LARC uptake increased over time with no significant change in level of LARC use after ACA implementation in January 2013 (P=0.44) and a slightly slower rate of growth post-ACA than previously reported (β coefficient for trend, -0.004; P<0.001)., Conclusions: The ACA has significantly decreased LARC cost-sharing, but during its first year had not yet increased LARC initiation rates.

This final rule sets forth payment parameters and provisions related to the risk adjustment, reinsurance, and risk corridors programs; cost-sharing parameters and cost-sharing reductions; and user fees for Federally-facilitated Exchanges. It also provides additional amendments regarding the annual open enrollment period for the individual market for the 2017 and 2018 benefit years; essential health benefits; cost sharing; qualified health plans; Exchange consumer assistance programs; network adequacy; patient safety; the Small Business Health Options Program; stand-alone dental plans; third-party payments to qualified health plans; the definitions of large employer and small employer; fair health insurance premiums; student health insurance coverage; the rate review program; the medical loss ratio program; eligibility and enrollment; exemptions and appeals; and other related topics.

This final rule revises the benefit payment provision for nonparticipating providers to more closely mirror industry practices by requiring TDP nonparticipating providers to be reimbursed (minus the appropriate cost-share) at the lesser of billed charges or the network maximum allowable charge for similar services in that same locality (region) or state. This rule also updates the regulatory provisions regarding dental sealants to clearly categorize them as a preventive service and, consequently, eliminate the current 20 percent cost-share applicable to sealants to conform with the language in the regulation to the statute.

Health insurers selling plans in the Affordable Care Act's market­places are required to reduce cost-sharing in silver plans for low- and moderate-income people earning between 100 percent and 250 percent of the federal pov­erty level. In 2016, as many as 7 million Americans may have plans with these cost-sharing reductions. In the largest markets in the 38 states using the federal website for marketplace enrollment, the cost-sharing reductions substantially lower projected out-of-pocket costs for people who qualify for them. However, the degree to which consumers' out-of-pocket spending will fall varies by plan and how much health care they use. This is because insurers use deductibles, out-of-pocket limits, and copayments in different combinations to lower cost-sharing for eligible enrollees. In 2017, marketplace insurers will have the option of offering standard plans, which may help simplify consumers' choices and lead to more equal cost-sharing.

Over the last decade, there has been increased development and use of oral anticancer medications, which sometimes leads to high cost sharing for patients. Drug parity laws require insurance plans to cover oral anticancer medications with the same cost sharing as intravenous/injected chemotherapy or have a capped limit on out-of-pocket costs. There are currently 36 enacted state laws (plus the District of Columbia) addressing drug parity, but no federal laws. In this policy perspective piece, we discuss the history, opportunities, and limitations of drug parity laws in oncology. We also discuss the implications of provisions of the Affordable Care Act and other proposed policy reforms on financing oral chemotherapy., (Copyright © 2016 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.)

This document contains final regulations regarding grandfathered health plans, preexisting condition exclusions, lifetime and annual dollar limits on benefits, rescissions, coverage of dependent children to age 26, internal claims and appeal and external review processes, and patient protections under the Affordable Care Act. It finalizes changes to the proposed and interim final rules based on comments and incorporates subregulatory guidance issued since publication of the proposed and interim final rules.

This document contains final regulations regarding coverage of certain preventive services under section 2713 of the Public Health Service Act (PHS Act), added by the Patient Protection and Affordable Care Act, as amended, and incorporated into the Employee Retirement Income Security Act of 1974 and the Internal Revenue Code. Section 2713 of the PHS Act requires coverage without cost sharing of certain preventive health services by non-grandfathered group health plans and health insurance coverage. These regulations finalize provisions from three rulemaking actions: Interim final regulations issued in July 2010 related to coverage of preventive services, interim final regulations issued in August 2014 related to the process an eligible organization uses to provide notice of its religious objection to the coverage of contraceptive services, and proposed regulations issued in August 2014 related to the definition of "eligible organization,'' which would expand the set of entities that may avail themselves of an accommodation with respect to the coverage of contraceptive services.

Affordable Care Act provisions implemented in 2010 required insurance plans to offer dependent coverage to people ages 19-25 and to provide targeted preventive services with zero cost sharing. These provisions both increased the percentage of young adults with any source of health insurance coverage and improved the generosity of coverage. We examined how these provisions affected use of the human papillomavirus (HPV) vaccine, which is among the most expensive of recommended vaccines, among young adult women. Using 2008-12 data from the National Health Interview Survey, we estimated that the 2010 policy implementation increased the likelihood of HPV vaccine initiation and completion by 7.7 and 5.8 percentage points, respectively, for women ages 19-25 relative to a control group of women age 18 or 26. These estimates translate to approximately 1.1 million young women initiating and 854,000 young women completing the vaccine series., (Project HOPE—The People-to-People Health Foundation, Inc.)