Issue Briefs | Jun 27, 2014

Applicability of All-Payer Claims Databases for Rate Review and Other Regulatory Functions

Wakely Consulting Group – Julia Lerche and Ross Winkelman

All-payer claims databases (APCDs) collect and compile medical, pharmacy, and sometimes dental claims, eligibility, and provider files from public and private payers.  APCDs are currently being used for a variety of functions, including population health analysis, comparative analysis of provider and facility quality, cost management for Medicaid and other public programs, support for provider payment reform initiatives, and consumer transparency tools.  This issue brief, prepared by Wakely Consulting Group, builds on conversations with a number of states at the State Network All-Payer Claims Database Small Group Convening in January 2014, and is intended to explain the potential uses of APCDs for rate review and other regulatory functions.  It includes descriptions of possible uses for APCDs and ranks the level of effort necessary to use an APCD for those purposes, along with the relative value of doing so.


Expert Perspectives

April 12, 2024

The Final 2025 Notice of Benefit and Payment Parameters: Implications for States

On April 2, 2024, the Centers for Medicare & Medicaid Services released the final Notice of Benefit and Payment Parameters for 2025, the annual rule which governs core provisions of the Affordable Care Act. This expert perspective focuses on provisions of the final rule of interest to state officials, including requirements for State-Based Marketplaces to adhere to standards that align more with the Federally Facilitated Marketplace, improvements to the processes for states to determine and update essential health benefits, and initiatives designed to streamline the eligibility and enrollment process for consumers.