The Medicare Prescription Payment Plan (MPPP), part of the Inflation Reduction Act, aims to smoothen Out-of-Pocket (OOP) prescription costs for Medicare beneficiaries by spreading upfront expenses over 12 months. To implement MPPP effectively, health plans and Pharmacy Benefit Managers (PBMs) must adopt advanced technology solutions, including automated billing tools and member self-service portals. This transition from manual processes to tech-driven methods ensures accurate billing, seamless data exchange, timely reporting, and proactive member communication. Health plans and PBMs must invest in automated tools to meet regulatory requirements and enhance member experience. This report explores MPPP’s objectives and key roles and considerations for health plans and PBMs. It highlights essential components for successful MPPP implementation, such as billing tools, self-service portals, and customer support. Scope Industry: Healthcare Geography: North America Contents In this report, we: Explain the MPPP objectives Highlight key roles and considerations for health plans and PBMs to implement MPPP Detail essential technology solutions required, including automated billing tools, reporting tools, customer service portal, and member self-service portals Outline key performance indicators to assess the effectiveness of implementing MPPP Membership(s) Healthcare Payer and Provider Information Technology Sourcing and Vendor Management

The healthcare industry is facing several challenges, particularly in the aftermath of the pandemic. Vulnerable and low-income populations are at a greater risk during this period and have higher health needs. Medicaid is a jointly funded health insurance program provided by the federal and state governments, serving as the primary payer for low-income individuals, senior citizens, people with disabilities, children, and pregnant women. Enrollment in Medicaid has increased significantly due to various factors such as the Affordable Care Act (ACA) expansion, rise in eligible beneficiaries resulting from pandemic-related unemployment, and the continuous coverage mandate from the Centers for Medicare and Medicaid Services (CMS) under the Public Health Emergency (PHE). Consequently, stakeholders such as health plans, government authorities, investors, and providers, are reshaping the program to improve health outcomes for the target population. As a result, there is a greater focus on improving the efficiency of Medicaid delivery through managed care organizations, use of technologies such as automation and predictive analytics, and leveraging data-driven insights to positively impact health equity in the country. In this report, we examine some of the major trends in the US Medicaid market and the sourcing implications for providers operating in this segment. Scope Industry: healthcare Geography: North America Contents In this report, we Examine the US health expenditure on Medicaid Analyze key themes in the Medicaid market Study the Medicaid Business Process Services (BPS) market size Membership(s) Healthcare Payer and Provider Business Process Sourcing and Vendor Management

The US state Medicaid market is marred by legacy, monolithic Medicaid Management Information Systems (MMIS), which strain the government’s resources. Most initiatives to modernize these aging systems were accompanied by budget and timeline overruns in the past, and, in a few cases, lawsuits by vendors and the government. In such a scenario, CMS’ move to introduce modularity in MMIS was touted as the next big thing in US healthcare. A new modular MMIS was envisioned, which broke the siloed system into multiple modules and made the MMIS technologically superior, operationally more effective, and financially cheaper. While this is true, modularity has also introduced new complexities and challenges in the system. In this viewpoint, we analyze modularity in MMIS and discuss its adoption among various states. We also look at how the vendor landscape has evolved due to modularity and what are some of the factors that could impact modularity in the future. Scope Industry: healthcare Geography: US Contents In this paper, we: Talk about the introduction of modularity and its subsequent adoption by various states Present a case study of a state that adopted modularity and the key learnings from it Analyze how the vendor landscape has changed due to modularity Do a critical analysis and compare the pros and cons of a modular approach Comment on the future outlook of modularity Membership(s) Healthcare Payer and Provider Business Process Sourcing and Vendor Management

Amidst falling profitability, declining margins, and persistent regulatory uncertainty, healthcare payers are aggressively looking for opportunities to sustain their business. With most of the large payers strategically prioritizing growth in the Medicare Advantage (MA) market, it is evident that they believe MA is one such opportunity to make profits, even in these uncertain market conditions. Enrollment in Medicare Advantage plans has grown at a CAGR of 10.3% in the last 12 years. This staggering growth over a decade suggests that these plans have created immense value for both the payers and the beneficiaries. As in every business, payers and enrollees in the Medicare Advantage market segment are also facing some challenges. The future strategy of the stakeholders in this market will depend on a variety of factors including, but not limited to, government policies, ability to overcome the existing business challenges, and the continuously evolving market conditions. To understand the factors that have led to the rise of Medicare Advantage in the healthcare payer industry, Everest Group looks at some basic questions such as: What is Medicare Advantage and how is it different from Original Medicare? Why has Medicare Advantage gained prominence in the healthcare payer ecosystem? What are the benefits and challenges of Medicare Advantage for the payers? What are the benefits and challenges of Medicare Advantage for the beneficiaries? Which specific areas should the payers focus on to extract the maximum benefit out of the Medicare Advantage market? What lies ahead for the Medicare Advantage market? Membership(s) Healthcare & Life Sciences Business Process Outsourcing Healthcare & Life Sciences IT Outsourcing

Medicare / Medicaid market in the United States witnessed many changes during 2010-2015 driven by the regulatory push from the authorities. Regulations such as Patient Protection & Affordable care Act (PPACA) and American Recovery and Reinvestment Act of 2009 (ARRA) revitalized growth in the market by significantly enhancing the scope of the healthcare coverage in the country. The increased scope led to fast pace increase in enrollment of both the plans. With the onset of the second wave of regulations (such as MACRA), the Medicare / Medicaid market in the country is expected to witness another overhaul during 2015-2020. Additional factors such as uncertain political scenario, fast pace growth in the number of elderly people (65+ age), and industry shift towards value-based care would also be driving the growth in the market. These changing market dynamics bring several opportunities for various stakeholders, including healthcare payers, if they are aware of the key happenings and know how to respond to some challenges. This viewpoint explores the Medicare / Medicaid market in the United States in terms of industry size and growth, drivers/trends, challenges/concerns, and opportunities. Membership(s) Healthcare & Life Sciences Business Process Outsourcing Healthcare &amp Life Sciences IT Outsourcing