Last month, the U.S. Department of Health and Human Services Office of Inspector (“OIG”) released a report that studied prior authorization denials and payment denials by Medicare Advantage Organizations (“MAOs”) (the...more
On March 2, 2022, the Department of Health and Human Services (“HHS”) Office of the Inspector General (the “OIG”) issued a new advisory opinion (“AO 22-04”) related to a program through which the Requestor would provide...more
On February 24, 2022, the Centers for Medicare & Medicaid Services (CMS) announced its redesign of the Global and Professional Direct Contracting Model (GPDC), which now will be called the Accountable Care Organization (ACO)...more
On January 6, 2022, the Centers for Medicare and Medicaid Services (“CMS”) issued the proposed rule on Contract Year 2023 Policy and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Benefit Programs...more
1/12/2022
/ Affordable Care Act ,
Centers for Medicare & Medicaid Services (CMS) ,
CLIA ,
Coronavirus/COVID-19 ,
Medicare Advantage ,
Medicare Advantage Organizations (MAOs) ,
Medicare Part A ,
Medicare Part B ,
Medicare Part D ,
Out-of-Pocket Expenses ,
Proposed Rules ,
Public Health Emergency ,
Risk Assessment
On August 13, 2021, the D.C. Circuit Court of Appeals reversed a district court opinion vacating CMS’ Overpayment Rule, 42 C.F.R. 422.326, for Medicare Advantage organizations (“MAOs”). UnitedHealthcare Insurance Co. et al....more
The Biden Administration used the annual rulemaking that governs health plans sold on the Affordable Care Act’s exchanges to lower health care costs for consumers and improve access to health care. Part 2 of the Notice of...more
On March 4th, the U.S. District Court for the District of Maryland struck down four provisions of the Trump Administration’s Notice of Benefit and Payment Parameters for 2019, 83 Fed. Reg. 16930 (April 17, 2018) (the “Rule”),...more
On February 26, 2021, the Departments of Labor, Health and Human Services (HHS), and the Treasury issued Frequently Asked Questions (FAQs) on the implementation of the Families First Coronavirus Response Act (“FFCRA”), the...more
3/3/2021
/ CARES Act ,
Coronavirus/COVID-19 ,
Corporate Counsel ,
Department of Health and Human Services (HHS) ,
Department of Labor (DOL) ,
Employer Group Health Plans ,
Families First Coronavirus Response Act (FFCRA) ,
Health Insurance ,
Insurance Industry ,
Non-Grandfathered Health Plans ,
U.S. Treasury ,
Vaccinations ,
Virus Testing
On October 29, 2020, the Department of Health and Human Services (“HHS”), the Department of Labor, and the Department of the Treasury (collectively, the “Departments”) released the Transparency in Coverage Final Rules (the...more
11/14/2020
/ Department of Health and Human Services (HHS) ,
Department of Labor (DOL) ,
Employer Group Health Plans ,
Final Rules ,
Health Insurance ,
Negotiated Rate Agreements ,
Non-Grandfathered Health Plans ,
Out-of-Pocket Expenses ,
Prescription Drug Coverage ,
Pricing Requirements ,
Transparency ,
Trump Administration ,
U.S. Treasury
On September 14, 2020, the Centers for Medicare & Medicaid Services (“CMS”) issued the Advance Notice of Methodological Changes for Calendar Year (CY) 2022 for Medicare Advantage (MA) Capitation Rates and Part C and Part D...more
Earlier this month, the U.S. Department of Health and Human Services Office of the Inspector General (the “OIG”) released a report highlighting concerns about the extent to which Medicare Advantage Organizations (“MAOs”) are...more
The Supreme Court issued a long-awaited ruling on April 27, 2020, directed at a more than $12 billion challenge related to the temporary risk corridors program established by the Affordable Care Act (the “ACA”). Challenges...more
4/29/2020
/ Affordable Care Act ,
Appropriations Bill ,
Corporate Counsel ,
Court of Federal Claims ,
Damages ,
Government Payments ,
Health Insurance ,
Insurance Industry ,
Land of Lincoln Mutual Health Insurance Co. v. United States ,
Maine Community Health Options v. United States ,
Moda Health Plan Inc. v. United States ,
Reimbursements ,
Remand ,
Repeal ,
Reversal ,
Risk Corridors Statute ,
SCOTUS ,
Tucker Act
CMS has issued long-awaited guidance on the use of diagnoses from telehealth services for risk adjusted payment purposes. The guidance applies to Medicare Advantage, Cost, PACE, and Demonstration organizations...more
On Friday, March 27, the Coronavirus Aid, Relief, and Economic Security Act (the “CARES Act”) was enacted. Organized below are concise summaries of select CARES Act sections that will impact various sectors of the health...more
3/31/2020
/ CARES Act ,
Centers for Disease Control and Prevention (CDC) ,
Coronavirus/COVID-19 ,
Department of Health and Human Services (HHS) ,
FQHC ,
Health Care Providers ,
Health Insurance Portability and Accountability Act (HIPAA) ,
Long Term Care Facilities ,
Material Adverse Change Clauses (MACs) ,
Relief Measures ,
SBA ,
Telehealth ,
Waivers
In a much needed sign of bipartisanship, the Senate passed and President Trump signed last night the Families First Coronavirus Response Act. The new law is effective today and requires insurers and group health plans to...more
The Centers for Medicare and Medicaid Services (CMS) and the Office of Personnel Management (OPM) issued guidance to their contracting carriers on various issues surrounding the novel coronavirus or COVID-19. These guidance...more
3/17/2020
/ Centers for Medicare & Medicaid Services (CMS) ,
Coronavirus/COVID-19 ,
Emergency Management Plans ,
Health Care Providers ,
Medicare ,
Medicare Advantage ,
Medicare Advantage Organizations (MAOs) ,
Medicare Part A ,
Medicare Part B ,
Medicare Part D ,
OPM ,
Prescription Drugs ,
Public Employees
As promised, here is a summary of some key provisions in CMS’ proposed rule relating to the Medicare Advantage and Part D programs for contract years 2021 and 2022. CMS is soliciting comments on a number of issues and we urge...more
2/14/2020
/ 21st Century Cures Act ,
Bipartisan Budget Act ,
Centers for Medicare & Medicaid Services (CMS) ,
Comment Period ,
ESRD ,
Health Care Providers ,
Medicare ,
Medicare Advantage ,
Medicare Advantage Organizations (MAOs) ,
Medicare Part D ,
Past Performance ,
Proposed Regulation
In an evening email that is sure to ruin the weekend for many, CMS announced on February 5, 2020, that it is proposing changes to the Medicare Advantage and Part D Programs for CY 2021 and 2022. CMS will not issue a Call...more
2/7/2020
/ Call Letter ,
Centers for Medicare & Medicaid Services (CMS) ,
Healthcare Reform ,
Medical Loss Ratio ,
Medicare ,
Medicare Advantage ,
Medicare Part D ,
Prescription Drug Coverage ,
Prescription Drugs ,
Regulatory Agenda ,
Regulatory Burden ,
Rulemaking Process
On August 13, 2018, President Trump signed into law the National Defense Authorization Act (NDAA) of 2019. While the annual NDAAs are tracked, analyzed, and picked apart with great care by the federal contracting community,...more
1/31/2020
/ China ,
Department of Veterans Affairs ,
Federal Contractors ,
Health Care Providers ,
Huawei ,
National Institute of Health (NIH) ,
NDAA ,
Prime Contractor ,
Technology ,
TRICARE ,
ZTE
The House and Senate continue to focus on prescription drug pricing though it is unclear whether any of the proposals currently pending in either chamber will become law. On December 6th, Senators Grassley and Wyden...more
12/30/2019
/ Congressional Budget Office ,
Consumer Price Index ,
Drug Pricing ,
Health Plan Sponsors ,
Medicare ,
Medicare Part D ,
Nancy Pelosi ,
Pending Legislation ,
Pharmaceutical Industry ,
Prescription Drugs ,
Rebates
On August 19, 2019, the Centers for Medicare and Medicaid Services (“CMS”) announced plans for two updates to its Overall Hospital Quality Star Ratings (“Star Ratings”). The first, in early 2020, to “refresh” the Star Ratings...more
In a rare act of bipartisanship, Senate Finance Committee Chairman Chuck Grassley, R-Iowa, and Ranking Member Ron Wyden, D-Ore., introduced on July 23rd a chairman’s mark, the Prescription Drug Pricing Reduction Act (PDPRA)...more
7/26/2019
/ Ambulatory Surgery Centers ,
Conflicts of Interest ,
Congressional Budget Office ,
Drug Pricing ,
Health Insurance ,
Hospitals ,
Managed Care Contracts ,
Manufacturers ,
Medicaid ,
Medicare ,
Medicare Part D ,
Outpatient Services ,
Pharmaceutical Industry ,
Pharmacy Benefit Manager (PBM) ,
Physician Fee Schedule ,
Prescription Drug Coverage ,
Prescription Drugs ,
Price Transparency ,
Public Disclosure ,
Rebates ,
Risk-Sharing
Earlier this week, the Supreme Court upheld a D.C. Circuit Court decision vacating a policy of the Centers for Medicare and Medicaid Services (“CMS”) that would have “dramatically – and retroactively – reduced payments to...more
6/7/2019
/ Administrative Procedure Act ,
Azar v Allina Health Services ,
Department of Health and Human Services (HHS) ,
Hospitals ,
Low-Income Issues ,
Medicare ,
Medicare Advantage ,
Medicare Part A ,
Medicare Part C ,
Notice and Comment ,
Pay Reductions ,
Provider Payments ,
Reaffirmation ,
Retroactive Application ,
SCOTUS ,
Substantive Rule ,
Vacated
On April 10, 2019, the Department of Justice filed notices appealing two District Court rulings that struck down Medicaid work requirements in both Kentucky and Arkansas to the U.S. Court of Appeals for the District of...more
4/26/2019
/ 1115 Waivers ,
Administrative Procedure Act ,
Appeals ,
Arbitrary and Capricious ,
Denial of Insurance Coverage ,
Department of Health and Human Services (HHS) ,
Department of Justice (DOJ) ,
Governor Hutchinson ,
Health Insurance ,
Low-Income Issues ,
Medicaid ,
Medicaid Work Requirements ,
Proposed Amendments ,
Remand ,
Secretary of HHS ,
Statutory Authority ,
Take Care Clause ,
Vacated
The Office for Civil Rights (“OCR”) issued a request for information (“RFI”) to assist OCR in identifying provisions of the Health Insurance Portability and Accountability Act (“HIPAA”) privacy and security regulations (the...more
12/17/2018
/ Caregivers ,
Comment Period ,
Covered Entities ,
Data Privacy ,
Data Security ,
Disclosure ,
Health Care Providers ,
Health Insurance Portability and Accountability Act (HIPAA) ,
HITECH Act ,
Information Sharing ,
Mental Illness ,
OCR ,
Opioid ,
Personal Data ,
PHI ,
Privacy Policy ,
Public Comment ,
Regulatory Agenda ,
Regulatory Burden ,
Request For Information ,
Substance Abuse ,
Value-Based Care