In recent years, the Centers for Medicare & Medicaid Services (CMS) has approved demonstrations under Section 1115 of the Social Security Act, providing federal matching funds for state expenditures for Designated State...more
The U.S. Supreme Court’s ruling in American Hospital Association (“AHA”) v. Becerra (2022) sent shockwaves through the 340B drug pricing program when it held that CMS’ reduction of reimbursement for drugs purchased under the...more
On September 23, 2024, the U.S. Departments of Labor, the Treasury, and Health and Human Services (collectively, the “Departments”) released final rules (the “Final Rules”) that implement requirements under the Mental Health...more
10/3/2024
/ Department of Health and Human Services (HHS) ,
Department of Labor (DOL) ,
Employee Benefits ,
Employer Group Health Plans ,
Final Rules ,
Health and Welfare Plans ,
Health Insurance ,
Healthcare Reform ,
Mental Health ,
Mental Health Parity Rule ,
MHPAEA ,
NQTLs ,
U.S. Treasury
On January 9, 2024, the Centers for Medicare & Medicaid Services (CMS) approved New York’s recent 1115 demonstration waiver.
Among other things, this most recent demonstration waiver provides significant federal funding...more
On January 9, 2024, the Center for Medicare and Medicaid Services (CMS) sent a letter to New York’s Medicaid director approving New York’s Section 1115 Waiver amendment, which the state submitted for approval on September 2,...more
In November 2023, the Centers for Medicare & Medicaid Services (CMS) published a final rule, “Medicare Program; Hospital Outpatient Prospective Payment System: Remedy for the 340B-Acquired Drug Payment Policy for Calendar...more
Under the Biden administration, the Centers for Medicare & Medicaid Services published a health equity framework that drastically changed the playing field for health plans and other risk-bearing entities.
In the wake of...more
The Centers for Medicare & Medicaid Services (CMS) recently issued its Medicare Physician Fee Schedule (PFS) final rule (the “final rule”), with most changes becoming effective January 1, 2023....more
The Program The ACO REACH (short for “Accountable Care Organization Realizing Equity, Access, and Community Health”) Model is the new Medicare value-based payment demonstration model for providers launched this year by the...more
In December 2015, we wrote about the many failed health insurance co-ops created under the Affordable Care Act (“ACA”), and the impact of those failures on providers and other creditors, consumers, and taxpayers. At that...more
On March 10, 2021, the New York State Department of Financial Services (“DFS”) issued Insurance Circular Letter No. 4 (“Circular Letter”), which both explains modifications to the Insurance Law and the Public Health Law...more
On November 12, 2020, the Trump administration published its final rule on price transparency (the “Final Rule”) requiring affected entities to publicly release personalized information on out-of-pocket costs as well as...more
One of the many relief efforts contained in the Coronavirus Aid, Relief, and Economic Security Act (the “CARES Act”), signed into law on March 27th, 2020, is a hiatus of sequestration as it applies to Medicare payments....more
As infections of COVID-19 continue to increase throughout the nation, health care policymakers have focused primarily on increasing acute-care hospital bed capacity, promoting (and decreasing the regulatory requirements...more
The ongoing pandemic caused by the novel coronavirus has upended the American health care system in many ways. One of the many effects of COVID-19 will likely be substantial disruption in value-based payment arrangements...more
As communities throughout the nation and world continue to grapple with the 2019 novel coronavirus (“COVID-19”) pandemic, health care providers and plans are struggling not only to maintain standard operations but also to...more
The Centers for Medicare & Medicaid Services (“CMS”) recently issued a final rule requiring hospitals to publicly disclose their rates, including negotiated rates with third-party payors regardless of product line, by January...more
The Centers for Medicare & Medicaid Services (“CMS”) recently introduced three new population-based payment (“PBP”) risk-sharing Direct Contracting (“DC”) model options that intend to decrease expenditures and increase...more
New Jersey’s Out-of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act (“NJ Law”) creates a statutory framework that attempts to protect consumers from medical bills for out-of-network services...more
Earlier this year, New Jersey Governor Phil Murphy signed into law the Out-of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act (“Law”), creating a statutory framework attempting to protect...more
On June 19, 2018, the Trump administration finalized a rule that will enable small businesses and self-employed individuals to band together to offer access to large group health plans, which are typically less expensive (but...more
After nearly decade of deliberation, on June 1, 2018, New Jersey Governor Phil Murphy signed into law the Out-of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act (“Law”),creating regulations...more
The Trump Administration has published a proposed rule allowing a significant change to the definition of "employer" under ERISA that would enable small businesses and self-employed individuals to band together to create...more
For value-based payments, encounter data[1] provides valuable information in much the same way that claims data does for fee-for-service arrangements. With the growing prevalence of value-based payments, especially in the...more
11/8/2017
/ Audits ,
Centers for Medicare & Medicaid Services (CMS) ,
Children's Health Insurance Program (CHIP) ,
Data Collection ,
False Claims Act (FCA) ,
Fee-for-Service ,
MCOs ,
Medicaid ,
Provider Payments ,
Reporting Requirements ,
Value-Based Payments
On October 12, 2017, President Donald Trump signed an executive order (the “Order”) designed to “promote healthcare choice and competition across the United States,” which in effect will allow many Americans to sidestep...more