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 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
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
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
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
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 March 8, 2016, the Centers for Medicare & Medicaid Services (“CMS”) released a final rule titled “Patient Protection and Affordable Care Act; CMS Notice of Benefit and Payment Parameters for 2017” (“Final Rule”)[1] setting...more
On May 26, 2015, the Centers for Medicare & Medicaid Services (“CMS”) released a proposed rule (“Proposed Rule”) containing the first proposed revisions to the Medicaid managed care (“MMC”) program’s regulations in more than...more