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Category Archives: Payer/Insurance Reform

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CMS Finalizes Medicare Part C and Part D Program Changes for Contract Year 2015: Moderate Deviations from Proposed Rule

Posted in Compliance, Department of Health and Human Services, False Claims Act, Fraud and Abuse, Insurance, Managed Care, Medicare Part D, Payer/Insurance Reform, Payment Methodologies, Pharmaceutical, PPACA, Publications

On January 8, 2014, we noted several proposed changes to the Medicare Part C and D programs as delineated in CMS’ January 8th proposed rule (hereinafter “Proposed Rule”). On Monday, May 19, 2014, CMS issued the final rule, titled Medicare Program; Contract Year 2015 Policy and Technical Changes to the Medicare Advantage and the Medicare… Continue Reading

Is Your Name on the List?

Posted in Compliance, Department of Health and Human Services, False Claims Act, Fraud and Abuse, Managed Care, Medicare Advantage, Medicare Part D, Payer/Insurance Reform, Payment Methodologies, Physician Practice

Given the 880,000 names of physicians released by Medicare Wednesday, physicians who treat Medicare patients can expect their names to be on the list.  The list, searchable here, contains the name of the provider, the specialty area, the city, county and state as well as the total payments made to the provider by Medicare for… Continue Reading

Essential Health Benefits Continue to Be Clarified by State Insurance Departments

Posted in Insurance, Payer/Insurance Reform, PPACA

On February 27, 2014, the D.C. Department of Insurance, Securities, and Banking (DISB) released a bulletin reminding insurers that medically necessary treatment for gender dysphoria, including gender reassignment surgeries, is a mandated benefit in the District of Columbia.  This is not the case in every state and serves as a reminder for health insurance plans… Continue Reading

CMS Adds to the Growing Guidance on Third Party Premium Payments

Posted in Department of Health and Human Services, Hospitals, Insurance, Payer/Insurance Reform, Payment Methodologies, PPACA

On February 7, 2014, the Centers for Medicare and Medicaid Services (CMS) issued a memorandum that adds to the growing library of federal guidance on the permissibility of and limitations for health care providers and other entities paying the premiums of patients covered by qualified health plans (QHPs) in the health insurance exchanges or marketplaces. … Continue Reading

CMS Ushers in the New Year with Medicare Part C and Part D Proposed Rules: HHS Hopes to Save $1.3 Billion

Posted in Compliance, Department of Health and Human Services, Insurance, Managed Care, Medicare Advantage, Medicare Part D, Payer/Insurance Reform, Payment Methodologies, PPACA, Regulatory Compliance

On January 10, 2014, CMS will publish the proposed rule titled Medicare Program: Contract Year 2015 and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs (the “Proposed Rule”).  The Proposed Rule propositions extensive reforms to the Medicare Advantage (“Part C”) and Medicare Prescription Drug Benefit Program (“Part D”), partly through… Continue Reading

Corporate Health Exchanges: The Next Big Thing in the Obamacare Era?

Posted in Insurance, Labor and Employment, Managed Care, Payer/Insurance Reform, Payment Methodologies, PPACA

Last Wednesday, September 18, 2013, Walgreen Company (“Walgreen”) announced its plan to move approximately 160,000 employees to Aon Hewitt’s private health exchange (the “Aon Exchange”) in 2014. This move marks a significant decrease in risk for Walgreen as the company will shift to a defined contribution model for funding its employees’ health insurance. Under the… Continue Reading

HHS Releases “Rate Review” Impact Data: Policyholders Save $1.2 Billion Nationwide

Posted in Accountable Care Organizations, Department of Health and Human Services, Hospitals, Insurance, Managed Care, Medicare Advantage, Medicare Part D, Payer/Insurance Reform, Payment Methodologies, PPACA

Last Thursday, September 12, 2013, the Department of Health and Human Services (“HHS”) reported that the rate review provisions (the “Rate Review Provisions”) of the Affordable Care Act (“ACA”) saved an estimated $1.2 billion on health insurance premiums in 2012 for 6.8 million policyholders.  The Rate Review Provisions are intended to increase transparency behind premium… Continue Reading

Another Extension for States to Decide About Insurance Exchanges

Posted in Department of Health and Human Services, Payer/Insurance Reform, PPACA

For the second time in a week, the federal government has extended deadlines relating to state insurance exchanges.  Today was originally the deadline for each state to submit an application to the federal government if the state would be running its own insurance exchange.  For any state that does not set up its own exchange, the federal government… Continue Reading

Rivell v. PHCS: Network Provider Contracts’ Unintentional Limits on Network Rentals and Provider Marketing

Posted in Payer/Insurance Reform

On August 13, 2012, in Rivell v. Private Health Care Systems Inc., the U.S. District Court for the Southern District of Georgia dismissed the plaintiffs’ claims arising from the rental of a health care provider network by a preferred provider organization (“PPO”) to a discount medical plan (“DMP”) as time barred for two plaintiffs and… Continue Reading

David Moore v. John Deere Health Care Plan Inc.: The Mostly Right Way for Managed Care Organizations to Terminate an Incompetent Network Provider

Posted in Payer/Insurance Reform, PPACA

When facing an incompetent network health care provider and angry members, a managed care organization (MCO), such as a health maintenance organization (HMO), a preferred provider organization, or a physician-hospital organization, must take action to protect its members.  How can the MCO terminate the provider’s contract without becoming liable to that provider for damages? In… Continue Reading

CMS to Increase Payments to Primary Care Physicians in CY 2013

Posted in Payer/Insurance Reform

The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that will increase Medicare payments to primary care physicians by 7 percent and other practitioners providing primary care services between 3 and 5 percent.  This proposed payment increase is part of the Medicare Physician Fee Schedule (MPFS) for calendar year (CY) 2013 and… Continue Reading

Insurers Promise Some Continued Benefits, Regardless of Supreme Court Decision on PPACA

Posted in Payer/Insurance Reform, PPACA

As we get closer to receiving a decision from the U.S. Supreme Court on the constitutionality of PPACA and its individual insurance mandate, three major insurers have committed to continue some benefits that were required by PPACA.  These announcements address some of the uncertainty being experienced by insureds who don’t know what will happen or how quickly changes… Continue Reading

Affordable Care Act Grants Improve Consumer Health Awareness

Posted in Community Benefit, Payer/Insurance Reform, PPACA

The Affordable Care Act provides for nearly $30 million in grant funding for states to establish and strengthen Consumer Assistance Programs.   States must apply for the grants and articulate how they will use the funding to assist their residents with problems and related questions regarding health insurance coverage.  Consumer Assistance Programs provide assistance to state… Continue Reading

Comprehensive Primary Care Initiative

Posted in Payer/Insurance Reform

Yesterday, 45 commercial, federal and State insurers in seven markets today pledged to work with the Centers for Medicare & Medicaid Services (CMS) to improve access to quality health care at lower cost. Under the Comprehensive Primary Care initiative, CMS will pay primary care practices a care management fee, initially set at an average of… Continue Reading

More Constitutional Decisions on PPACA

Posted in Payer/Insurance Reform, PPACA

The constitutional challenges to PPACA keep coming in.  So far, the tally is two decisions for and two against.  Two decisions are currently on appeal, and the most recent decision will likely be headed to the appellate courts soon. The decisions in favor of PPACA: As reported earlier here and at SSD’s Sixth Circuit blog, in… Continue Reading

Constitutional Decisions on PPACA Begin

Posted in Payer/Insurance Reform, PPACA

We are beginning to see action (and divergent results) on the various court challenges to PPACA, starting with two recent decisions. As explained in SSD’s Sixth Circuit Blog, the federal court for the Western District of Michigan dismissed the case of Thomas More Law Center, et al. v. Obama (E.D. Mich., Case No. 10-CV-11156) (PDF) that challenged whether Congress has authority… Continue Reading

NAIC Releases Draft Regulation on Medical Loss Ratios; Expresses Concerns Over Implementation [UPDATED]

Posted in Payer/Insurance Reform, PPACA

On October 14, 2010, the National Association of Insurance Commissioners (NAIC) Health Insurance and Managed Care Committee approved model regulations relating to insurer calculation of medical loss ratio (MLR) for health coverages as required under the Patient Protection and Affordable Care Act (PPACA).  [UPDATE: On October 21, Executive and Plenary committees of the National Association… Continue Reading