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Category Archives: PPACA

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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

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

Facing the Medical Device Tax Head On: Strategic Contracting for Hospital Cost-Reduction

Posted in Hospitals, Physician Practice, PPACA, Regulatory Compliance, Tax, Technology

With approximately two months having passed since the end of the government shutdown, the fundamental question still remains; what exactly did Congress achieve through the contentious shutdown negotiations?  The shutdown was spurred in part by certain Congressional Members’  opposition to the funding and implementation  of the Affordable Care Act (“ACA”).  A centerpiece of these oppositional… Continue Reading

Tuomey Ordered to Pay $237 Million

Posted in False Claims Act, Fraud and Abuse, Governance/Management, Hospitals, Payment Methodologies, Physician Practice, PPACA

Capping a case that has drawn the attention of healthcare lawyers and hospital executives nationwide, the U.S. District Court for the District of South Carolina has ordered Tuomey Healthcare System, Inc. (“Tuomey”) to pay over $237* million for violations of the Stark Law and False Claims Act arising from certain employment agreements between Tuomey and… 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

Full Medicaid Expansion Required for States to See Full Federal Funding

Posted in Department of Health and Human Services, PPACA

Yesterday, the federal government announced that the federal government will not provide 100% funding for states that do not participate in the full Medicaid expansion contained in PPACA, as described by the Washington Post.  Partial expansions will be permitted but will only receive matching federal money at the existing rate, at least for 2014-2017. As we… 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

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

U.S. Supreme Court Rules the Individual Mandate Is Constitutional and Limits Medicaid Expansion Laws

Posted in Department of Health and Human Services, PPACA

The decision we’ve all been waiting for is in — the U.S. Supreme Court has ruled that the statute commonly known as the individual insurance mandate (everyone must have minimum health insurance coverage or pay a penalty) is constitutional under Congress’ taxing power.  Because the individual mandate was upheld, the rest of the Affordable Care Act (“PPACA”) has also survived.  The… Continue Reading

PPACA decision likely to come Thursday

Posted in PPACA

The U.S. Supreme Court has completed announcing its decisions for today, and still no decision on PPACA (Department of Health and Human Servs. v. Florida (No.11-398) and National Federation of Independent Business v. Sebelius (No. 11-393)). The Court is sitting again on Thursday and will likely announce decisions in the remaining cases from this term… 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

PPACA – Day 3

Posted in PPACA

A long day today at the U.S. Supreme Court for PPACA attorneys.  This morning, argument was all about whether any unconstitutional parts of PPACA can be severed from the entire Act or if the whole Act must be stricken.  As before, oral arguments are available in audio and transcript on the Court’s website. The afternoon… Continue Reading

PPACA – Day 2

Posted in PPACA

Definitely more drama today, as the Supreme Court heard 2 hours of arguments on the constitutionality of PPACA.  The general opinion following arguments is that the Justices’ questions indicate they may not view the government’s position favorably.  The audio and transcript from today have been posted by the Court, and analysis from Court watchers abounds, including… Continue Reading

PPACA – Day 1

Posted in PPACA

Today’s arguments at the Supreme Court were 90 minutes on the issue of whether the Court has jurisdiction to decide the constitutional questions now, or if the challengers must wait until the individual mandate and its associated penalties begin in 2014.  The audio and transcript of today’s arguments are now available from the Court. Not a… Continue Reading

Coming Monday — Supreme Court Arguments on PPACA

Posted in Department of Health and Human Services, PPACA

Next week, the drama begins — the Supreme Court will hold what promises to be the biggest (an impressive 6 hours) and most important series of oral arguments of the decade, if not the century — to decide the future of Obama’s health care reform, PPACA.  The government will be primarily represented by Solicitor General Don Verilli; arguing most… Continue Reading

PPACA Lawsuits Quickly Moving to the U.S. Supreme Court

Posted in PPACA

Well, this was a big week for the PPACA lawsuits, with multiple filings in the Supreme Court.  These quick moves seem designed to get the case heard this term, which means a decision would come out by June 2012 and be fodder for the November 2012 presidential elections.  It remains to be seen whether that decision upholds PPACA,… Continue Reading