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CMS Updates the Part D Prescription Drug Benefit Manual – Chapter 13 & 14

Last month, CMS updated Chapters 13 and 14 from the Part D Prescription Drug Benefit Manual (PDBM). These updates affect Part D plan sponsor operations as well as network and non-network pharmacies. In Chapter 13, CMS updated its guidance on premium and cost sharing subsidies for low-income beneficiaries under the Part D program. In Chapter … Continue Reading

DOL Issues Final Rule Expanding Access to Association Health Plans

On June 21, 2018, the US Department of Labor (DOL or the Department) published its final rule, amending the definition of “employer” under section 3(5) of the Employee Retirement Income Security Act (ERISA) to allow for the establishment of group or association health plans (AHPs) (Final Rule). Similar to a corresponding proposed rule issued earlier … Continue Reading

Right to Try Investigational Drugs Signed Into Law

Right to Try Investigational Drugs Signed Into Law On May 30, 2018, S. 204, the Trickett Wendler, Frank Mongiello, Jordan McLinn, and Matthew Bellina Right to Try Act of 2017 (Pub. L. No. 115-176, “Right to Try Act”) was signed into law. The Right to Try Act amends the Federal Food, Drug, and Cosmetic Act … Continue Reading

Recent Federal District Court Ruling Considers Who May Bring EMTALA Claims

The United States District Court for the Northern District of Georgia recently granted several defending healthcare insurers’ motions to compel arbitration and (in part) to dismiss claims alleging improper reimbursement practices brought under the Emergency Medical Treatment and Labor Act (“EMTALA”), Affordable Care Act (“ACA”), COBRA, and various Georgia state law theories.  The order, styled … Continue Reading

House Prevails in Challenge to Administration’s Funding of ACA Cost-Sharing Provision

Yesterday, in a blow to the Obama Administration, the United States District Court for the District of Columbia struck down a key ACA provision designed to reduce insurance costs. Specifically, Section 1402 of the ACA requires insurers participating in the Exchanges to reduce deductibles, coinsurance, copayments, and other means of cost-sharing on qualified health plans. … Continue Reading

CMS Creates Standardized Plans for Health Insurance Exchanges

On February 29th, CMS published its final rule regarding the 2017 benefit and payment parameters for the Federally-facilitated health insurance exchanges.  As part of the final rule, CMS creates standardized health care plans that insurers can offer on the exchanges. CMS created the standardized plans in order to simplify health insurance shopping for consumers.  According … Continue Reading

US Supreme Court Oral Argument on Tax Subsidies for Federal Exchange

This morning, the U.S. Supreme Court heard oral argument in King v. Burwell, which raises the issue of whether the federal government can provide tax subsidies to people who buy insurance on the federal exchange because their state declined to establish its own insurance exchange.  Our earlier post details  the arguments at play.  SCOTUS Blog … Continue Reading

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

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

Florida Proposes Pharmacy Audit Rights Legislation

The Florida legislature is currently considering proposed legislation that may affect the way in which managed care organizations, insurers, third-party payors, pharmacy benefit managers and other entities audit pharmacies in Florida.  The Florida House of Representatives, Health Innovation Subcommittee, is reviewing HB 745, which proposes to create a “Pharmacy audit bill of rights.”  The Health … Continue Reading

Essential Health Benefits Continue to Be Clarified by State Insurance Departments

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

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

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?

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

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

Ohio Senate Bill 140 Proposes Sweeping Changes to Ohio Insurance Laws

Introduced on June 4, 2013, Ohio S.B. 140 proposes to make some of the most significant changes to Ohio’s insurance laws since perhaps the Ohio Healthcare Simplification Act (H.B. 125) in 2008.  If passed, the bill will impact everything from insurer’s filing and disclosure obligations, reinsurance options, online and other automated transactions, risk management programs … Continue Reading
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