On 5 June 2024, the Australian Information Commissioner commenced civil penalty proceedings in the Australian Federal Court against Medibank Private Limited (an Australian health insurance provider) in relation to an October 2022 data breach. On 25 October 2022, Medibank notified the Office of the Australian Information Commissioner (OAIC) of a data breach concerning sensitive personal … Continue Reading
On January 17, 2024, the Centers for Medicare & Medicaid Services (“CMS”) issued a final rule regarding interoperability and prior authorization (the “Rule”). CMS-0057-F. The Rule’s goals, according to CMS, are to facilitate the electronic exchange of health-care data, improve and expedite prior authorization processes, and reduce related burdens for payers, healthcare providers, and patients, … Continue Reading
In August, the Office of Inspector General (“OIG”) of the U.S. Department of Health and Human Services (“HHS”) introduced a new “Strategic Plan for Oversight of Managed Care for Medicare and Medicaid” (the “Strategic Plan”). The introduction of the Strategic Plan is in response to the continued growth of managed care in government sponsored health … Continue Reading
On July 25, 2023, the Departments of Labor, Health and Human Services, and the Treasury (the “Departments”) proposed rules designed to strengthen the Mental Health Parity and Addiction Equity Act’s (“MHPAEA”) goal of ensuring people seeking treatment for mental health and substance use disorders (“MH/SUD”) face no greater barriers to accessing care than those seeking … Continue Reading
On May 10, 2023, the Center for Medicare & Medicare Services (“CMS”) issued guidance to clarify the definition of “marketing” for Medicare Advantage Plans (“MA Plans”) and Prescription Drug Plans (“PDPs”).[1] The new definition expands “marketing” to include activities intended to draw a consumer’s attention to an MA Plan or PDP, influence a consumer’s decision-making … Continue Reading
As we recently reported, on February 6, 2023, Judge Kernodle of the United States District Court for the Eastern District of Texas issued a decision in Texas Medical Association v. U.S. Dep’t of H.H.S., Case No. 6:22-cv-372 vacating certain portions of the regulations governing the dispute resolution process governing reimbursement disputes under the No Surprises … Continue Reading
On February 6, 2023, Judge Kernodle of the Eastern District of Texas once again vacated certain provisions of an agency rule as inconsistent with the No Surprises Act (the “NSA”). Almost a year ago, Judge Kernodle issued a similar decision, which we blogged about. Both decisions concerned the independent dispute resolution (“IDR”) process the NSA … Continue Reading
In April of 2022, the Secretary of Health and Human Services (“HHS”) asked the Federal Communications Commission (“FCC”) to clarify that automated calls and texts, or prerecorded telephone calls made to encourage individuals to renew enrollment in their state Medicaid program (“Medicaid”) Children’s Health Insurance Program (“CHIP”), Basic Health Program (“BHP”) or Health Insurance Marketplace … Continue Reading
Pursuant to federal regulations that took effect on January 1, 2023, individuals who lose Medicaid coverage will be granted a special enrollment right to enroll in Medicare Part B coverage.[1] This special enrollment right was created in part because the COVID health emergency order may soon end, resulting in many people losing Medicaid coverage. In … Continue Reading
The No Surprises Act (the “NSA”), which was enacted as part of the Consolidated Appropriations Act, 2021 (Pub. L. 116-260) provides protections to privately insured patients against “surprise billing” with respect to emergency services, non-emergency services provided by out-of-network providers at in-network health care facilities, and air ambulance services furnished by out-of-network providers. As part … Continue Reading
In an effort to expand access to mental health services, on September 30, 2022, California’s Governor approved Senate Bill 1019, which modifies the California Welfare & Institutions Code as it relates to Medi-Cal managed care plans (“MMCP”). No later than January 1, 2025, MMCPs must develop and implement an annual outreach and education plan for … Continue Reading
On Monday, September 19, 2022, D.C. District Court Judge Carl J. Nichols rejected the Department of Justice’s (“DOJ”) request to block UnitedHealth’s $13.8 billion acquisition of Change Healthcare. UnitedHealth is the largest health insurer in the United States, while Change Healthcare is a leading data clearinghouse for insurance claims. The DOJ initially filed suit to … Continue Reading
On February 24, 2022, the U.S. Department of Justice (“DOJ”) filed suit to block UnitedHealth’s proposed acquisition of Change Healthcare. UnitedHealth owns the largest health insurer in the U.S., while Change Healthcare is a data company whose software is the largest processor of health insurance claims in the U.S. The DOJ alleges that the acquisition, … Continue Reading
The Biden Administration’s Interim Final Rule implementing provisions of the No Surprises Act suffered its first major legal setback yesterday. Judge Kernodle of the Eastern District of Texas issued a decision vacating portions of the Rule relating to the independent dispute resolution (“IDR”) process that the Act creates. As we’ve previously reported, the No Surprises … Continue Reading
The American Medical Association and the American Hospital Association filed suit under the Administrative Procedure Act in the District of Columbia District Court challenging portions of the interim final rule (the “Rule”) issued by the Department of Health and Human Services, the Department of Labor, the Department of the Treasury, and the Office of Personnel … Continue Reading
The United States Supreme Court ruled in an 8-1 decision Monday in favor of four health insurers seeking hundreds of millions of dollars from the federal government related to the Affordable Care Act’s “risk corridor” program, reversing a lower court’s decision that Congress had suspended the government’s obligation to make such payments. Collectively, the decision was a … Continue Reading
Coronavirus disease 2019 (COVID-19) is a rapidly spreading global health problem. Over the past week, state and federal regulators have issued guidance and imposed requirements on health insurance companies and managed care plans (health insurers) to broaden and tailor coverage to COVID-19. This alert serves as a guide to assist our clients with understanding the … Continue Reading
Affinity programs involving insurance companies and associations are on the rise as to all lines of insurance business. An affinity program is an arrangement in which a business offers discounts on products or services to an organization’s membership. In Friedman v. AARP, a federal court considered whether an affinity arrangement between United HealthCare (“UHC”) and … Continue Reading
In a unanimous decision, the United States Court of Appeals for the Tenth Circuit reversed a district court decision holding that HHS’ use of the statewide premium average to calculate Affordable Care Act (ACA) risk adjustment charges and payments from 2014 to 2018 was arbitrary and capricious. See N.M. Health Connections v. U.S. Dep’t of … Continue Reading
The Eighth Circuit has recently reviewed whether a pharmacy benefit manager (”PBM”) is a “health benefit plan” within the meaning of the state statutes in Mississippi, North Carolina, and Georgia such that a pharmacy may bring a claim to enforce the any willing provider laws against PBMs. Many states have enacted some version of any … Continue Reading
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
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 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
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
