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HHS OIG Introduces Managed Care Strategic Plan

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

The Departments of Labor, Health and Human Services, and the Treasury Issue Notice of Proposed Rulemaking Related to the Mental Health Parity and Addiction Equity Act

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

New Medicare Marketing Definition

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

CMS Instructs IDR Entities Not To Issue New Payment Determinations Pending Further Guidance from Departments

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

District Court Declares Portion of Regulations Governing NSA’s Dispute Resolution Process Invalid

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

FEDERAL COMMUNICATIONS COMMISSION AUTHORIZES USE OF AUTOMATED AND PRERECORDED VOICE TECHNOLOGY OUTREACH FOR CERTAIN HEALTH POLICY RENEWALS

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

Individuals that Lose Medicaid Coverage May Enroll in Medicare Part B Nationally and Medicare Supplement Coverage in Some States including Soon in Ohio

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

IDR Payment Disputes are Far Outpacing Projections, Creating Backlogs

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

California’s Senate Bill 1019 Seeks to Expand Access to Mental Health Benefits for Medicaid Enrollees

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

Court Rejects Vertical Merger Challenge Brought by DOJ

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

Government Continues Aggressive Antitrust Enforcement in the Healthcare Space

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

Judge Strikes Down Part Of Administration’s Surprise Billing Rules In Win For Physicians

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

AMA and AHA Challenge IDR Process under the No Surprises Act

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

Supreme Court Rules in Favor of Health Insurers Under Affordable Care Act’s Risk Corridor Program

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

COVID-19 and US Health Insurance – New Regulatory Directives

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 Arrangements between Insurance Companies and Associations may give rise to Regulatory Issues

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

Tenth Circuit Reverses District Court and Upholds ACA’s Statewide Average Premium Risk Adjustment Methodology

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

Pharmacy Benefit Managers Are Not Subject to the Any Willing Provider Laws in GA, MS, or NC, says Eighth Circuit

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

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
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