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
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
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
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
The Kentucky Court of Appeals recently affirmed dismissal of numerous lawsuits filed by Medicaid enrollees against Managed Care Organizations (“MCOs”) and the Commonwealth’s Cabinet for Health and Family Services (the “Cabinet”). Appalachian Reg’l Healthcare, Inc. v. Commonwealth, No. 2015-CA-001670-MR, 2019 Ky. App. Unpub. LEXIS 629 (Ct. App. Aug. 30, 2019). Applying recent Kentucky Supreme Court … Continue Reading
Last week, CMS released its final rule updating the requirements that Long-Term Care (LTC) facilities must meet to participate in Medicare and Medicaid. Among the requirements is a new regulation under 42 C.F.R. § 483.70(n) (the “Rule”) which prohibits LTC facilities from entering into “pre-dispute” binding arbitration agreements with any facility resident or such resident’s … Continue Reading
Beginning in January 2017, primary care physicians and their practices (PCPs) will be able to participate in a multi-payer payment reform and care delivery transformation aimed at strengthening primary care. Dubbed the Comprehensive Primary Care Plus (CPC+) initiative, the recently unveiled primary care medical home model is CMS’s latest effort to encourage value-based payment methodology, … Continue Reading
The World Economic Forum has identified that today’s global infrastructure demand is estimated at approximately US$ 4 trillion in annual expenditures, with a gap – or missed opportunity – of at least US$ 1 trillion every year. Despite existing supply of private capital, much more is needed to fill this gap. This demand for infrastructure … Continue Reading
On May 26, 2015, CMS released a proposed rule for Medicaid managed care plans with the objective of creating more standardized practices across states, and to align Medicaid managed care with other major sources of coverage, including those offered by the private market. The proposed rule would be the first update to Medicaid managed care … Continue Reading
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
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
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
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
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
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
“[T]his is managed care,” observed the U.S. District Court for the Northern District of California in its June 3rd order granting Sutter Health’s motion to dismiss an antitrust suit. In so concluding, the court was merely echoing the same observation that Sutter Health repeated throughout its motion to dismiss. While the case, Sidibe v. Sutter … Continue Reading
The June 2013 edition of Managed HealthCare Executive magazine includes an article authored by Squire Sanders partner Lisa Han and associate David Kopans entitled, “Highmark Buy Continues National Insurer Trend.” The article focuses on the trend of insurer and provider integration, which blurs the line between the two. With the Highmark Inc. and West Penn … Continue Reading
