Payer/Insurance Reform

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CMS Finalizes a New Rule to Require Extensive API Implementation and Quicker Turnaround for Prior Authorization Decisions: What Payers Should Know

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

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

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

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

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

HHS Final Rule Scales Back Affordable Care Act Regulations

Earlier this month, the US Department of Health and Human Services (HHS) published a Final Rule in the Federal Register that will scale back regulations applicable to health insurance subject to the Patient Protection and Affordable Care Act (ACA). In issuing the Final Notice of Benefit and Payment Parameters for 2019 Rule (Final Rule), HHS … 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

With New Primary Care Compensation Model, CMS Continues Efforts to Promote Value-Based Payments

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

Two-Midnight Rule Update: CMS Proposes to Eliminate .2% Payment Reduction By Increasing FY 2017 IPPS Rates

Today, CMS submitted to the Federal Register (for publication on April 27th) its annual notice of proposed IPPS rates and policy changes for federal fiscal year (“FY”) 2017.  Today’s notice contains a proposal to eliminate permanently the .2% payment reduction that CMS had implemented in FY 2014 to offset a projected net increase in IPPS … 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

Is Your Name on the List?

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

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

Another Extension for States to Decide About Insurance Exchanges

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

Rivell v. PHCS: Network Provider Contracts’ Unintentional Limits on Network Rentals and Provider Marketing

On August 13, 2012, in Rivell v. Private Health Care Systems Inc., the U.S. District Court for the Southern District of Georgia dismissed the plaintiffs’ claims arising from the rental of a health care provider network by a preferred provider organization (“PPO”) to a discount medical plan (“DMP”) as time barred for two plaintiffs and … 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

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

CMS to Increase Payments to Primary Care Physicians in CY 2013

The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that will increase Medicare payments to primary care physicians by 7 percent and other practitioners providing primary care services between 3 and 5 percent.  This proposed payment increase is part of the Medicare Physician Fee Schedule (MPFS) for calendar year (CY) 2013 and … Continue Reading

Insurers Promise Some Continued Benefits, Regardless of Supreme Court Decision on 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

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

Comprehensive Primary Care Initiative

Yesterday, 45 commercial, federal and State insurers in seven markets today pledged to work with the Centers for Medicare & Medicaid Services (CMS) to improve access to quality health care at lower cost. Under the Comprehensive Primary Care initiative, CMS will pay primary care practices a care management fee, initially set at an average of … Continue Reading
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