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CMS Aims to Stabilize Exchanges but Does Not Address Issuers’ Biggest Questions

CMS recently released a final rule with the goal of stabilizing Exchange markets for 2018. The agency also issued several significant guidance documents where CMS extended the deadlines for 2018 rate and Exchange qualified...more

Final Policies on Encounter Data and the Star Ratings Released

The Centers for Medicare and Medicaid Services recently finalized meaningful Medicare Advantage policy changes in response to industry concerns, including those regarding data integrity, the Star Ratings and encounter data....more

Trump Administration Takes First Steps to Support Exchanges, but Key Questions Remain

In an effort to stabilize the Exchanges and encourage issuer participation, the Centers for Medicare & Medicaid Services (CMS) recently extended the federal Exchange application and rate filing deadlines and published a...more

Medicare Advantage Draft Call Letter Addresses Encounter Data, Star Ratings

On February 1, 2017, the Centers for Medicare & Medicaid Services (CMS) released proposed updates to the Medicare Advantage (MA) and Part D programs through the CY 2018 Advance Notice and Draft Call Letter. Despite largely...more

21st Century Cures: A Closer Look

On December 7, 2016, the US Congress enacted the 21st Century Cures Act, substantial legislation intended to accelerate “discovery, development and delivery” of medical therapies by encouraging biomedical research investment,...more

21st Century Cures: Congress Enacts Medicare Advantage and Small Business Insurance Market Reforms

The 21st Century Cures Act encourages biomedical research investment and facilitates innovation review and approval processes, but also serves as a vehicle for a wide variety of other health-related measures, including...more

CMS Releases Plan for Expanded Monitoring of Medicare Advantage and Part D Appeals and Grievances

In Depth - The Centers for Medicare & Medicaid Services (CMS) recently announced that it will monitor—beginning in January 2017—Part C and D appeals timeliness on an industry-wide basis. Under this initiative, all...more

Managing the Transition to Transformation: Alternative Payment Systems: Evolving Compliance Challenges

McDermott’s Managing the Transition to Transformation series is designed to help health systems and other health care industry leaders address the many challenges presented by the transformation in payment and care delivery...more

How Congress, President-Elect Trump Might Proceed on Promise to Repeal, Replace ACA

President-elect Donald Trump has vowed to repeal and replace the Affordable Care Act (ACA). This campaign promise, which echoes a familiar refrain from Republicans since ACA’s passage, is more complex than it may seem....more

Federal Court Strikes Down ACA Cost Sharing Reduction Payments

In Depth - A federal district court judge in Washington, DC ruled on May 12, 2016, that Congress did not appropriate funds for the Affordable Care Act’s (ACA) cost-sharing reduction (CSR) subsidies. See United States...more

CMS’s Final Medicaid Rule Creates a Medicaid MLR Framework but Leaves Room for State Variation

In Depth - The final Medicaid managed care rule issued by the Centers for Medicare & Medicaid Services (CMS) on April 25, 2016, (the Final Rule) establishes a new federal medical loss ratio (MLR) standard for Medicaid...more

MA Changes Shift Funding and Add Uncertainty to Already Complex Payment Methodologies

In Depth - The Centers for Medicare & Medicaid Services has enacted significant changes to Medicare Advantage (MA) payment methodologies that will shift payment towards MA organizations (MAOs) enrolling significant...more

Preview of Medicare Advantage and Part D Advance Notice and Call Letter: CMS Likely to Address Risk Adjustment, Provider Network,...

The federal government will soon kick off the all-important annual sub-regulatory cycle for the Medicare Advantage (MA) and Part D programs, issuing proposed policy changes and payment rates for calendar year (CY) 2017. The...more

King v. Burwell Decision Upholds Subsidies in Federal Exchanges

On June 25, 2015, the Supreme Court of the United States ruled in King v. Burwell that the Affordable Care Act (ACA) requires premium tax credits to be made available in states that use a federal exchange. The case challenged...more

King v. Burwell: When Would a Supreme Court Ruling Restricting Affordable Care Act Premium Subsidies Go into Effect?

The Supreme Court of the United States is poised to decide a critical question under the Affordable Care Act: whether the federal government can subsidize health insurance premiums for residents of states that did not...more

U.S. Appeals Courts Issue Conflicting Decisions on Whether ACA Permits Tax Subsidies of Health Care Coverage Purchased Through...

On July 22, 2014, three-judge panels of the U.S. Courts of Appeals for the District of Columbia and Fourth Circuits issued conflicting decisions regarding whether the Affordable Care Act (ACA) permits federal tax credits for...more

2015 Notice of Benefit and Payment Parameters

The Centers for Medicare & Medicaid Services (CMS or the agency) kicked off a flurry of springtime regulatory activity for health insurance issuers with publication of the final Notice of Benefit and Payment Parameters for...more

CMS Indicates Select Controversial Part D Proposals Will Not Be Finalized

Acknowledging concerns regarding some proposals in the January 2014 proposed rule for the Medicare Advantage and Part D Programs, the Centers for Medicare & Medicaid Services states it does “not plan to finalize” certain...more

3/17/2014  /  CMS , Healthcare , Medicare , Medicare Part D

CMS Proposes to Restrict Diagnoses from Home Visits for Medicare Advantage Risk Adjustment

The Centers for Medicare and Medicaid Services has proposed to limit how Medicare Advantage Organizations can use in-home wellness or risk assessment visits of their enrollees to affect the risk adjusted payments they...more

CMS Proposed Rule Would Modify Risk Adjustment Data Collection, Data Validation Audits with Some Material Effects

The Centers for Medicare & Medicaid Services’ proposal for risk adjustment data collection demonstrates the agency’s continued concern that Medicare Advantage Organizations’ activities are resulting in more “intense” coding,...more

1/29/2014  /  Audits , CMS , Data Collection , Healthcare

CMS Proposes Significant Changes to Medicare Part D Program’s Administration

The Centers for Medicare & Medicaid Services proposes significant changes to several key Medicare Part D Program components, such as the “any willing pharmacy” contracting requirement, that will affect all industry...more

Proposed Overpayment Reporting Requirements for MA and Part D Programs May Increase False Claims Act Liability

The Centers for Medicare & Medicaid Services continues to take an expansive view of the overpayment refund requirement, which in turn can give rise to False Claims Act liability for Medicare Advantage Organizations and Part D...more

CMS Proposed Rule Reflects Increased Sophistication in Administration of MA/Part D Programs

Addressing issues ranging from participation in Part D Plan pharmacy networks to compliance training for so-called first-tier, downstream and related entities, the Proposed Rule covers numerous topics with varying degrees of...more

1/22/2014  /  CMS , Healthcare , Medicare , Medicare Part D

HHS Clarifies that ACA Qualified Health Plans are Not Subject to Federal Anti-Kickback Statute; Expresses Concern about Providers...

The U.S. Department of Health and Human Services recently announced that Qualified Health Plans (sold on and off the Exchanges) are not “Federal health care programs” for purposes of the federal anti-kickback statute. The...more

CMS Releases 2014 Advance Notice and Proposed MA and Part D Program MLR Regulations

On February 15, 2013, the Centers for Medicare & Medicaid Services released for comment two key documents affecting the Medicare Advantage (MA) and Part D Programs: (1) the Advance Notice of Methodological Changes for...more

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