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New Coverage, Delivery, and Payment for Health-Related Social Needs Services Under New York’s Approved 1115 Medicaid Waiver...

On January 9, 2024, the Centers for Medicare & Medicaid Services (CMS) approved New York’s recent 1115 demonstration waiver. Among other things, this most recent demonstration waiver provides significant federal funding...more

An Overview of the CMS Approved New York 1115 Medicaid Waiver

On January 9, 2024, the Center for Medicare and Medicaid Services (CMS) sent a letter to New York’s Medicaid director approving New York’s Section 1115 Waiver amendment, which the state submitted for approval on September 2,...more

Hospital and MA Plan Considerations for CMS Final Rule to Remedy 340B Drug Payment Policy

In November 2023, the Centers for Medicare & Medicaid Services (CMS) published a final rule, “Medicare Program; Hospital Outpatient Prospective Payment System: Remedy for the 340B-Acquired Drug Payment Policy for Calendar...more

Podcast: Health Equity – Behind the Buzzwords – Diagnosing Health Care [Video]

Under the Biden administration, the Centers for Medicare & Medicaid Services published a health equity framework that drastically changed the playing field for health plans and other risk-bearing entities. In the wake of...more

2023 Physician Fee Schedule Final Rule Supports Health Equity Through Investments in Accountable Care Organizations

The Centers for Medicare & Medicaid Services (CMS) recently issued its Medicare Physician Fee Schedule (PFS) final rule (the “final rule”), with most changes becoming effective January 1, 2023....more

ACO REACH Model: Legal Requirements for ACO Agreements with Providers

The Program The ACO REACH (short for “Accountable Care Organization Realizing Equity, Access, and Community Health”) Model is the new Medicare value-based payment demonstration model for providers launched this year by the...more

Health Care Providers with Claims Arising Out of New York’s Failed Health Republic Insurance Co. to Be Paid in Full

In December 2015, we wrote about the many failed health insurance co-ops created under the Affordable Care Act (“ACA”), and the impact of those failures on providers and other creditors, consumers, and taxpayers. At that...more

New York State Department of Financial Services Summarizes Changes Relating to Administrative Denials, Prior Authorizations, and...

On March 10, 2021, the New York State Department of Financial Services (“DFS”) issued Insurance Circular Letter No. 4 (“Circular Letter”), which both explains modifications to the Insurance Law and the Public Health Law...more

New Health Care Transparency Requirements: Will They Lower Cost and Improve Quality?

On November 12, 2020, the Trump administration published its final rule on price transparency (the “Final Rule”) requiring affected entities to publicly release personalized information on out-of-pocket costs as well as...more

CARES Act Temporarily Suspends Sequestration: How Will It Affect Provider Reimbursement?

One of the many relief efforts contained in the Coronavirus Aid, Relief, and Economic Security Act (the “CARES Act”), signed into law on March 27th, 2020, is a hiatus of sequestration as it applies to Medicare payments....more

Post-Acute Care and “COVID-19 Centers of Excellence”

As infections of COVID-19 continue to increase throughout the nation, health care policymakers have focused primarily on increasing acute-care hospital bed capacity, promoting (and decreasing the regulatory requirements...more

Value-Based Payment Arrangements During the COVID-19 Pandemic

The ongoing pandemic caused by the novel coronavirus has upended the American health care system in many ways. One of the many effects of COVID-19 will likely be substantial disruption in value-based payment arrangements...more

Families First Coronavirus Response Act: Guidance for Health Care Providers and Plans Regarding COVID-19

As communities throughout the nation and world continue to grapple with the 2019 novel coronavirus (“COVID-19”) pandemic, health care providers and plans are struggling not only to maintain standard operations but also to...more

Despite Issuance of Final Rule on Price Transparency, Are Health Care Rates Too Complicated to Be “Consumer Friendly”?

The Centers for Medicare & Medicaid Services (“CMS”) recently issued a final rule requiring hospitals to publicly disclose their rates, including negotiated rates with third-party payors regardless of product line, by January...more

CMS’s Direct Contracting Model: What’s New from Next Gen?

The Centers for Medicare & Medicaid Services (“CMS”) recently introduced three new population-based payment (“PBP”) risk-sharing Direct Contracting (“DC”) model options that intend to decrease expenditures and increase...more

New Jersey’s Surprise Medical Bill Law: Part 2: Comparison to New York’s and California’s “Surprise Bill” Laws

New Jersey’s Out-of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act (“NJ Law”) creates a statutory framework that attempts to protect consumers from medical bills for out-of-network services...more

New Jersey’s Surprise Medical Bill Law: Part 1: Regulatory Issuances by New Jersey Agencies

Earlier this year, New Jersey Governor Phil Murphy signed into law the Out-of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act (“Law”), creating a statutory framework attempting to protect...more

Association Health Plans: Federal Rule Broadens Opportunities, but Some States Clamp Down

On June 19, 2018, the Trump administration finalized a rule that will enable small businesses and self-employed individuals to band together to offer access to large group health plans, which are typically less expensive (but...more

New Jersey’s Surprise Medical Bill Law: Implications and National Trends

After nearly decade of deliberation, on June 1, 2018, New Jersey Governor Phil Murphy signed into law the Out-of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act (“Law”),creating regulations...more

Association Health Plans: New Proposed Rule to Help Convert Small Businesses and Self-Employed Individuals into a Status Similar...

The Trump Administration has published a proposed rule allowing a significant change to the definition of "employer" under ERISA that would enable small businesses and self-employed individuals to band together to create...more

New Audits and Penalties on Medicaid Plans and Providers Related to Encounter Data in Value-Based Payment Models

For value-based payments, encounter data[1] provides valuable information in much the same way that claims data does for fee-for-service arrangements. With the growing prevalence of value-based payments, especially in the...more

Assessing President Trump’s “Executive Order Promoting Health Care Choice and Competition”

On October 12, 2017, President Donald Trump signed an executive order (the “Order”) designed to “promote healthcare choice and competition across the United States,” which in effect will allow many Americans to sidestep...more

California’s Surprise Medical Bill Statute: Part 2: Comparison to New York’s Emergency Medical Services and Surprise Bills Law

Executive Summary - On September 23, 2016, the California Legislature passed, and Governor Jerry Brown signed, Assembly Bill 72 (“the Law”), creating a new regime for the regulation of “surprise bills.”...more

California’s Surprise Medical Bill Statute: Part 1: Implications and National Trends

I. Executive Summary - On September 23, 2016, the California Legislature passed, and Governor Jerry Brown signed, Assembly Bill 72 (“the Law”), creating a new regime for the regulation of “surprise bills.” Surprise bills...more

HHS Sets New Requirements to Limit Surprise Medical Bills from Out-of-Network Providers

The U.S. Department of Health and Human Services (“HHS”) recently released a final rule titled “Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2017” (“Final Rule”)[1] that sets...more

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