Medicare Advantage

News & Analysis as of

GAO Report Calls for Enhanced Medicare Advantage Network Oversight

On September 28, 2015, the Government Accountability Office (GAO) released a report regarding CMS controls of provider adequacy in Medicare Advantage Organization (MAO) networks. The GAO pursued its review because many MAOs...more

CMS Proposes Major Changes to Medicare Clinical Lab Test Payment Policy

On October 1, 2015, the Centers for Medicare & Medicaid Services (CMS) published its long-awaited proposed rule to base Medicare clinical laboratory fee schedule (CLFS) reimbursement on private insurance payment amounts...more

Phishing for Cybersecurity Coverage: When is a Fraud a “Computer Fraud”?

In late June, the New York Court of Appeals affirmed a trial court ruling that there was no coverage for a health insurance company policyholder, under a “Computer Systems Fraud” rider issued by its insurer, for an underlying...more

Uncovering the mysteries behind GME payments for Medicare Advantage patients: Carve-outs and shadow bills

Medicare makes graduate medical education (GME) payments to teaching hospitals to pay Medicare's share of the teaching and patient care costs associated with Medicare Advantage (MA) patients. Under the Balanced Budget Act...more

CMS Proposes Lab Data Collection Requirements to Update Fee Schedule

On September 25, 2015, CMS released proposed rulemaking that would extensively revise payment and reporting requirements for clinical diagnostic laboratory tests (CDLTs), as paid on the Clinical Laboratory Fee Schedule...more

MedPAC Meeting on Medicare Policies (Oct. 8-9)

The next Medicare Payment Advisory Commission (MedPAC) meeting is scheduled for October 8 -9, 2015. Topics on the agenda include: Medicare drug spending; Alternative Payment Models and the Merit-based Incentive Payment...more

CMS Proposes Overhaul of Clinical Lab Payment Methodology: What You Need To Know

On Friday, the Centers for Medicare & Medicaid Services (“CMS”) issued a long-awaited proposed rule that would drastically change the payment rates for clinical laboratory services beginning January 1, 2017 (the “Proposed...more

Washington Healthcare Update

This Week: Senate Judiciary Committee Hearing Focuses on Health Insurers Merger... Arkansas to Delay Setting Up Its Own State Exchange...The Centers for Medicare and Medicaid Services (CMS) Announces Medicare Advantage...more

Health Update - September 2015

Latest Healthcare False Claims Act Roundup and Top 3 Best Practices to Reduce Exposure - As the legal landscape in healthcare becomes increasingly complex, healthcare companies that receive federal program funds face...more

MedPAC Convenes to Discuss Open Payments, Payment for Post-Acute Care, and Other Issues

On September 10-11, 2015, MedPAC held a meeting to discuss several issues related to the Medicare program, including (1) improving the Open Payments program, which makes public the payments from drug and device manufacturers...more

CMS to Test Value-Based Insurance Design in Medicare Advantage

While CMS’s demonstration model will allow for reduced cost sharing and other benefit design elements to encourage targeted use of high-value clinical services, Medicare Advantage Organizations should be aware of certain...more

Medicare to Permit Value-Based Insurance Design in Medicare Advantage Plans

The Centers for Medicare & Medicaid Services (“CMS”) recently announced that, beginning January 1, 2017, Medicare Advantage plans in Arizona, Indiana, Iowa, Massachusetts, Oregon, Pennsylvania and Tennessee will be permitted...more

New Value-Based Insurance Design Model for Medicare Advantage Plans Is the First of Multiple Medicare Plan Innovations Anticipated...

On September 1, 2015, the Centers for Medicare & Medicaid Services (“CMS”) announced[1] the opportunity for plan sponsors to test value-based insurance design (“VBID”) in the Medicare Advantage (“MA”) market. VBID refers to...more

Medicare Telehealth Services in Puerto Rico

As U.S. health care providers continue to use telehealth, telemedicine, and virtual care services to expand their services and geographic footprint overseas, they are beginning to ask whether or not Medicare will cover...more

CMS Announces New Value-Based Insurance Design Model for Medicare Advantage

On September 1, 2015, CMS unveiled a new Medicare Advantage Value-Based Insurance Design (MA-VBID) model, which will allow Medicare Advantage plans to offer clinically-nuanced benefit packages aimed at improving quality of...more

CMS Launches New Medicare Advantage Innovation Model

The latest CMS “innovation model” focuses on options for redesigning Medicare Advantage (MA) to improve health outcomes while reducing expenditures. Specifically, the Medicare Advantage Value-Based Insurance Design (VBID)...more

Know Your Options Before Signing Up for Medicare

As you get ready to turn 65, you may be inundated with information about Medicare. All this information is confusing, but it is important to do your research before choosing your plan. If you aren’t fully informed, you could...more

Medicare Advantage Value-Based Insurance Design Model

CMS, through the Center for Medicare and Medicaid Innovation, announced on September 1, 2015, the introduction of the Medicare Advantage Value-Based Insurance Design (VBID) Model as part of the Health Plan Innovations...more

Health Insurers Announce Merger Plans; Congress Announces Intention to Review

In the last few months, several of the largest commercial health insurers in the nation have announced their intentions to merge. First, Aetna (currently the nation’s third largest health insurer by revenue) announced its...more

MedPAC Issues 2015 Medicare Data Book

The Medicare Payment Advisory Commission (MedPAC) has released its 2015 Data Book on Health Care Spending and the Medicare Program. The publication provides information on national health care and Medicare spending, Medicare...more

Washington Healthcare Update

This Week: CMS Releases Guidance on Fast Track Process for 1115 Waivers for Medicaid and CHIP... CEO Sends Letter to State Insurance Commissioners Concerning 2016 Premium Decisions... Medicare Board of Trustees...more

Regulators Likely To Heavily Scrutinize Proposed Humana-Aetna Merger

At the beginning of the month, insurance companies Aetna Inc. and Humana Inc. announced they would be pursuing a merger, with the former company acquiring the latter. Aetna, sources say, will be purchasing Humana for roughly...more

Agencies Issue Final Regulations on the Summary of Benefits and Coverage (SBC) Requirements

As promised in the FAQ issued on March 30, 2015, the U.S. Departments of the Treasury, Labor and Health and Human Services (the Departments) have issued final regulations regarding the summary of benefits and coverage (SBC)...more

MedPAC Report to Congress on Medicare and the Health Care Delivery System

The Medicare Payment Advisory Commission (MedPAC) has released its June 2015 Report to the Congress on Medicare and the Health Care Delivery System. The report includes a series of recommendations on Medicare hospital...more

House Passes Bills to Repeal ACA Medical Device Tax and IPAB, Revise Medicare Advantage Policy

The House of Representatives has taken action on a number of bills to modify certain Affordable Care Act (ACA) provisions, revise Medicare Advantage policies, and make other health policy changes. On June 23, 2015, the...more

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