Social Security Act

News & Analysis as of

GAO Calls for Tighter Reins on Section 1115 Demonstrations

A recent GAO report examined expenditure authorities in “section 1115” demonstrations approved by HHS between June 2012 and October 2013. Section 1115 of the Social Security Act gives HHS broad authority to approve...more

Reasonable Suspicion of a Crime in a Long-Term Care Facility and OIG Findings

On June 17, 2011, CMS published a memorandum detailing the reporting requirements when there is a reasonable suspicion of a crime in a long-term care facility as required by section 1150B of the Social Security Act....more

Legislation to Curb Medicare and Medicaid Fraud Would Increase Cost and Compliance Burdens on Health Care Providers

On March 25, 2015, a bipartisan group of U.S. Senators reintroduced the Preventing and Reducing Improper Medicare and Medicaid Expenditures Act (“PRIME Act” or “Act”) following the lead of the U.S. House of Representatives,...more

CMS Delays 60-Day Rule, But Overpayment Case Law Emerging

The Centers for Medicare & Medicaid Services (CMS) recently announced a one-year delay in finalizing the long-awaited and closely watched rule addressing the 60-day deadline to return Medicare and Medicaid overpayments (the...more

CMS Needs More Time to Finalize ACA Rule on Return of Medicare Overpayments

CMS warns requirement to report/return overpayments is in effect even without regulations - The Centers for Medicare & Medicaid Services (CMS) needs more time to finalize its February 16, 2012 proposed rule on reporting...more

Who is “Disabled” under ABLE?

The recently-enacted federal ABLE statute provides a long-awaited vehicle for tax-exempt investing to meet future disability-related expenses of disabled individuals. Although new Section 529A of the Internal Revenue Code is...more

CMS Defines “Uninsured” for Medicaid DSH Payments But Leaves Impact on Hospital-Specific Payments Undefined

CMS’ Final Rule, “Medicaid; Disproportionate Share Hospital Payments – Uninsured Definition”, published on December 3, 2014, may offer relief to some hospitals receiving Medicaid disproportionate share hospital (DSH) payments...more

The 2015 Retirement Plan Limits are in

The Internal Revenue Service (IRS) announced cost of living adjustments affecting dollar limitations for pension plans and other retirement-related items for tax year 2015. The elective deferral (contribution) limit...more

Proposed Regulation Would Significantly Expand OIG’s Exclusion Authority

On May 9, 2014, the Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services published a proposed rule that significantly expands the OIG’s exclusion authority. 79 Fed. Reg. 26810. The...more

CMS Proposes Rule to Expand Authorization Program, Solicits Comments on Implementation

On May 28, the Department of Health and Human Services (HHS), Centers for Medicare & Medicaid Services (CMS) published a proposed rule to establish a prior authorization process for certain durable medical equipment,...more

CMS Changes to Medicare Advantage and Prescription Drug Benefit Programs for Contract Year 2015

On May 19, 2014, the Centers for Medicare & Medicaid Services (“CMS”) issued a final rule, published in the Federal Register on May 23, 2014, that sets forth changes to requirements for Medicare Advantage (“MA”) and...more

CMS Self-referral Disclosure Protocol: 2013 Update and Summary of Settlements

The CMS Self-referral Disclosure Protocol – Background - Under delegated authority, the Centers for Medicare and Medicaid Services (CMS) released its Self-Referral Disclosure Protocol (SRDP) on September 23, 2010, with...more

Healthcare Provider Fees May Constitute Kickbacks Even Without Direct Referrals

In a recent advisory opinion, the Department of Health and Human Services inspector general warned health care providers about entering into contracts that may generate illegal kickbacks and result in administrative...more

HHS Guidance Clouds Earlier Statement, Discourages Providers From Purchasing Insurance For Patients

There has been much speculation in the health care community that it may be financially beneficial, under certain circumstances, for hospitals and other large providers to purchase health care coverage for their indigent...more

HHS Says Qualified Health Plans Are Not ‘Federal Health Care Programs’

The Department of Health and Human Services (HHS) recently announced that qualified health plans (QHPs) established by the Affordable Care Act (ACA)—which include federally-facilitated insurance exchanges and federal...more

ICE Guidance on the Use of Information Provided by Individuals Applying for Healthcare Under ACA

The Patient Protection and Affordable Care Act (ACA), and the Social Security Act (SSA) require that individuals seeking coverage under a qualified health plan offered on a Health Insurance Marketplace or through an insurance...more

CMS Releases Proposed Calendar Year 2014 Updates to Home Health Prospective Payment System

On June 27, 2013, the Centers for Medicare & Medicaid Services (CMS) released its proposed Calendar Year 2014 rate update to the Home Health Prospective Payment System. In addition to reducing reimbursement rates, CMS is...more

Benefit Issues in Puerto Rico: Impact of the ACA, ERISA and the PBGC

This article highlights some recent developments that employers with Puerto Rico employee benefits arrangements should consider concerning compliance with U.S. federal laws on health care reform and the Patient Protection and...more

Rural Hospital Cardiac Catheterization Lab Cost Savings Program issued favorable OIG Advisory Opinion

On December 31, 2012 the U.S. Department of Health and Human Services Office of Inspector General ("OIG") issued a favorable Advisory Opinion No.12-22 for a hospital cardiology group compensation arrangement that includes a...more

Extension of Time for Overpayment Recoveries in Fiscal Cliff Law Not as Broad as it Sounds

The recently passed fiscal cliff legislation, i.e., the American Taxpayer Relief Act of 2012 (Act) [PDF], includes a number of provisions addressing Medicare and Medicaid. One of these provisions extends the recovery period...more

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