California is among a handful of states that seeks to regulate the use of artificial intelligence (“AI”) in connection with utilization review in the managed care space. SB 1120, sponsored by the California Medical...more
5/9/2024
/ Affordable Care Act ,
Algorithms ,
Analytics ,
Artificial Intelligence ,
Bias ,
California ,
Centers for Medicare & Medicaid Services (CMS) ,
Discrimination ,
Health Care Providers ,
Healthcare ,
Insurance Industry ,
Machine Learning ,
Managed Care Contracts ,
Popular ,
Section 1557
On Friday, August 26, 2022, the Department of Health and Human Services’ Centers for Medicare and Medicaid Services (“CMS”), the Department of Labor’s Employee Benefits Security Administration and the Department of Treasury’s...more
On Thursday, April 8, 2021, the Center for Medicare and Medicaid Innovation (the “Innovation Center”) announced its final list of 53 organizations set to participate in the Global and Professional Direct Contracting (“GPDC”)...more
On October 6, 2020, the US Supreme Court (the “Court”) heard arguments on an Employee Retirement Income Security Act (“ERISA”) case that has the potential to curtail the rights of states to regulate their individual...more
On Thursday, April 16, 2020, the California Department of Managed Health Care (the “Department”) released an all plan letter (the “Letter”) regarding changes to the Department’s General Licensure Regulation (the “Regulation”)...more
On Tuesday, April 7, 2020, the California Department of Managed Health Care (the “DMHC”) released a guidance letter (the “Letter”) to all health care service plans regarding billing for and delivering telehealth services...more
This COVID-19 – LEGAL GUIDE FOR MEDICAL GROUPS (“Guide”) provides a general discussion of legal issues confronting medical groups as a result of COVID-19, including employee protections, infection control, and reporting...more
On December 20, 2019, the Centers for Medicare and Medicaid Services (CMS) issued a final rule on program integrity for Affordable Care Act (ACA) exchange plans. This rule implements a number of provisions from the ACA,...more
On June 28, 2018, California’s new privacy bill A.B-375 was signed into law as the California Consumer Privacy Act of 2018 (“CCPA”). On October 10, 2019, the California Attorney General issued proposed regulations for...more
11/22/2019
/ California Consumer Privacy Act (CCPA) ,
Consumer Privacy Rights ,
Data Breach ,
Data Collection ,
Data Privacy ,
Data Protection ,
Health Care Providers ,
Hospitals ,
Information Requests ,
Information Sharing ,
Opt-Outs ,
Personally Identifiable Information ,
Privacy Laws ,
Private Right of Action ,
Proposed Regulation ,
Regulatory Requirements ,
Right to Delete
On Monday, August 8th, the Deputy Director of Legislative Affairs of the Department of Managed Health Care (the “Department”) released a letter of opposition (the “Letter”) to Assembly Bill 1249 (“AB 1249”). The Letter was...more
On March 4, 2019, the Centers for Medicare & Medicaid Services (“CMS”) published a wide-ranging proposed rule (“Proposed Rule”) with the intent to “move the health care ecosystem in the direction of interoperability” in...more
4/22/2019
/ 21st Century Cures Act ,
Centers for Medicare & Medicaid Services (CMS) ,
Children's Health Insurance Program (CHIP) ,
Data-Sharing ,
Department of Health and Human Services (HHS) ,
Electronic Protected Health Information (ePHI) ,
Health Care Providers ,
Health Information Technologies ,
Hospitals ,
Medicare Access and CHIP Reauthorization (MACRA) ,
Policies and Procedures ,
Proposed Rules ,
Regulatory Requirements
After a protracted comment period, the California Department of Managed Health Care (the “Department”) formally adopted its much anticipated “global risk” regulation (the “Regulation”), which will go into effect on July 1,...more
Balanced billing or “surprise billing” has been getting increased attention at both the federal and state level. Balance bills arise when a payor covers out-of-network care, but the provider bills the patient for amounts...more
Dual Special Needs Plans -
This part 6 of our 7 part series focuses on the provisions regarding dual special needs plans (“D-SNPs”) released by the Centers for Medicare and Medicaid Services (“CMS”) in the proposed rule...more
11/15/2018
/ Appeals ,
Centers for Medicare & Medicaid Services (CMS) ,
Dual Eligibility ,
Enrollment ,
Fee-for-Service ,
Filing Grievances ,
Health Care Providers ,
Hospitals ,
Managed Care Contracts ,
MCOs ,
Medicaid ,
Medicare ,
Medicare Advantage ,
Medicare Beneficiaries ,
Pharmaceutical Industry ,
Pharmacies ,
Physicians ,
Prescription Drug Coverage ,
Prescription Drugs ,
Proposed Rules
California recently passed Assembly Bill 315 to create greater regulatory oversight of pharmacy benefit managers (“PBMs”). The bill requires PBMs to provide more transparency regarding their operations. PBMs will have to...more
On September 7, 2018, Governor Jerry Brown signed into law Assembly Bill No. 595, A.B. 595, which amends the California Health and Safety Code to increase oversight by the California Department of Managed Health Care (“DMHC”)...more
Medicare Part C and Part D Star Ratings are used by CMS to measure the quality of and reflect the experiences of beneficiaries in Medicare Advantage (“MA”) and Prescription Drug Plans (“PDPs”). Below is a summary of CMS’...more
On March 21, 2018, a representative from the Hospital and Ambulatory Policy Group at the CMS, held a listening session regarding proposed updates to documentation guidelines for Evaluation and Management (“E/M”) Services. The...more
The most recent MA Call Letter, “Announcement of Calendar Year (CY) 2018 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter and Request for Information” (Call Letter)...more
California became the first state to set limits on how long HMO patients must wait to see a physician when the California Department of Managed Health Care (“DMHC”) adopted certain “timely access” regulations in 2010, based...more
The Office of the National Coordinator for Health Information Technology (ONC) has released a final rule (Final Rule) introducing a new regulatory framework for certified health information technology (Health IT). The use of...more
The Department of Health & Human Services (DHHS) Office of Civil Rights (OCR) recently announced it will devote more resources to investigate smaller HIPAA breaches. Before this announcement, OCR typically opened...more
This past May, the Department of Health and Human Services (HHS) issued a final rule implementing Section 1557 of the Affordable Care Act (ACA), which prohibits discrimination on the basis of race, color, national origin,...more
8/5/2016
/ Affordable Care Act ,
Children's Health Insurance Program (CHIP) ,
Contraceptive Coverage Mandate ,
Covered Entities ,
Department of Health and Human Services (HHS) ,
Federal Funding ,
Final Rules ,
Gender Identity ,
Health Care Providers ,
Health Insurance ,
Healthcare ,
LGBTQ ,
Medicaid ,
Medicare ,
Non-Discrimination Rules ,
Section 1557 ,
Sex Discrimination ,
Sexual Orientation Discrimination ,
Transgender
The Center for Medicare & Medicaid Innovation first introduced its Oncology Care Model (OCM) last year. OCM went into effect July 1, 2016, and will run through June 30, 2021. The new multi-payer model is the first CMS...more
On June 27, CMS issued a proposal for the 2017 Medicare home health prospective payment system (HH PPS).
CMS is proposing a $180 million reduction in 2017. This equates to a 1% drop in reimbursements for home health...more