News & Analysis as of

Healthcare Beneficiaries

Bass, Berry & Sims PLC

CMS Finalizes CY 2025 Medicare Advantage Rule, Confirming Continued Focus on Marketing Practices and Health Equity

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On April 4, the Centers for Medicare & Medicaid Services (CMS) issued the Contract Year (CY) 2025 Medicare Advantage (MA) Final Rule (Final Rule), which will have significant implications for MA plans and other industry...more

Sheppard Mullin Richter & Hampton LLP

District Court Elucidates the Meaning of “to Induce” Under the Federal Health Care Program Anti-Kickback Statute

The United States District Court for the Eastern District of Virginia recently dismissed an appeal by the Pharmaceutical Coalition for Patient Access (“PCPA”) that challenged a negative opinion issued by the U.S. Department...more

Mintz - Health Care Viewpoints

CMS Announces New Model for the Delivery of Integrated Behavioral and Physical Health Care

With the goal of enhancing health care quality and outcomes for individuals with moderate to severe behavioral health conditions and substance use disorders (SUD), the Centers for Medicare & Medicaid Services (CMS) recently...more

Foley Hoag LLP - Medicaid and the Law

CMS Issues Rule Implementing Medicaid Redetermination Policies

We’ve written recently about the process that states are undertaking to begin to wind down the Medicaid enrollment expansion that was necessitated by the enactment of the Families First Coronavirus Response Act in March of...more

Foley & Lardner LLP

Medicare Advantage Agent and Broker Compensation: Commissions, Administrative Payments, and Referral Fees under 42 C.F.R. §...

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A common question in the context of Medicare Advantage (“MA”) distribution and compensation is how agents and brokers may be compensated for commissions and administrative payments and whether, and to what extent, referral...more

Harris Beach PLLC

Veterans Day: Benefits For Those Planning Their Estates

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With Veterans Day upon us, it is a perfect time to not only thank those who served our country, but remind them of the special benefits available to them as they plan their estates. The U.S. Department of Veterans...more

Chambliss, Bahner & Stophel, P.C.

Seniors Often Must Fight for Medicare Home Health Benefits

Medicare is mandated to cover your home health benefits with no limit on the time you are covered. Unfortunately, few Medicare beneficiaries get the level of service they are entitled to, and many find their services cut off...more

King & Spalding

OIG Issues Advisory Opinion Regarding Pharmaceutical Manufacturers’ Program to Provide Free Limited Drugs to Beneficiaries When...

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On August 12, 2015, the Department of Health and Human Services Office of Inspector General (OIG) posted Advisory Opinion No. 15-11, finding that a program to supply a limited amount of free cancer drugs to federal health...more

King & Spalding

OIG Recommends Improvements to Skilled Nursing Facility Billing Policies Regarding Changes in Therapy

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The Department of Health and Human Services Office of Inspector General (OIG) recently issued a report that calls for CMS to accelerate its efforts to implement a new method for paying for changes in skilled nursing facility...more

McDermott Will & Emery

CMS Proposes Value-Based Purchasing Model, Other Updates to the 2016 Home Health Prospective Payment System

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The U.S. Department of Health and Human Services (HHS) Centers for Medicare & Medicaid Services (CMS) published its proposed update to the home health prospective payment system (HHPPS) for calendar year (CY) 2016 in the July...more

Arnall Golden Gregory LLP

CMS Proposes to Establish Separate Payment for End of Life Planning Services

On July 8, 2015, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule that updates payment rates and related reimbursement and quality policies for physician services furnished under the Medicare...more

Mintz - Health Care Viewpoints

Delivery System Reform 2.0: Scaling Alternative Payment Models is the New Normal

For some health care providers, a pair of recent announcements made by the Obama Administration to implement mandatory alternative payment models (APMs) for home health value-based purchasing and bundled payments for hip and...more

Arnall Golden Gregory LLP

GAO Recommends Congress Reduce Incentives for Prescribing 340B Drugs

The United States Government Accountability Office (GAO) recently released a report entitled “Medicare Part B Drugs: Action Needed to Reduce Financial Incentives to Prescribe 340B Drugs at Participating Hospitals” (“the...more

Foley & Lardner LLP

Beneficiary Assignment Under the MSSP Final Rule

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This is the fourth post in Health Care Law Today’s series on the final rule. This post addresses how CMS assigns beneficiaries to an ACO participating in the MSSP. In the MSSP ACO Final Rule, CMS finalized new...more

Foley & Lardner LLP

Beneficiary Assignment in the Proposed Revised Medicare Shared Savings Program Regulations

Foley & Lardner LLP on

This post addresses the changes that the rule would make to how CMS assigns beneficiaries to an ACO participating in the MSSP. The Proposed Rule places a renewed emphasis on primary care for beneficiary assignment. Section...more

Littler

Ninth Circuit Rules Assignee Health Care Providers May Sue Health Plans Under ERISA for Payment of Benefits

Littler on

In an opinion with mixed implications for both insurers and health care providers, the U.S. Court of Appeals for the Ninth Circuit recently ruled that when plan beneficiaries assign their claims for payment of benefits to...more

Laner Muchin, Ltd.

Self-Insured Health Plans May Be Required To Allow Health Care Providers Access To Their Claims And Appeals Process

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In a precedent-setting case, a district court in the Northern District of Illinois recently ruled that in-network chiropractors were considered “beneficiaries” under the Employee Retirement Income Security Act of 1974 (ERISA)...more

King & Spalding

OIG Reports Limited Compliance with Face-to-Face Certification Requirement for Home Health

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The OIG recently released a report summarizing the details of its study regarding compliance with the requirement that physicians (or certain practitioners working with them) who certify beneficiaries as eligible for Medicare...more

BakerHostetler

Marketing to Medicaid Beneficiaries: Texas Proposed Rule Highlights Pitfalls for Providers

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Earlier this month, the Texas Health and Human Services Commission (Commission) released a proposed rule, 1 TAC § 354.1452 that prohibits certain marketing activity by Medicaid and CHIP providers. The proposed rule has been...more

Mintz - Health Care Viewpoints

Government Imposes Moratorium on Medicare Hearings and Appeals

The Federal Office of Medicare Hearings and Appeals (OMHA) was established in July 2005 to administer the Medicare appeals program. OMHA adjudicates appeals regarding Medicare entitlement and Medicare provider reimbursement....more

King & Spalding

Federal District Court Rules that Provider Can Challenge Recoupment Activity Under ERISA

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The United States District Court for the Northern District of Illinois recently granted summary judgment in favor of a chiropractor who alleged that Anthem VA, a Virginia-based subsidiary of WellPoint, Inc., violated the...more

King & Spalding

CMS Issues Guidance On Medicare Coverage of Items and Services Furnished to Beneficiaries in Custody Under a Penal Authority

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In October 2013, CMS issued a Fact Sheet outlining its policy regarding beneficiaries who are incarcerated or in custody. Pursuant to 42 C.F.R. §§ 411.4, 411.6 and 411.8, where a beneficiary is in custody on the date items or...more

BakerHostetler

The Limits of Discretion: Trust Distributions for Health, Education, Maintenance and Support

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Trustees are often granted the power to distribute trust property “in the Trustee’s discretion” for a beneficiary’s “general well-being,” “best interests,” “comfort,” or, most commonly, “health, education, maintenance and...more

King & Spalding

Ninth Circuit Vacates Injunctions Barring HHS From Seeking Prepayment of Medicare Secondary Payer Reimbursements

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The United States Court of Appeals for the Ninth Circuit recently vacated injunctions entered by a district court that banned HHS from seeking “up front” reimbursements for Medicare secondary payments from beneficiaries who...more

Sheppard Mullin Richter & Hampton LLP

A Review of CMS' Approach to $125 Million Recoupment of Payments to Providers for Services to Incarcerated / Unlawfully Present...

CMS seeks to recover from providers $125 million in alleged overpayments for services to beneficiaries who are belatedly identified as ineligible (incarcerated/unlawfully present). In this post, Sheppard Mullin examines the...more

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