News & Analysis as of

Health Maintenance Organizations

NAIC Working Group Exposes Proposed Revisions to Life and Health Guaranty Association Model Act

by Locke Lord LLP on

On October 27, the NAIC Model Law (E) Working Group released an exposure draft of its proposed revisions to the Life and Health Guaranty Association Model Act (#520), intended to address the financial challenges of Long Term...more

Are You Ready for AB 72?

by Buchalter on

To protect patients from receiving an unexpected surprise bill when they seek care at in-network facilities from out-of-network providers, Governor Brown signed AB 72: California’s surprise out-of-network law. The new law...more

California HMO Timely Access Report Available

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

MoFo New York Tax Insights - Volume 8, Issue 1

by Morrison & Foerster LLP on

The Top 10 New York Tax Highlights of 2016 - It’s the New Year, and before we begin afresh, we look back at this past year with our list of the Top 10 New York tax highlights of 2016. 1. The New York State Tax...more

Medicare Coverage While Traveling Within the U.S.

When people retire they often have more time to travel. Although Medicare coverage is generally not available when beneficiaries are overseas, what about coverage for those exploring our own varied and scenic land?...more

New Study Finds Medicare Advantage Plans Pay Lower Prices Than Traditional Medicare

A new study by Stanford University researchers finds that Medicare Advantage plans pay lower prices than traditional fee-for-service (FFS) Medicare for most types of hospital admissions. According to the study—published...more

Anti-Discrimination, Language Access Rules Compliance Deadline Fast Approaching for Health Insurers

Health insurers and HMOs have a limited time to review the new federal meaningful access rules and amend plan documents accordingly. However, many payors still have not revised their plans to include the required language,...more

No More Surprises: Florida Ends Certain Medical Balance Billing

by Carlton Fields on

"Surprise medical billing" occurs when a patient receives care at a facility and receives treatment from a provider, such as an anesthesiologist or radiologist, who is not contracted with the patient’s health insurance plan....more

MoFo New York Tax Insights - Volume 7, Issue 7

by Morrison & Foerster LLP on

ALJ holds NYS Real Estate Transfer Tax Cannot Be Imposed on Sale of 45% Membership Interest in LLC - In an issue of first impression under the New York State real estate transfer tax, a New York State Administrative Law...more

Broad Examination of Narrow Networks: First-of-Its-Kind Study Examines Hospitals in Medicare Advantage Plans

by Faegre Baker Daniels on

On June 20, 2016, The Kaiser Family Foundation issued the first ever broad-based study of Medicare Advantage hospital networks. The study — "Medicare Advantage Hospital Networks: How Much Do They Vary?"— analyzed 409 plans in...more

No Surprises in the Final Rules Issued Under ACA

Final rules have been issued regarding grandfathered plans, pre-existing conditions, rescissions, dollar limits, claims and appeals procedures, and patient protections. These rules, effective on the first day of the plan year...more

Insurers May Not Terminate Physicians for Recommending Out-of-Network Providers

by Jackson Walker on

Under a new Texas law, effective September 1, 2015, health maintenance organizations (HMOs) and Preferred Provider Benefit Plans (PPO) (collectively referred to as "Insurers") can no longer terminate a physician from their...more

CMS to Test Value-Based Insurance Design in Medicare Advantage

by McDermott Will & Emery on

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 Advantage Value-Based Insurance Design Model

by Foley & Lardner LLP on

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

Send Lawyers, Guns and Money:* Providers Lining Up Against Anthem/Cigna and Aetna/Humana Mergers

by BakerHostetler on

In the wake of Anthem’s proposed acquisition of Cigna and Aetna’s proposed acquisition of Humana, providers are lining up to be heard. Take the American Medical Association (AMA), for example, which is urging federal and...more

HMOs May Not Terminate Physicians for Recommending Out-of-Network Providers

by Jackson Walker on

Under a new Texas law, effective September 1, 2015, health maintenance organizations (HMOs) can no longer terminate a physician from their networks solely because the physician informs his or her patients about the full range...more

Antitrust Issues Facing Physicians in Medicaid and Professional Licensing

by Burr & Forman on

Physicians who were practicing in the 1990s were involved in numerous attempts to organize themselves in order to be able to participate in and even financially survive the onslaught of managed care delivery systems. The new...more

FTC Comment: Minnesota Law Requiring Public Disclosure of Health Care Contract Data Increases Risk of Anticompetitive Behavior

by McDermott Will & Emery on

On June 29, 2015, the Federal Trade Commission (FTC) responded to a request for comment from two Minnesota state legislators concerning recently enacted amendments to the Minnesota Government Data Practices Act (MGDPA). Under...more

IREG Update

by Dentons on

Commercial Accountable Care Organizations - Models of health care delivery are evolving on many fronts, driven by the overriding goals of lowering the cost of health care and increasing its quality. Traditional private...more

PPOs and Other Non-HMO Products Now Require Approval and Periodic Reviews of Network Adequacy in New York

by Epstein Becker & Green on

The New York Legislature recently enacted legislation that will require all health insurance plans that issue policies that provide for the use of a provider network to obtain network adequacy certification. The new...more

View From McDermott: A New Type of ERISA-Based Hold-Up—The Rise of Out-of-Network Provider Suits Against Self-Funded Health Care...

by McDermott Will & Emery on

Over the past decade, there has been a significant increase in the number of physicians who have dropped out of Preferred Provider Organization (‘‘PPO’’) and Health Maintenance Organization (‘‘HMO’’) networks and attempted to...more

DC Circuit Dismisses Appeal By Three Hospitals Challenging Subcontractor Status

On November 14, 2014, the United States Court of Appeals for the District of Columbia dismissed as moot an appeal by three hospitals affiliated with the University of Pittsburgh Medical Center. The hospitals had challenged...more

Recent Developments in PA and NJ Regarding Scope of Privilege for Health Care Facilities Engaged in Peer Reviews and Self-Critical...

by Pepper Hamilton LLP on

Three recent cases offer guidance to health care entities in Pennsylvania and New Jersey regarding the discovery of documents created in connection with peer reviews, quality of care reviews and adverse event investigations...more

New York’s “Emergency Medical Services and Surprise Bills” Law

by Epstein Becker & Green on

Earlier this year, the New York Legislature enacted, and Governor Cuomo signed, legislation that will impact billing and reimbursement for some out-of-network health care services, require new disclosures from providers...more

MoFo New York Tax Insights - Volume 5, Issue 9 - September 2014

by Morrison & Foerster LLP on

In This Issue: - ALJ Upholds Denial of Sales Tax Refund Because Vendor Failed to First Make Refunds to Customers - HMO Held Exempt from New York City General Corporation Tax - State Tax Department Issues...more

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