Category Archives: Affordable Care Act (ACA)

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Part 4: The ACA, Post-Inauguration

In Parts I-III of our blog series, Very Opaque to Slightly Transparent: Shedding Light on the Future of Healthcare, we considered the healthcare landscape before implementation of the Affordable Care Act (ACA), and explored potential market outcomes under partial repeal and potential “repeal and replace” scenarios.  Although we are just a couple weeks into the … Continue Reading

Food for Thought (and Health): Day 2 Notes from the JP Morgan Healthcare Conference

Addressing the Social Determinants of Health:  Is the healthcare industry pushing a rock up a hill?  We collectively are trying to provide healthcare with improved quality and reduced cost, but the structure of the nation’s healthcare system remains heavily siloed with the social determinants of health often falling wholly or partly outside the mandate and … Continue Reading

Medicaid Demonstration Waivers: A Shorter Path to Increasing State Control Over Healthcare Policy?

Seema Verma’s nomination to head the Centers for Medicare and Medicaid Services (CMS) places Section 1115 Medicaid demonstration waivers into increasing spotlight. This article explores some of the current applications of waiver authority and the role it may play in the new administration.… Continue Reading

Part 3: Exploring “Repeal and Replace”

In Part II of our blog series, Very Opaque to Slightly Transparent: Shedding Light on the Future of Healthcare, we considered potential healthcare market consequences of a partial repeal of the Affordable Care Act (ACA).  In this Part III, we explore several potential “repeal and replace” scenarios that could unfold under the Trump Administration.… Continue Reading

Part 2: Implications of a Partial Obamacare Repeal

In Part I of our blog series, Very Opaque to Slightly Transparent: Shedding Light on the Future of Healthcare, we discussed what the healthcare landscape looked like before the Affordable Care Act (ACA), how the law emerged from the healthcare reform policy debates and some of the major industry developments that have occurred since the … Continue Reading

Part I: How We Got Here: President Obama to Obamacare to President-elect Trump

One thing that has become clear since the election of Donald Trump last week is that efforts to repeal or amend the Affordable Care Act (ACA) will be a high priority legislative item for next year’s Congress and the incoming Administration. But to have a better grasp of what the future of health care might … Continue Reading

Very Opaque to Slightly Transparent: Shedding Light on the Future of Healthcare

In a November 14, 2016 Forbes article entitled, “Under Trump, Americans Can Finally Put ObamaCare Behind Us,” Sally Pipes wrote, “ObamaCare in a full-on ‘death spiral,’ voters were clearly in no mood for Clinton’s plan to ‘build on’ the president’s healthcare law. Instead, they chose a president who has said that his first order of … Continue Reading

Vermont to Launch a First-in-the-Nation All-Payer System for All Healthcare Providers

As recently reported by Modern Healthcare and other major healthcare news outlets, the Obama administration has granted tentative approval for Vermont to establish an all-payer reimbursement system. If granted final approval, the Vermont All Payer Accountable Care Organization Model (Model) would be effective for five years from January 1, 2017 to December 31, 2022. The … Continue Reading

HHS Final Rule Extends Anti-Discrimination Protection to Transgender Patients

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, sex, age, or disability in the healthcare system. While Section 1557 has been in effect since 2010, the final rule … Continue Reading

New Affordable Care Act and Medicaid Regulations Will Require Covered Entities Providing Healthcare Programs and Services to Have Accessible Websites

There has been a proliferation of ADA lawsuits alleging that websites are not accessible to the blind or deaf.  Individuals who are blind or have low vision may require assistive devices and specialized software to access the Internet.  These devices often include software that enables them to magnify the content of a web page, reads … Continue Reading

The Overpayment Rule and the Implied False Claims Theory: “What You Don’t Know Can Still Hurt You”

In 2010, the Affordable Care Act (“ACA”) enacted new rules governing overpayments made by the Medicare and Medicaid programs. Under these rules, providers have 60 days from the date that the overpayment has been identified to return the overpayment or face penalties and treble damages under the False Claims Act (“FCA”).  As described below, recent … Continue Reading

FTC Stands Down in Latest Head-to-Head Battle Between Federal and State Oversight of Healthcare Collaborations

In what will undoubtedly be seen by all interested parties as a significant setback in the Federal Trade Commission’s active opposition to potentially anticompetitive healthcare collaborations, the FTC voted unanimously on Wednesday to dismiss its challenge to Cabell Huntington Hospital’s acquisition of St. Mary’s Medical Center – two hospitals serving patients in the Huntington area … Continue Reading

Medicare Board of Trustees Releases 2016 Annual Report: Hospital Trust Fund Insolvency Projected by 2028

The Medicare Board of Trustees is calling for urgent legislative action to address the impending financial insolvency of the Medicare hospital benefit program. The Board’s 2016 report reveals the trust fund that pays for hospital services under Medicare Part A will be depleted by year 2028. At that time, the report indicates Medicare revenue will … Continue Reading

CMS 2017 Proposal Reduces Home Health Reimbursements by $180 Million

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 agencies caring for Medicare beneficiaries. This cut is the next in a series of reductions mandated by … Continue Reading

Maryland Co-Op Claims Risk Adjustment Formula Discriminates Against Smaller Insurers

Maryland’s Evergreen Health Cooperative has filed for an injunction against the federal government to halt payment by the  Consumer Operated and Oriented Plan (co-op) of the $22 million it owes to CareFirst BlueCross BlueShield based on the Affordable Care Act’s risk adjustment formula.  Of the 23 co-ops that launched in 2014, at least half of … Continue Reading

Mississippi Advances with Telehealth, Shows Promise for Improved Diabetes Disease Management

Rightly or wrongly, Mississippi is not generally regarded as a leader in health. The state, which opted out of the Affordable Care Act (ACA) Medicaid expansion, consistently ranks in the bottom two states for most health indicators: infant mortality and low birth weight, obesity, cancer deaths, and diabetes outcomes.  Mississippi, however, is making significant efforts … Continue Reading

New Amendments Grant Failing ACA Co-Op Program Access to Private Capital and Limit Special Enrollment Eligibility

Earlier this month, the Centers for Medicare and Medicaid Services (CMS) passed an interim final rule that amends regulations governing Consumer Operated and Oriented Plans (Co-ops) and tightens restrictions on special enrollment period (SEP) eligibility in the Health Insurance Marketplace. Of the 23 co-op plans established through the Affordable Care Act (ACA), only 11 are … Continue Reading

CMS Clarifies 60 Day Overpayment Rule

The Department of Health and Human Services’ (HHS) Center for Medicare and Medicaid Services (CMS), is set to publish a final rule that will provide some much needed relief to healthcare providers from the burdens of the so-called 60-Day Overpayment Rule.  The final rule clarifies (1) the 60 day period for refunding overpayments is not … Continue Reading

The Supreme Court Upholds The Availability Of Subsidies On The Federal Exchange—Where Do We Go From Here?

One of the most highly anticipated decisions of the term—at least among the Sheppard Mullin Healthcare team—was issued today by the Supreme Court: King v. Burwell.[1]   Six of the justices, including Chief Justice Roberts, voted to uphold the Administration’s interpretation of the law, leaving the availability of tax credits to people insured on the federal … Continue Reading

Stripping the ACA of Both the Carrot and the Stick: Sticking it to Consumers On and Off the Federal Exchange

Even as we write and you read, the Supreme Court in King v. Burwell is considering whether qualifying (often low income) individuals and families who have an opportunity to purchase healthcare coverage through the Affordable Care Act’s (“ACA’s”) federal exchange also have the right to federal premium subsidies/tax credits when determining the premium costs associated … Continue Reading

Medicare ACO v. 3.0—More Risk, More Money?

The Centers for Medicare and Medicaid (CMS) announced on March 10, 2015 that it is adding a new Accountable Care Organization (ACO) model to its cadre of innovative models.[1] Titled the “Next Generation ACO Model,” CMS’ new ACO model allows provider groups to assume higher levels of financial risk and reward than currently available under … Continue Reading

Round and Round and Round She Goes, and Where She Lands, Nobody Knows: The Future of Obamacare and Why King v. Burwell Matters – A Five-Part Series

Last week, on Wednesday, March 4, the U.S. Supreme Court heard oral argument in the highly publicized case of King. v. Burwell—a lawsuit challenging the Affordable Care Act or “Obamacare” based upon what many would call the most pernicious of statutory problems – poor drafting. The exact issue presented to the Supreme Court by the … Continue Reading
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