Affordable Care Act (ACA)

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As budget negotiations heat up in Washington, Medicaid has emerged as a key target for cost-cutting measures. With policymakers looking to trim federal spending while maintaining commitments to Social Security and Medicare, Medicaid is one of the few major programs left on the table. Proposals floating around Capitol Hill include everything from block grants and per capita caps to stricter eligibility requirements and reductions in federal matching rates. These potential changes could fundamentally alter the structure of Medicaid, shifting more financial responsibility to states and reshaping access to care for millions of Americans.Continue Reading Medicaid in the Crosshairs What Restructuring Could Mean for States, Providers, and Beneficiaries

In a Final Rule issued on May 6, 2024, the U.S. Department of Health and Human Services (“DHHS”) finalized regulations implementing Section 1557 of the Affordable Care Act (“Section 1557”). The Final Rule updates and strengthens protections for individuals who participate in health programs or activities that receive Federal financial assistance (“Covered Entities,” as further defined below). Continue Reading DHHS Bolsters Non-Discrimination Protections for Recipients of Covered Health Care Services and Activities

On April 29, 2024, the U.S. Department of Labor (the “DOL”) issued a final rule (the “Final Rule”) rescinding the 2018 Association Health Plan rule (“2018 AHP Rule”), thereby marking a return to the more rigid pre-2018 regulatory framework governing association health plans. The 2018 AHP Rule, officially titled “Definition of Employer Under Section 3(5) of ERISA – Association Health Plans,” allowed these plans to bypass certain requirements under the Affordable Care Act (“ACA”). The Final Rule will take effect on July 1, 2024.Continue Reading U.S. Department of Labor Rescinds Trump-Era Rule on Association Health Plans (AHPs)

On November 24, 2023, the U.S. Department of Health and Human Services’ Centers for Medicare and Medicaid Services (“CMS”) published a proposed rule to modify certain Patient Protection and Affordable Care Act (“ACA”) standards that apply to issuers and Marketplaces, as well as requirements for agents, brokers, web-brokers, direct enrollment entities, and assisters that help Marketplace consumers (the “Proposed Rule”).[1] These modifications are intended to further the Biden Administration’s goals of advancing health equity by addressing disparities in access to quality care while minimizing administrative burdens and ensuring program integrity.Continue Reading CMS Promotes Health Equity through Marketplace Standards and More in New Proposed Rule

On March 30, Judge Reed O’Connor of the U.S. District Court for the Northern District of Texas issued a decision in Braidwood Management Inc. v. Becerra (“Braidwood”), invalidating the Affordable Care Act’s (“ACA’s”) mandate requiring health plans and health insurers offering health insurance coverage to provide coverage for preventative care services recommended by the U.S. Preventive Services Task Force (“USPSTF”). The case was pursued by religious individuals and businesses that asserted that they were harmed by being required to pay for health insurance coverage which included services that they do not want to cover on religious grounds.Continue Reading Navigating the Wild West of the New ACA Preventative Care Ruling

The Centers for Medicare and Medicaid Services (“CMS”) issued a proposed rule, “Advancing Interoperability and Improving Prior Authorization Processes” (the “Proposed Rule”), that is intended to improve patient and provider access to health information and streamline processes related to prior authorization for medical items and services. The Proposed Rule would withdraw CMS’s December 18, 2020 Interoperability and Prior Authorization proposed rule, build on the policies finalized in the agency’s May 1, 2020 Interoperability and Patient Access final rule, and incorporate feedback CMS received from commenters on the December 2020 proposed rule.Continue Reading CMS Includes MAOs in Data Exchange and Prior Authorization Requirements

On July 25, 2022, the U.S. Department of Health and Human Services (“HHS”) issued a proposed new rule[1] that significantly expands the scope of protection available to vulnerable populations under Section 1557 of the Affordable Care Act (the “ACA”).Continue Reading Proposed Rule Leverages Section 1557 for Healthcare Equity

Last month, in Cummings v. Premier Rehab Keller, P.L.L.C., the Supreme Court denied a petitioner’s right to emotional distress damages in a private action brought under federal anti-discrimination laws. The Petitioner, a woman who is both deaf and legally blind, alleged that when she requested an American Sign Language interpreter at Premier Rehab Keller (“Premier”), the clinic denied her request, resulting in her inability to receive treatment. She filed suit under Section 504 of the Rehabilitation Act (“Rehab Act”) and Section 1557 of the Affordable Care Act (“ACA”), two federal statutes that prohibit recipients of federal funding from discriminating in the delivery of services based on disability. The Fifth Circuit dismissed her claim, reasoning that emotional distress damages are categorically unavailable in private actions and cannot be used to enforce either the Rehab Act or the ACA. As explained below, the Supreme Court affirmed the Fifth Circuit ruling.Continue Reading Supreme Court Discrimination Case Narrows Scope of Restitution for Individuals

Various smaller health insurance issuers have challenged the risk-adjustment program under the Patient Protection and Affordable Care Act (ACA), alleging, among other things, that its underlying methodology favors larger insurers. Last week the Fifth Circuit issued an opinion in one of those cases, affirming the lower court’s rulings in favor of the United States Department of Health and Human Services (HHS) and its administration of the risk-adjustment program. See Vista Health Plan, Inc. v. United States Dep’t of Health & Hum. Servs., No. 20-50963, 2022 WL 807554, at *1 (5th Cir. Mar. 17, 2022).
Continue Reading Fifth Circuit Upholds ACA Risk Adjustment Program

On June 17, 2021, the Supreme Court of the United States issued its opinion in California v. Texas (No. 19-840) and Texas v. California (No. 19-1019), holding 7-2 (Justice Breyer, joined by Chief Justice Roberts, and Justices Thomas (concurring), Sotomayor, Kagan, Kavanaugh, and Barrett; Justice Alito, dissenting, joined by Justice Gorsuch) that neither the individual plaintiffs nor the states had standing to challenge the constitutionality of the Affordable Care Act’s (ACA) minimum essential coverage provision because none of them sustained any injury in fact.
Continue Reading Not with a Bang, But a Whimper—Supreme Court Kicks Latest ACA Challenge for Lack of Standing

The Biden Administration’s American Rescue Plan Act of 2021 (H.R. 1319) (the “Act”) could present an opportunity for the growth of utilization of ambulatory surgery centers (“ASCs”), continuing the trend of migration of inpatient procedures to the outpatient setting.  This shift toward the outpatient setting initially began prior to the COVID-19 public health emergency, but was accelerated by the pandemic’s effect on hospitals, likely continuing the substantial increase in investment in the ASC marketplace.
Continue Reading Biden’s American Rescue Plan Follows Trend Toward Outpatient Setting, Increase in ASC Investment