Centers for Medicare and Medicaid Services ("CMS")

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 November 17, 2023, the U.S. Department of Health and Human Services’ Centers for Medicare and Medicaid Services (“CMS”) will publish a final rule requiring Medicare skilled nursing facilities (“SNFs”) and Medicaid nursing facilities (“Facilities”) to provide more detailed ownership, managerial and other information on Form CMS-855A (the “Final Rule”).[1] The Final Rule also includes new definitions of “private equity company” and “real estate investment trust” for Medicare enrollment purposes for all Medicare institutional providers and suppliers.Continue Reading CMS Issues a Final Rule Requiring Nursing Facilities and Other Providers and Suppliers to Disclose Additional Ownership Information

On November 6, 2023, the Centers for Medicare and Medicaid Services (“CMS”) released the contract year 2025 proposed rule for Medicare Advantage (“MA”) organizations and Part D sponsors (the “Proposed Rule”). The Proposed Rule covers an array of regulatory topics including the Star Ratings program, marketing and communications, agent and broker compensation, health equity, dual eligible special needs plans (“D-SNPs”), utilization management, network adequacy, and access to biosimilars.Continue Reading CMS Promotes Competition, Transparency, Health Equity and More in the CY2025 Medicare Advantage and Part D Proposed Rule

As individuals continue to live longer beyond retirement and the U.S. population size of those 65 years and older continues to increase, the demand for long-term services and supports (“LTSS”) is also expected to increase.[1] LTSS represents the wide-ranging health and social services that individuals require over an extended period of time, including assistive services.[2] The increasing demand for these services will also likely proportionally increase health care expenditures of LTSS. According to the Congressional Research Service, which analyzed data from the Centers for Medicare & Medicaid Services (“CMS”) National Health Expenditure Accounts (“NHEA”) on the personal health expenditures for LTSS by payer, in 2021, an estimated $467.4 billion was spent on LTSS. This represents 13.2% of the $3.6 trillion spent on personal health care.[3] Notably, the first and second largest payers of LTSS are Medicaid and Medicare, respectively, accounting for 64.1% of all LTSS spending nationwide in 2021.[4] Absent public LTSS funding, individuals must rely on private funding, and in 2021, private sources accounted for just 28.6% of LTSS spending.[5]Continue Reading The PACE Solution to Increasing Demands for Long-Term Services and Supports in the U.S.

The Centers for Medicare & Medicaid Services (“CMS”) released the final rule on risk adjustment data validation (“RADV”) audits of Medicare Advantage (“MA”) organizations (the “Final Rule”) on January 30, 2023. Among other changes, this Final Rule will allow CMS to audit a sample of an MA organization’s (“MAO”) diagnoses reported for risk adjustment purposes (from 2018 and later) and then use the audit findings to calculate an extrapolated improper payment amount for the MAO’s contract. This extrapolation technique is controversial for a number of reasons, including whether CMS has the authority to use it in the manner proposed in the Final Rule, and whether it is an actuarially sound method of auditing. As we predicted in February, this Final Rule is now being challenged in court.Continue Reading Medicare Advantage RADV Audit Final Rule Challenged in Court

On August 14, 2023, the Centers for Medicare & Medicaid Services (CMS) released guidance on changes to the Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH) Model starting in performance year 2024 (PY2024). The changes came about in response to stakeholder and participant feedback. All ACO REACH participants should familiarize themselves with the upcoming changes.Continue Reading CMS Announces Changes to ACO REACH Model

On September 1, 2023, the Centers for Medicare and Medicaid Services (CMS) issued a long-awaited proposal to establish new federal minimum staffing standards for long-term care facilities.[1] If the proposed rule is finalized, CMS estimates that approximately 75% of all nursing homes would have to “strengthen staffing in their facilities” in order to meet the new requirements.[2]Continue Reading Long Term Care Facilities Face Mandatory Minimum Staffing Requirements

On July 13, 2023, the Centers for Medicare & Medicaid Services (“CMS”) issued its proposed rule (the “Proposed Rule”) for the 2024 Medicare Physician Fee Schedule (“PFS”). The Proposed Rule, which was issued in the Federal Register on August 7, 2023,  includes updated payment rates, changes to reimbursement for services related to health equity and social determinants of health, increases to payment for cancer care support, and changes to enrollment for mental health providers. CMS projects that the Proposed Rule will lead to growth in the Medicare Shared Savings Program (“MSSP”).Continue Reading CMS Announces Proposed Rule for 2024 Medicare Physician Fee Schedule

On April 26, 2023, the Centers for Medicare and Medicaid Services (“CMS”) released a fact sheet on Hospital Price Transparency Enforcement Updates[1] (the “Fact Sheet”) under the Hospital Price Transparency Rule (the “Rule”).[2] CMS’ updates were targeted at increasing compliance by hospitals with the Rule and providing a more streamlined enforcement process for violations of the Rule.Continue Reading CMS Releases Updates to Hospital Pricing Transparency Rule

With the Medicare Comprehensive Error Rate Testing program projected error rate for skilled nursing facilities (SNFs) showing a significant increase in 2022 (15.1%, up from 7.9% in 2021), the Centers for Medicare and Medicaid Services (CMS) has instructed each of its Medicare Administrative Contractors (MACs) that review SNF Medicare claims to initiate a five-claim probe and educate medical review for each SNF in the MAC’s jurisdiction.Continue Reading CMS Takes Steps to Lower SNF Medicare Payment Error Rates