Healthcare Legislation and Rulemaking

On May 3, 2019, the Centers for Medicare & Medicaid Services (“CMS”) published a comprehensive proposed rule (“Proposed Rule”) to revise the Medicare payment structure for inpatient prospective payment systems (“IPPS”) hospitals. According to the preamble of the Proposed Rule, the purpose of the Proposed Rule is to bump up Medicare’s reimbursements to rural hospitals, some of which receive the lowest rates in the country.

Unfortunately for urban hospitals, any proposed changes in the Medicare reimbursement system must be budget-neutral; therefore, any increase in rural hospital reimbursement must be matched with an equal and offsetting decrease in urban hospital reimbursement.[1] As reported in the Kaiser Health News on June 3, 2019, the Kaiser Family Foundation likens this to a Robin Hood-like effect – robbing from the rich to give to the poor. Like in Sherwood Forest, there are winners and losers in the world of Medicare reimbursement.
Continue Reading CMS Proposes Changes to Medicare Wage Index that Would Increase Reimbursement Rates to Rural Hospitals at the Expense of Urban Hospitals

The Office for Civil Rights (“OCR”) issued a request for information (“RFI”) to assist OCR in identifying provisions of the Health Insurance Portability and Accountability Act (“HIPAA”) privacy and security regulations (the “HIPAA Rules”) that may impede the transformation to value-based health care or that limit or discourage coordinated care among individuals and covered entities without meaningfully contributing to the protection of the privacy or security of individuals’ protected health information (“PHI”).
Continue Reading OCR Seeks Ideas on HIPAA Rule Changes to Promote Value-Based Care and Coordinated Care

Part C and Part D Quality Rating System

The November 1, 2018 proposed rule issued by the Centers for Medicare & Medicaid Services (“CMS”) includes enhancements and substantive changes to the Star Rating System in order to increase the stability and predictability of the Medicare Advantage program (aka “Part C”) and the Medicare Prescription Drug Benefit program (aka “Part D”) Star Ratings.

Measure Level Star Ratings.

CMS’ Star Ratings proposals are intended to eliminate some of the volatility and unpredictability of the calculation methodology, which is a welcome change for Medicare Advantage organizations (“MAOs”) and Part D plan sponsors. Based on stakeholder feedback and analyses of the data, CMS proposes two enhancements to the current hierarchical clustering methodology that is used to set cut points for non-Consumer Assessment of Healthcare Providers and Systems (“CAHPS”) measures:
Continue Reading Blog Series Part 7: CMS Proposed Rule on Policy and Technical Changes to the Medicare Advantage, Medicare Prescription Drug Benefit, Medicaid Fee-For-Service, and Medicaid Managed Care Programs for 2020 and 2021

Dual Special Needs Plans

This part 6 of our 7 part series focuses on the provisions regarding dual special needs plans (“D-SNPs”) released by the Centers for Medicare and Medicaid Services (“CMS”) in the proposed rule issued on November 1, 2018 (the “Proposed Rule”). D-SNPs enroll individuals who are entitled to both Medicare and medical assistance from a state under Medicaid. States cover some Medicare costs, depending on the particular state and the member’s eligibility. As reported by the Kaiser Family Foundation in “Medicare Advantage 2017 Spotlight: Enrollment Market Update,” Gretchen Jacobson, Anthony Damico, Tricia Neuman, and Marsha Gold ( June 6, 2017), enrollment in special needs plans increased from 2.1 million in 2016 to 2.3 million in 2017 – and 81% of members of these plans are enrolled in D-SNPs.
Continue Reading Blog Series Part 6: CMS Proposed Rule on Policy and Technical Changes to the Medicare Advantage, Medicare Prescription Drug Benefit, Medicaid Fee-For-Service and Medicaid Managed Care Programs for Years 2020 and 2021

Part D Plan Sponsors’ Access to Medicare Parts A and B Claims Data Extracts

As detailed in previous posts in this series, one major objective that the Centers for Medicare and Medicaid Services (“CMS”) addressed in a proposed rule issued November 1, 2018 (the “Proposed Rule”), was to implement new Social Security Act provisions that Congress added in the Bipartisan Budget Act of 2018 (“BBA”). One such provision will open fee-for-service Medicare data up to prescription drug benefit (“Part D”) plans.
Continue Reading Blog Series Part 5: CMS Proposed Rule on Policy and Technical Changes to the Medicare Advantage, Medicare Prescription Drug Benefit, Medicaid Fee-For-Service, and Medicaid Managed Care Programs for 2020 and 2021

Quality Improvement Programs

The proposed rule issued November 1, 2018 (the “Proposed Rule”) by the Centers for Medicare and Medicaid Services (“CMS”) includes two technical changes to 42 C.F.R. Part 422. The first change involves a clarification regarding the accreditation “deeming” standard for Medicare Advantage (“MA”) quality improvement programs. The second change, also related to accreditation, simply proposes the deletion of language regarding the soon to be eliminated requirement that MA organizations (“MAOs”) conduct quality improvement projects.
Continue Reading Blog Series Part 4: CMS Proposed Rule on Policy and Technical Changes to the Medicare Advantage, Medicare Prescription Drug Benefit, Medicaid Fee-For-Service, and Medicaid Managed Care Programs for Years 2020 and 2021

Medicare Advantage and Part D Preclusion List

The proposed rule issued November 1, 2018 (the “Proposed Rule”) by the Centers for Medicare and Medicaid Services (“CMS”) includes a number of regulatory changes to the manner in which providers are to be included on CMS’ Medicare Advantage and Part D “Preclusion List”, providers’ appeal rights prior to such inclusion, the timeframes that providers must remain on the list, and the financial impact to beneficiaries and claimants who receive and provide items and services furnished or prescribed by a precluded provider.
Continue Reading Blog Series Part 3: CMS Proposed Rule on Policy and Technical Changes to the Medicare Advantage, Medicare Prescription Drug Benefit, Medicaid Fee-For-Service, and Medicaid Managed Care Programs for Years 2020 and 2021

On October 26, 2018, the Centers for Medicare and Medicaid Services (“CMS”) released for viewing a proposed rule that includes significant changes for Medicare Advantage organizations (“MAOs”), Part D prescription drug plan sponsors (“PDPs”), Medicaid managed care organizations (“MCOs”), and the providers and suppliers that contract with them (the “Proposed Rule”). CMS anticipates that the Proposed Rule will be formally published in the Federal Register on November 1, 2018.
Continue Reading Blog Series: CMS Proposed Rule on Policy and Technical Changes to the Medicare Advantage, Medicare Prescription Drug Benefit, Medicaid Fee-For-Service, and Medicaid Managed Care Programs for Years 2020 and 2021