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On November 25, 2025, CMS released the Contract Year (“CY”) 2027 Medicare Advantage (“MA”) and Part D proposed rule (the “Proposed Rule”). The Proposed Rule would make significant changes to the MA and Part D programs, including revising measures under the Star Ratings program, creating a new special enrollment period for enrollees impacted by a provider termination, expanding access to risk adjustment data, relaxing requirements for marketing and communications materials, shortening certain record retention requirements, and easing certain requirements for offering dual eligible special needs plans (“D-SNPs”). In addition, as previewed in the CY2026 final rule and CMS memoranda to plans, the Proposed Rule would rescind several regulatory requirements promulgated under the prior administration. The Proposed Rule also codifies existing CMS guidance in several areas including Part D Redesign. Finally, the Proposed Rule includes several requests for information that are focused on “approaches and opportunities to streamline regulations and reduce administrative burdens on providers, suppliers, beneficiaries, and other interested parties participating in the Medicare program.”Continue Reading Happy Holidays? CMS Contract Year 2027 Medicare Advantage and Part D Proposed Rule Has Winners and Losers

The Centers for Medicare & Medicaid Services (“CMS”) recently finalized a rule establishing the new Ambulatory Specialty Model (“ASM”)— a mandatory value-based payment model that could apply to nearly one-quarter of all physicians in select specialties starting January 1, 2027. The ASM applies to physicians providing services to address two high-expenditure chronic conditions among Medicare patients: heart failure (cardiology) and low-back pain (pain management, interventional pain, neurosurgery, orthopedic surgery, and physical medicine and rehabilitation). Participation will be mandatory for eligible clinicians practicing in geographic areas selected by CMS that will likely encompass approximately one-quarter of U.S. Core-Based Statistical Areas (“CBSAs”) or metropolitan divisions nationwide. Published in connection with the Calendar Year (“CY”) 2026 Medicare Physician Fee Schedule (“PFS”), this alternative payment model represents a significant step in CMS’s transition toward specialty-specific accountability for cost, quality, and care coordination in ambulatory care. The model has significant implications for specialty practices, particularly those participating in or aspiring to join Accountable Care Organizations (“ACOs”). Additionally, the ASM will leverage components of the existing Merit-based Incentive Payment System (“MIPS”)/Medicare Value Pathways (“MVPs”) frameworks. For clinicians subject to MIPS/MVP, this model introduces a revised approach to performance scoring under a familiar framework.Continue Reading CMS Finalizes Mandatory Ambulatory Specialty Model for Cardiology and Low-Back Pain

For years, the conversation around health insurer consolidation and vertical integration has simmered through antitrust inquiries, oversight hearings, and policy papers. The Patients Over Profit Act (the “POP Act”)[i], introduced in both chambers of Congress this fall, marks a decisive shift. Rather than regulating insurer-provider integration, the POP Act proposes to ban it outright.Continue Reading Patients Over Profit Act: A Federal Inflection Point on Insurer-Provider Integration and What Comes Next

The Centers for Medicare & Medicaid Services recently published the calendar year (“CY”) 2026 proposed rule for Medicare payment for services provided in hospital outpatient departments under the Outpatient Prospective Payment System (“OPPS”) and services provided in ambulatory surgery centers (“ASCs”) (“the Proposed Rule”). Comments are due by September 15, 2025.Continue Reading Proposed Medicare Payment Policies for Hospital Outpatient and Ambulatory Surgery Center Services

On August 1, 2025, the Health Resources and Services Administration (“HRSA”) issued a Notice announcing the launch of the 340B Rebate Model Pilot Program (“Pilot Program”), that would dramatically change the way in which participating drug manufacturers provide discounts to healthcare entities eligible to participate in the 340B Program.Continue Reading HRSA Launches and Seeks Comments on 340B Rebate Model Pilot Program

In June 2025, the U.S. House of Representatives introduced a budget reconciliation bill titled the One Big Beautiful Bill Act (OBBBA). The legislation proposes a number of administrative changes to existing federal health programs, including modifications to automatic enrollment procedures affecting individuals who qualify for both Medicare and Medicaid. The bill does not repeal current benefit programs but includes provisions that would revise the process through which certain low-income individuals access premium and cost-sharing assistance programs.Continue Reading Congressional Budget Proposal Includes Adjustments to Dual-Eligible Enrollment Pathways and Medicare Savings Program Rules

The Centers for Medicare & Medicaid Services (CMS) recently published the fiscal year (“FY”) 2026 proposed rule for Hospital Inpatient Prospective Payment Systems (IPPS) (the “Proposed Rule”). Comments to the Proposed Rule must be submitted by 5 p.m. EDT on June 10, 2025.Continue Reading CMS Proposes Medicare Payment Policies for Hospital Inpatient Services for Federal Fiscal Year 2026

On April 4, 2025, the Centers for Medicare & Medicaid Services (“CMS”) released the contract year (“CY”) 2026 final rule for the Medicare Advantage (“MA”) program, Medicare Prescription Drug Benefit Program (“Part D”), Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly (the “Final Rule”). While CMS finalized several proposals of its Proposed Rule, it did not finalize many of its key proposals, including on anti-obesity medication (“AOM”) coverage, enhanced guardrails for artificial intelligence (“AI”), and various health equity related initiatives in MA and Part D.Continue Reading CMS Issues CY 2026 Medicare Advantage and Part D Final Rule

The litigator’s adage “it’s easy to plead, it’s hard to prove” once again came true in the long-running False Claims Act (FCA) case targeting Medicare Advantage (“MA”) plans operated by UnitedHealth (United). Eight years after the complaint was filed, a Special Master recommended granting United’s motion for summary judgment. U.S. ex rel. Poehling v. UnitedHealth Group, Inc., 2025 U.S. Dist. LEXIS 40921 (CD CA). Both the litigation and the Special Master’s report contain valuable insights for all FCA defendants, and especially for those matters involving allegations related to diagnosis coding.Continue Reading Proving Fraud is and Should Be Hard: Lessons from a Recent Medicare Advantage False Claims Act Decision

The rising cost of prescription drugs under Medicare continues to pose significant challenges for seniors, a population that relies heavily on consistent and affordable access to medications. This issue underscores broader gaps in the healthcare system and highlights the critical need for legal, regulatory, and economic strategies that prioritize aging populations.Continue Reading The Legal and Economic Realities of Medicare Drug Pricing: Navigating Opportunities and Challenges

With only two weeks remaining in the year, Congress is considering a government funding deal (the “Further Continuing Appropriations and Disaster Relief Supplemental Appropriations Act, 2025” or the “Bill”) that includes a welcome holiday gift for health care providers and patients – an expansive health care package that would extend certain telehealth flexibilities promulgated during the COVID-19 public health emergency (“PHE”) for an additional two years. The extended telehealth flexibilities are currently set to expire on December 31, 2024. This extension would generally allow providers to continue to serve Medicare patients via telehealth consistent with the current practices.Continue Reading Congress Extends Telehealth Flexibilities for Two More Years