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

Requirements for MA Plans Offering Additional Telehealth Benefits

As part of the proposed rule issued November 1, 2018 by the Centers for Medicare and Medicaid Services (“CMS”) regarding updates to the Medicare Advantage (“MA”) and Medicare prescription drug benefit programs, CMS addressed expanding the ability of MA plans to offer telehealth benefits to their enrollees. The proposed telehealth regulations come on the heels of the Bipartisan Budget Act of 2018 and implement § 50323 related to “additional telehealth benefits.”
Continue Reading Blog Series Part 2: 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

In a key case being watched by the industry, Judge Collyer of the United States District Court for the District of Columbia issued an opinion today granting UnitedHealthcare’s Motion for Summary Judgment in UnitedHealthcare Insurance Co. v. Azar, No. 16-157 (D.D.C.), which challenged CMS’ 2014 Overpayment Rule (the “Rule”). Judge Collyer’s decision vacated the Rule in its entirety, finding that, by effectively imposing a 100% accuracy requirement on the data that Medicare Advantage organizations (“MAOs”) report to CMS for risk adjusted payment purposes, the Rule violated the statutory mandate of “actuarial equivalence” between CMS payments for healthcare coverage under traditional Medicare and Medicare Advantage (“MA”). Moreover, the Court found that the Rule’s facilitation of False Claims Act liability for MAOs’ failures to engage in “reasonable diligence” overshot CMS’ statutory authority, and that its definition of when an overpayment is “identified” was finalized without adequate notice as required by the Administrative Procedure Act. These latter two holdings may also have significant implications in the context of CMS’ separate but similar overpayment rule for Medicare Part A and Part B providers.
Continue Reading CMS’ Medicare Advantage Overpayment Rule: Arbitrary, Capricious, and Vacated

On April 4, 2018, the Centers for Medicare & Medicaid Services (“CMS”) finalized guidance and policies for the Medicare Advantage program that will expand the supplemental benefits afforded to beneficiaries to include items and services that address certain “social determinants of health” (“SDOH”). SDOH refers to a wide range of factors and conditions that are known to have an impact on healthcare, ranging from socioeconomic status, education and employment, to one’s physical environment and access to healthcare. Previously, CMS did not allow an item or service to be eligible as a supplemental benefit if the primary purpose was for daily maintenance. CMS’ reinterpretation of the statute to expand the scope of the primarily health-related supplemental benefit standard is an important step in encouraging value-based care.
Continue Reading Medicare Advantage to Address Social Determinants of Health: An Important Step for Value-Based Care