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On October 29, 2020, the Department of Health and Human Services (“HHS”), the Department of Labor, and the Department of the Treasury (collectively, the “Departments”) released the Transparency in Coverage Final Rules (the “Final Rules”), which require non-grandfathered group health plans and health insurance issuers offering non-grandfathered health insurance coverage in the individual and group markets to disclose certain information including negotiated rates with providers and estimated out-of-pocket expenses to enable consumers to make informed health care purchasing decisions.
Continue Reading Trump Administration Finalizes The Transparency in Coverage Rule

On September 14, 2020, the Centers for Medicare & Medicaid Services (“CMS”) issued the Advance Notice of Methodological Changes for Calendar Year (CY) 2022 for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies – Part I, CMS-HCC Risk Adjustment Model (the “Advance Notice”).  CMS is issuing the Advance Notice in two parts: Part I includes key information about the Medicare Advantage CMS-Hierarchical Condition Categories (“HCC”) risk adjustment model and the use of encounter data for CY2022.  Part II, which will include other changes to the CY2022 payment methodologies, will be issued later this Fall.   CMS will announce the CY2022 MA capitation rates and final payment policies no later than Monday, April 5, 2021.
Continue Reading CMS Issues the 2022 Medicare Advantage Advance Notice Part I – Risk Adjustment

Earlier this month, the U.S. Department of Health and Human Services Office of the Inspector General (the “OIG”) released a report highlighting concerns about the extent to which Medicare Advantage Organizations (“MAOs”) are using health risk assessments (“HRAs”) to improve care and health outcomes under the Medicare Advantage Program (“MA”), as intended, and about the sufficiency of oversight by the Centers for Medicare & Medicaid Services (“CMS”).
Continue Reading HHS OIG Issues Report Critical of Medicare Advantage Risk Adjustment Practices

The Supreme Court issued a long-awaited ruling on April 27, 2020, directed at a more than $12 billion challenge related to the temporary risk corridors program established by the Affordable Care Act (the “ACA”).  Challenges were brought under multiple consolidated cases, Maine Community Health Options v. United States, Moda Health Plan v. United States, Land of Lincoln Mutual Health v. United States, and Blue Cross Blue Shield of North Carolina v. United States (the “Consolidated Cases”).  In its decision, the Court reversed the decision of the United States Court of Appeals for the Federal Circuit and remanded the case for further proceedings.
Continue Reading Supreme Court Issues Long Awaited Ruling on Affordable Care Act Risk Corridors Program

On Friday, March 27, the Coronavirus Aid, Relief, and Economic Security Act (the “CARES Act”) was enacted.  Organized below are concise summaries of select CARES Act sections that will impact various sectors of the health care industry:
Continue Reading Key Health Care Provisions of the Coronavirus Aid, Relief, and Economic Security Act (the “CARES Act”)

In a much needed sign of bipartisanship, the Senate passed and President Trump signed last night  the Families First Coronavirus Response Act.  The new law is effective today and requires insurers and group health plans to provide coverage for FDA-approved COVID-19 testing and related items and services.  The mandated coverage applies during the current state of emergency.  Here are some highlights of the new law.
Continue Reading Families First Coronavirus Response Act Imposes Benefit Mandates on Insurers and Group Health Plans

The Centers for Medicare and Medicaid Services (CMS) and the Office of Personnel Management (OPM) issued guidance to their contracting carriers on various issues surrounding the novel coronavirus or COVID-19.  These guidance documents remind carriers of their contractual obligations as well as give carriers flexibility in the administration of their benefit plans during this crisis.
Continue Reading Medicare Advantage Plans, Medicare Prescription Drug Plans and FEHBP Carriers Take Note: CMS and OPM Announce Actions to Address the Threat of Coronavirus

As promised, here is a summary of some key provisions in CMS’ proposed rule relating to the Medicare Advantage and Part D programs for contract years 2021 and 2022.  CMS is soliciting comments on a number of issues and we urge stakeholders to take the opportunity to submit comments.  The deadline for comments is April 6, 2020.
Continue Reading Top 10 Provisions of CMS Proposed Rule: Medicare Advantage and Part D Programs for CY2021 and CY2022

In an evening email that is sure to ruin the weekend for many, CMS announced on February 5, 2020, that it is proposing changes to the Medicare Advantage and Part D Programs for CY 2021 and 2022. CMS will not issue a Call Letter for CY2021. The unpublished version of the proposed rule is available for inspection, and is scheduled to be published in the Federal Register on February 18, 2020. Comments are due April 6, 2020.
Continue Reading CMS Proposes Changes to the Medicare Advantage and Part D Programs for CY 2021 and 2022

On August 13, 2018, President Trump signed into law the National Defense Authorization Act (NDAA) of 2019. While the annual NDAAs are tracked, analyzed, and picked apart with great care by the federal contracting community, the health care industry typically pays them little mind. But ignoring the 2019 NDAA would be a big mistake, because tucked within its more than 1,000 sections is one that will have a significant impact on many health care industry players. It’s known as Section 889. Read our thoughts on Section 889’s impact on the Health Care industry here.
Continue Reading Why the Health Care Industry Should Be Concerned About Section 889 of the 2019 National Defense Authorization Act