Samuel Canales

Samuel Canales is a litigator and regulatory attorney, and an associate in the firm's Century City office.

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Fifth Circuit Upholds ACA Risk Adjustment Program

By Samuel Canales on March 25, 2022

Various smaller health insurance issuers have challenged the risk-adjustment program under the Patient Protection and Affordable Care Act (ACA), alleging, among other things, that its underlying methodology favors larger insurers. Last week the Fifth Circuit issued an opinion in one of those cases, affirming the lower court’s rulings in favor of the United States Department of Health and Human Services (HHS) and its administration of the risk-adjustment program. See Vista Health Plan, Inc. v. United States Dep’t of Health & Hum. Servs., No. 20-50963, 2022 WL 807554, at *1 (5th Cir. Mar. 17, 2022).
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“REACHing” For Health Equity: CMS Revamps The Global And Professional Direct Contracting Model

By Samuel Canales & Christine Clements on March 2, 2022

Posted in Accountable Care Organization (ACO), Centers for Medicare and Medicaid Services ("CMS")

On February 24, 2022, the Centers for Medicare & Medicaid Services (CMS) announced its redesign of the Global and Professional Direct Contracting Model (GPDC), which now will be called the Accountable Care Organization (ACO) Realizing Equity, Access, and Community Health (REACH) Model.
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CMS’s Contract Year 2023 Policy and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Benefit Programs

By Xavier Baker, Jarrod Brodsky, Samuel Canales, Christine Clements & Theresa Thompson on January 10, 2022

Posted in Centers for Medicare and Medicaid Services ("CMS"), Medicare, Medicare Advantage

On January 6, 2022, the Centers for Medicare and Medicaid Services (“CMS”) issued the proposed rule on Contract Year 2023 Policy and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Benefit Programs (the “Proposed Rule”). Per CMS, the Proposed Rule will reduce out-of-pocket prescription drug costs, improve price transparency and market competition under the Part D program, strengthen consumer protections to ensure Medicare Advantage (“MA”) and Part D beneficiaries have accurate and accessible information about their health plan choices and benefits, strengthen CMS oversight of MA and Part D plans, and improve the integration of Medicare and Medicaid programs for individuals enrolled in dual eligible special needs plans (“D-SNPs”). CMS failed to mention that the Proposed Rule will also result in additional administrative burdens and increased costs for MA organizations (“MAOs”) and Part D sponsors.
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HHS OIG Studies State Medicaid Programs’ Use of Telehealth

By Samuel Canales on November 15, 2021

Posted in Dept of Health & Human Services, Medicaid, Office of the Inspector General ("OIG"), Telehealth

The United States Department of Health and Human Services Office of Inspector General (“OIG”) recently issued a report concerning the use of telehealth to render behavioral health services to Medicaid enrollees, calling for greater evaluation and oversight in the hopes of encouraging states to implement changes to improve how their Medicaid programs use telehealth for behavioral health services, including mental health assessments, individual therapy, and medication management.
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