The Final Rule. In a Final Rule posted by CMS last Tuesday, July 24, 2018, CMS announced that $10.4 billion in “risk adjustment transfers” (“Risk Transfers”) for benefit year 2017 (as calculated pursuant to the Affordable Care Act’s Risk Adjustment Program (the “Risk Program”)) would be distributed to eligible exchange-participating insurers in September, 2018. The Final Rule adopts the previously published methodology for the 2017 benefit year with additional explanation. CMS says that it intends to issue a new proposed rule on the risk adjustment methodology for the 2018 benefit year.
Continue Reading No Longer in Suspense: CMS Issues Final Rule Announcing that Risk Adjustment Program Transfers for 2017 will be Distributed in September

On February 26, 2018, twenty states (the “Plaintiffs”) jointly filed a lawsuit[1] in the U.S. District Court for the Northern District of Texas requesting that the court strike down the Patient Protection and Affordable Care Act (“ACA”), as amended by the Tax Cuts and Jobs Act of 2017 (the “TCJA”), as unconstitutional. The Plaintiffs’ suit gained support from the White House last week, when Attorney General Jeff Sessions delivered a letter to House Speaker Paul Ryan on June 7, 2018 (the “Letter”), indicating that the Attorney General’s Office, with approval from President Trump, will not defend the constitutionality of the individual mandate – 26 U.S.C. 5000(A)(a) – and will argue that “certain provisions” of the ACA are inseverable from that provision.[2] The Letter indicates that this is “a rare case where the proper course is to forgo defense” of the individual mandate, reasoning that the Justice Department has declined to defend statutes in the past when the President has concluded that the statute is unconstitutional and clearly indicated that it should not be defended.
Continue Reading Following Repeal of the Individual Mandate, Twenty States Challenge the Affordable Care Act

Despite the Trump Administration’s unsuccessful attempts to fully repeal and replace the Affordable Care Act (the “ACA”), the Administration has continued to target the ACA. In the Administration’s latest salvo, the Centers for Medicare & Medicaid Services (“CMS”) announced in its Fiscal Year 2019 Performance Budget (the “Budget”)[1] – as released by the federal Office of Management and Budget on February 12, 2018 and as discussed in greater detail in CMS’s Justification of Estimates for Appropriations Committee released last week – a proposal to “wind down” its financial support for the federal health insurance exchanges. Specifically, the Budget explains that if Congress repeals the ACA, CMS will withdraw its support of the federal exchanges by plan year 2020.
Continue Reading CMS Proposes “Wind Down” Plan for Federal Exchanges

San Francisco (Monday, January 8, 2018): Outside it was raining heavily today in San Francisco, but inside the 2018 JP Morgan Healthcare Conference the weather was distinctly sunny. Nary a hint of gloom or pessimism was heard today from the hospitals and health plans presenting at the conference, even after the joys of last year’s “repeal and replace,” tax “relief” and the multiple redirections from CMS. Instead, we saw optimism, continuing implementation of prior strategic plans and, generally, continuing consensus of the need for greater scale; more analytics, digital engagement, big data and artificial intelligence; more population health management; and value-based/risk-based arrangements. Here’s some highlights from today’s proceedings:
Continue Reading Day 1 Notes from the 2018 JP Morgan Healthcare Conference in San Francisco

Today, President Trump signed into law a sweeping tax reform bill passed by the House and the Senate on Wednesday that will materially affect virtually every sector in the economy, including, perhaps to a greater degree than others, the healthcare sector. Between the bill’s repeal of the Affordable Care Act’s individual mandate penalty tax and other pertinent provisions, we might reasonably expect to see:
Continue Reading President Trump Signs Tax Reform Bill Into Law

The fifth Open Enrollment period under the Affordable Care Act (ACA) started on November 1st, and will continue for a scant 45 days ending on December 15, 2017. This year, not only has the Open Enrollment been cut in half, but obstacles abound – obstacles that were not part of the 2016 Open Enrollment Period. For example:

  • Healthcare.gov is undergoing maintenance that could interfere with access during the Open Enrollment Period;
  • Federal support for Open Enrollment outreach and advertising is substantially lower this year than it has been in prior Open Enrollment periods; and
  • The number of health insurers participating in the exchanges has dropped significantly from last year (prompted in part by well-founded concerns regarding the future of federal cost-sharing reduction (CSR) payments), and in some counties, only one plan is available to individuals and families seeking coverage through the exchanges.

Continue Reading Clean Up on Aisle 12! The Obamacare Pop-Up Store is Open but Stocks are Limited

Two of the nation’s most noteworthy companies in the Revenue Cycle Management (“RCM”) technology space, Navicure Inc., and ZirMed Inc., announced a merger on September 14, 2017.

Navicure is a medical claims management, patient payment and data analytics company and ZirMed is known for its predictive analytics technology that helps healthcare organizations capture more revenue. The parties have announced that Navicure will purchase ZirMed and the transaction is expected to close by the end of this year.
Continue Reading Recent Merger Reflects Enhanced Need for Revenue Cycle Management Platforms

Yesterday, Thursday, October 12th, on the heels of the recent and repeated failures to repeal and replace the Affordable Care Act (“ACA”), President Donald Trump signed an executive order nominally aimed at increasing competition in the healthcare marketplace, but widely believed to be driven by a desire to undermine the ACA. The executive order broadly tasks the Labor Department with changing the current policies on the accessibility of certain healthcare plans. The coming policy changes are speculated to expand the market for healthcare plans that are exempt from many of the regulations under the ACA. Such healthcare plans are known as Association Health Plans (“AHPs”).
Continue Reading Trump Administration Takes Aim at ACA With AHP Executive Order

The Future of CSRs – A Tale Told in Tweets. In follow-up to our May 5, 2017 blog post, “ACA Cost-Sharing Reductions: An Uncertain Future,” on August 16, 2017, the Trump Administration made an announcement (Announcement) that it will continue to fund cost-sharing reduction (CSR) payments to insurers in accordance with the CSR provisions in the Affordable Care Act (ACA) for the month of August. The Announcement did not include any commitments to fund CSR payments in September or anytime thereafter.
Continue Reading ACA Cost-Sharing Reductions– A Momentary Reprieve and Ongoing Doubts