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On January 5, 2022, we discussed the Notice of Benefit and Payment Parameters for 2023 proposed rule released by the Centers for Medicare & Medicaid Services (CMS). On April 28, 2022, CMS issued the NBPP 2023 Final Rule. CMS published a Fact Sheet and other resources on April 28, 2022. The rule will take effect on January 1, 2023, but the optional early bird application deadline is May 18, 2022 and the final deadline for issuers to submit changes to their QHP Application is August 17, 2022.
Continue Reading 2023 Payment Rule’s Nondiscrimination Provisions and Anticipation of New Section 1557 Rules

On April 29, 2022, the Centers for Medicare and Medicaid Services (“CMS”), issued the final rule on Contract Year 2023 Policy and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Benefit Programs (the “Final Rule”).  CMS promotes the Final Rule as advancing “CMS’ strategic vision of expanding access to affordable health care and improving health equity in Medicare Advantage (MA) and Part D through lower out-of-pocket prescription drug costs and improved consumer protections.”  With a few exceptions, the Final Rule is a wholesale codification of the proposed rule. Except as noted below, the requirements of the Final Rule are effective January 1, 2024.
Continue Reading CMS Issues Contract Year 2023 Final Rule for Medicare Advantage Organizations and Prescription Drug Sponsors

On April 1, 2022, the Centers for Medicare & Medicaid Services (“CMS”) announced states may seek to extend Medicaid postpartum coverage from 60 days to one year through a new state plan option offered by the American Rescue Plan Act (“ARPA”). The new state plan option allows state Medicaid and Children’s Health Insurance Program (“CHIP”) agencies to provide 12 months of continuous postpartum coverage, regardless of any changes in circumstances, through a state plan amendment (“SPA”). This option is available for five years and ends on March 31, 2027.
Continue Reading CMS Begins Option to Extend Medicaid Postpartum Coverage

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.
Continue Reading “REACHing” For Health Equity: CMS Revamps The Global And Professional Direct Contracting Model

Have you been working out recently? We hope so, for today, Day Three of the 40th Annual J.P. Morgan Healthcare Conference, was definitely a day for heavy lifting.  Got a challenge that seems overwhelming? A problem that’s big enough to totally scare other folks? Do you eat triathlons for lunch? Well, then you’re going to like the Day Three companies. Let’s talk about fixing the huge American diabetes problem, providing better healthcare for Medicaid and dual eligible beneficiaries, and helping people beat cancer.  All that, plus a COVID-19 thought exercise…
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Continue Reading Day Three Notes for the 40th Annual J.P. Morgan Healthcare Conference, 2022

On November 12, 2021, the Centers for Medicare and Medicaid Services (“CMS”) revised and finalized draft guidance first issued on May 3, 2019, for co-location of hospitals with other hospitals or healthcare providers[1] (the “Finalized Guidance”). The Finalized Guidance is intended to guide CMS Surveyors in evaluation of such hospitals’ compliance with Medicare Conditions of Participation related to shared space, services, and staff.
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Continue Reading CMS Loosens Restrictions on Co-Located Healthcare Providers; Enforcement Interpretation Still to Be Determined

On October 20, 2021, the Centers for Medicare and Medicaid (“CMS”) Innovation Center (“Innovation Center”) published a white paper detailing its vision for the next ten years: a health system that achieves equitable outcomes through high quality, affordable, person-centered care.  The white paper first recounts the last ten years of testing and learning that laid the foundation for the Innovation Center’s future strategy.  The future strategy is organized around five strategic objectives that will guide the Innovation’s Center’s models and priorities for the next ten years.  The five strategic objectives for advancing this systemwide transformation include (1) Drive Accountable Care, (2) Advance Health Equity, (3) Support Innovation, (4) Address Affordability, and (5) Partner to Achieve System Transformation.  These strategic objectives aim to guide the Innovation Center’s models which will seek to reduce program costs and improve quality and outcomes for Medicare and Medicaid beneficiaries.  Finally, the white paper emphasizes its approach to measuring the progress of each of these objectives and assessing the impact the objectives have on beneficiaries, providers, and the market as a whole.
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Continue Reading Centers for Medicare and Medicaid Innovation Center: Equity and Vision

On July 13, 2021, the Centers for Medicare & Medicaid Services (“CMS”) unveiled a proposal to temporarily extend Medicare coverage for particular telehealth services granted during the COVID-19 public health emergency (the “Pandemic”), in order to evaluate which services should be covered permanently. Through the 2022 Physician Fee Schedule (“PFS”), CMS is allowing certain services to remain on the telehealth list until the end of December 31, 2023.
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Continue Reading CMS’ Proposal to Expand Telehealth Coverage

On July 13, 2021, the Centers for Medicare and Medicaid Services (“CMS”) released a Proposed Rule that proposes to amend certain regulations implementing the Physician Self-Referral Law, otherwise known as the “Stark Law”. The Proposed Rule proposes to revise once again the definition of “indirect compensation arrangement” (ICA), effectively to revert the meaning of the definition back – for the vast majority of indirect financial relationships between DHS entities and referring physicians – to the definition of that term as it was in place prior to the latest Stark Law rulemaking, “Modernizing and Clarifying the Physician Self-Referral Regulations” (the “MCR Final Rule”), published on December 2, 2020.[1]  The Proposed Rule also proposes to define the term “unit” and the phrase “services that are personally performed”, both for purposes of the ICA definition.
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Continue Reading CMS Proposes to Revise, Again, the Stark Law’s Definition of “Indirect Compensation Arrangement”: What Was Old is New Again

In July 2020, we discussed a ruling by the D.C. Court of Appeals upholding the Department of Health and Human Services’ (HHS) site-neutral payment rules. On Monday, June 28, 2021, the Supreme Court declined, without comment, to hear an appeal from the American Hospital Association (AHA) and other provider groups asking it to reverse this ruling.
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Continue Reading Site-Neutral Payments Stand: SCOTUS Declines to Hear AHA Appeal, Preserving Lower Payments to Off-Campus Provider-Based Departments

On May 21, 2021, the Centers for Medicare and Medicaid Services (“CMS”) announced that the Next Generation Accountable Care Organization (“ACO”) Model (“NGACO Model” or “Model”), set to end December 31, 2021, will not be extended after receiving a one-year extension due to COVID-19.  The decision comes as a surprise to NGACO participants and other industry groups who have been calling on CMS to revisit its decision and closely consider the Model’s merits and potential as a permanent program option.  Industry stakeholders, such as the National Association of ACOs (“NAACOS”), expressed initial disappointment with CMS’ decision to end the program, but were later able to find some reprieve with CMS’ decision to “allow Next Gen ACOs a limited opportunity to apply for Direct Contracting . . . . starting next year.”
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Continue Reading CMS’ Next Generation Accountable Care Organization (NGACO) Model Set To End in December 2021