C&M Health Law

C&M Health Law

Analysis, commentary, and the latest developments in health care law and policy

Christine M. Clements

Christine M. Clements

Christine M. Clements is a partner in the firm’s Health Care Group with 25 years of experience on managed care law issues. Christine focuses her practice on federal health care government contract programs, with particular focus on the Medicare Advantage Program, the Medicare Prescription Drug Benefit, the Federal Employees Health Benefits Program, Medicaid managed care, and the Medicare and Medicaid Financial Alignment Demonstration. Christine advises clients on the issues most important to them, including contract application requirements, rate development and bidding, medical loss ratio and other financial and reporting requirements, risk adjustment, sales and marketing, benefit design, employer/union group offerings, provider and vendor contracting and payment, audit, fraud and abuse, and compliance programs.

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HHS Proposes New Regulations Aimed At Stabilizing the Individual Market

Posted in Exchanges, Health Care Reform & ACA
The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule  to stabilize the individual and small group markets to entice issuers to continue participation in the exchanges in 2018 despite continued uncertainty surrounding repeal and replacement proposals for the Affordable Care Act (ACA). The proposed rule, published today, would make the following changes… Continue Reading

GAO Finds HHS Exceeded Authority in Implementation of Transitional Reinsurance Program

Posted in Exchanges, Health Care Reform & ACA, Uncategorized
The Government Accountability Office (GAO), in a letter to members of Congress, found that the implementation of the Transitional Reinsurance Program by the U.S. Department of Health and Human Services (HHS) violates the Affordable Care Act. The Transitional Reinsurance Program is one of three premium stabilization programs authorized by the Affordable Care Act (ACA), commonly… Continue Reading

OIG Issues a Favorable Opinion Regarding a Drug Savings Card Program

Posted in Fraud, Waste & Abuse, Medicare
On June 27, 2016, the Department of Health and Human Services Office of Inspector General (“OIG”) issued a favorable Advisory Opinion, No. 16-07, relating to a savings card program under which individuals who have prescription drug coverage under Medicare Part D receive discounts on a drug that is statutorily excluded from Part D coverage. According… Continue Reading

CMS Suspends Automatic Reduction of Star Ratings for Plans and Sponsors Subject To Intermediate Sanction

Posted in Medicare
Last month, the Center for Medicare & Medicaid Services (CMS) issued a memorandum announcing a change pertaining to the effect of intermediate sanctions on the calculation of Star Ratings for Medicare Advantage organizations (MAOs) and Part D sponsors.  This is a significant change for plans. The Star Rating program has continued to evolve since being… Continue Reading

CMS Issues Comprehensive Care for Joint Replacement (CJR) Model Final Rule

Posted in Fraud, Waste & Abuse, Medicare
On November 16, 2016, CMS posted the final rule to implement the Comprehensive Care for Joint Replacement (CJR) model, which is a new Medicare payment model intended to hold acute care hospitals financially accountable for the quality and cost of a CJR episode of care and incentivize increased coordination of care among hospitals, physicians, and… Continue Reading

CMS Releases CY2016 Readiness Checklist

Posted in Fraud, Waste & Abuse, Medicare
CMS released the CY2016 Readiness Checklist, which highlights key compliance areas that Medicare Advantage organizations and Part D sponsors should be particularly mindful as they prepare for the 2016 contract year. The CY2016 Checklist includes new and modified requirements for CY2016 as well as other areas of CMS concern. CMS reminds organizations that, if they… Continue Reading

CMS Issues Guidance on Part D’s “Any Willing Pharmacy” Requirement

Posted in Health Care Reform & ACA, Medicare
Citing concerns about transparency and timing, on August 13, 2015, CMS issued a memorandum to clarify guidance to Medicare Part D sponsors regarding the any willing pharmacy requirement. Medicare Part D sponsors are required to contract with any pharmacy that meets the Part D sponsor’s standard terms and conditions.  CMS requires that the standard terms… Continue Reading

OPM Proposes New FEHB Rules on Subrogation, Post Termination Enrollment, and Rate Setting for Community-Rated Plans

Posted in Federal Employee Health Benefits Program (FEHB)
This week, the U.S. Office of Personnel Management (“OPM”) published three notices of proposed rulemaking (“NPRMs”) regarding the administration of the Federal Employees Health Benefits (“FEHB”) Program. The FEHB Program provides for coverage of federal employees and annuitants and their dependents. 5 U.S.C. § 8901, et seq. These three NPRMs address subrogation and reimbursement recovery,… Continue Reading

CMS Backpedals on DIR Pharmacy Price Concessions for CY2016

Posted in Medicare
In a memorandum released yesterday, CMS announced that it is not finalizing the proposed guidance issued on September 29, 2014 regarding Direct and Indirect Remuneration and Pharmacy Price Concessions for Contract Year 2016. The September 29th memorandum contained draft guidance that intended to implement changes to the Part D Program’s definition of “negotiated prices” that… Continue Reading

Mere Days After Comment Period Closed, CMS Abandons Four Aspects of CY 2015 Medicare Advantage and Part D Rule

Posted in Medicare
In a March 10, 2014 letter to Congress, CMS Administrator Marilyn Tavenner indicated that—based on concerns from Congress and the public—CMS shall not finalize the Proposed Rules’ proposals that would have: Removed the protected class definition for immunosuppressant drugs used in transplant patients, antidepressants, and antipsychotic medicines used to treat schizophrenia and certain related disorders… Continue Reading