Centers for Medicare & Medicaid Services (CMS)

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Overview

The President signed H.R. 1, the One Big Beautiful Bill Act (the “Act”), into law on July 4, 2025. In Section 71113, the Act restricts the flow of Federal Medicaid funds to certain “Prohibited Entities” for the one-year period following its enactment.

Section 71113 puts forth a set of specific criteria. The prohibition applies to any entity—and its affiliates, subsidiaries, successors, and clinics—that: 

  • As of October 1, 2025:
    • Will be an “essential community provider,” as defined by 45 C.F.R. § 156.235, that is primarily engaged in family planning services, reproductive health, and related care;
    • Will be structured as a 501(c)(3) nonprofit organization; and
    • Will provide abortions (except cases involving rape or incest or if the woman’s life is endangered); and
  • Received more than $800,000 in Federal and State Medicaid payments in fiscal year 2023.

The structure of Section 71113 has created considerable uncertainty. The restriction went into effect on July 4, 2025, but requires both a forward-looking assessment of the services a provider will provide as of October 1, 2025, and a backward-looking assessment of how much a provider received in Medicaid payments in 2023. This ambiguity has led to two separate legal challenges in the weeks following the Act’s enactment. As of July 28, 2025, the U.S. Department of Health and Human Services (“HHS”), HHS Secretary Kennedy, the Centers for Medicare and Medicaid Services (“CMS”), and CMS Administrator Oz are enjoined from enforcing, retroactively enforcing, or otherwise applying the provisions of Section 71113 against all Planned Parenthood health care providers pursuant to a preliminary injunction issued by the U.S. District Court for the District of Massachusetts.[1] On July 29, 2025, twenty-one state attorneys general and the Governor of Pennsylvania also filed suit regarding the constitutionality of Section 71113 in the U.S. District Court for the District of Massachusetts.[2]

Continue Reading Legal Challenges to the One Big Beautiful Bill Act’s Restrictions on Federal Medicaid Funding

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Spotlight on Best Practices, Litigation, Antitrust, and Tax for Health Care Companies

Crowell & Moring LLP is pleased to release its “2016 Litigation & Regulatory Forecasts: What Corporate Counsel Need to Know for the Coming Year.” The reports examine the trends and developments that will impact health care companies and other corporations in the coming year—from the last year of the Obama administration to how corporate litigation strategy is transforming from the inside out. This year will bring remarkable change for companies, as market disruptions and the speed of innovation transform industries like never before, and the litigation and regulatory environments in which they operate are keeping pace.Continue Reading Crowell & Moring’s 2016 Litigation & Regulatory Forecasts: What Corporate Counsel Need to Know for the Coming Year

Every year, the Department of Justice (DOJ) and the Department of Health and Human Services Office of the Inspector General (OIG) report the results of their fraud prevention and recovery efforts to Congress.  As recounted in the recently released Health Care Fraud and Abuse Control Program (HCFAC) report, the overall amount recovered in FY 2014 was $1 billion less than what the agencies reported in 2013 ($4.3 billion).  Nevertheless, the report touted the $2 increase in the return on investment from DOJ and OIG’s fraud and abuse investigations overall (from $5.70 to $7.70).  The HCFAC report shows that, despite losing $62.1 million in funding beginning in FY 2013 due to sequestration, both DOJ’s and OIG’s antifraud work remains potent  and is growing more sophisticated.

Here is an overall comparison of the FY 2014 and FY 2013 reports:

DOJ Activities FY 2013 FY 2014
New Criminal Investigations 1,013 924
New Civil Investigations 1,083 782
Health Care Fraud Convictions 718 734
Total Allocation $573,667,581 $571,702,217
OIG Activities FY 2013 FY 2014
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New Civil Actions 458 529
Individuals Excluded from Federal Health Care Programs 3,214 4,017
Total Allocation $487,381,848 $485,824,633

Continue Reading FY 2014 HCFAC Report Shows Increasing DOJ and OIG Fraud-Fighting Efficiency

On September 2, 2014, the Centers for Medicare & Medicaid Services (CMS) announced a Final Rule specifying enrollment notice requirements and re-enrollment options for plans offered through the Exchange in 2015. Regarding notice requirements, the Final Rule states that consumers in the Exchange will receive notices from the marketplace before open enrollment begins that explain…