C&M Health Law

C&M Health Law

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

Tag Archives: CMS

CMS Signals Future Patient Access Requirements for Medicare Advantage Plans

Posted in Health IT, Medicare
Building on momentum from Administrator Seema Verma’s announcement of the MyHealtheData initiative at HIMSS 2018, CMS has published more clues as to future action to liberate health information for patients. In the CY 2019 call letter to Medicare Advantage organizations and Part D programs, CMS describes the Blue Button 2.0 project and its use of… Continue Reading

Health Care Fraud and Abuse Control Program FY 2017: Insights from Our Enforcement Team

Posted in Fraud, Waste & Abuse
The Health Care Group’s newest partners, William S.W. Chang and Laura M. Kidd Cordova, along with Counsel Stephanie D. Willis, have authored an Alert about the 21st Health Care Fraud and Abuse Control Program (HCFAC) annual report released last Friday.  The HCFAC report is a joint effort of the U.S. Department of Justice (DOJ) and… Continue Reading

CMS Proposed Rule Would Reduce States’ Health Care Access Monitoring Requirements

Posted in Administrative Law, Medicaid
On March 22, 2018, the Centers for Medicare and Medicaid Services (CMS) announced a notice of proposed rulemaking (NPRM) that would, if finalized, exempt states with high rates of Medicaid beneficiaries in managed care plans from monitoring and reporting requirements related to Medicaid service access set forth in 42 C.F.R. §§ 447.203 and 447.204. The… Continue Reading

Liberating Data to Transform Value-Based Care: MyHealthEData, Blue Button 2.0, and Price Transparency

Posted in Health IT
On March 6, 2018 at the Healthcare Information and Management Systems Society (HIMSS) 2018 conference, Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma announced a new initiative furthering the current Administration’s focus on value-based care and increasing patient access to healthcare data. The initiative — called MyHealthEData — will be led by the… Continue Reading

Trump Administration Rejects (Nicely) Idaho’s Attempt to Skirt ACA

Posted in Exchanges, Health Care Reform & ACA
On Thursday, March 8, the Trump Administration rejected Idaho’s plan to sell health plans that do not include the consumer protections required by the Affordable Care Act (ACA). The rejection came in the form of a letter touting adherence to current law, though in many ways the letter was written by an apologetic Centers for… Continue Reading

Congress Remains Focused on Electronic Health Records

Posted in Digital Health, EHR, Health IT
Congress is considering several adjustments to health IT policy which may have significant impact on the Centers for Medicare and Medicaid Services’ (“CMS”) electronic health records (“EHR”) incentives. On July 20th and 21st, Representatives met to discuss bipartisan legislation to improve the Meaningful Use program and introduced legislation that would authorize a CMS Innovation Center… Continue Reading

CMS Delays Implementation of Episode Payment Models (EPMs)

Posted in Medicare
In an Interim Final Rule with Comment Period (IFC) published on March 21, 2017, CMS provided that implementation of the EPMs for cardiac and orthopedic care improvement, the cardiac rehabilitation incentive payment model, and the changes to the Comprehensive Care for Joint Replacement (CJR) model would be delayed from July 1, 2017 to October 1, 2017. The… Continue Reading

OIG Issues Advisory Opinion Rejecting the Labeling of Test Tubes at No Cost

Posted in Fraud, Waste & Abuse, Medicare
On November 28, 2016, the U.S. Department of Health and Human Services Office of the Inspector General (OIG) issued an unfavorable advisory opinion (No. 16-12) that addresses the permissibility, under the federal Anti-Kickback Statute (AKS), of a laboratory’s proposal to label test tubes and collect specimen containers at no cost to, and for the benefit… 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

Next Generation ACO Model Enters its Second & Final Application Cycle

Posted in Health Care Reform & ACA
This month, the Centers for Medicare & Medicaid Services (CMS) announced the beginning of the second application cycle for its Next Generation ACO Model (Next Gen Model).  We discussed the goals of the Next Gen Model and how it compares to the Medicare Shared Savings Program and Pioneer ACO models in this post from last… Continue Reading

New Core Quality Measures Seek to Align Payers and Reduce Burden for Providers

Posted in Health Care Reform & ACA
On February 16th, CMS, AHIP, and other Core Quality Measures Collaborative members unveiled new measure sets in an effort to streamline quality metrics reporting across commercial and government payers.  The seven new measure sets include metrics for accountable care organizations/patient-centered medical homes, primary care cardiology, gastroenterology, HIV/hepatitis C, medical oncology, orthopedics, obstetrics and gynecology.   For… Continue Reading

Medicaid Rules for Covered Outpatient Drugs Finalized by CMS; SIPs Required To Be Modified By April 1, 2017

Posted in Health Care Reform & ACA, Medicaid
Almost four years after publishing its proposed rule, the Centers for Medicare & Medicaid Services (CMS) released its final rule on February 1, 2016, pertaining to Medicaid reimbursement for covered outpatient drugs.  The finalized regulations implement provisions of the Affordable Care Act, and revise several key aspects of Medicaid program on drug rebates, and coverage… Continue Reading

CMS Issues Proposed 2017 Benefit and Payment Parameters Rule

Posted in Health Care Reform & ACA
On December 2, 2015, CMS will publish a notice of proposed rulemaking for its Notice of Benefit and Payment Parameters for 2017 (“Proposed Rule”). The Proposed Rule articulates the federal government’s policy for health care coverage under Affordable Care Act programs and would make several notable changes, including stricter network adequacy requirements for qualified health plans offering… 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

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

Posted in Fraud, Waste & Abuse
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… Continue Reading

Next Generation ACO Model Sets Tone for CMS’s Push Toward Value-Based Payment

Posted in Health Care Reform & ACA
Through the announcement of its new “Next Generation ACO Model” (Next Gen Model) program on March 10, 2015, the Centers for Medicare & Medicaid Services is making good on its recently proclaimed goal to tie half of its fee-for-service Medicare payments to value-based payment methodologies by the end of 2018. The program name aptly describes… Continue Reading

Settlement in FCA Qui Tam Case Disposes of Claims Alleging Falsely Certified Compliance with Medicare Advantage Rating Instructions

Posted in Fraud, Waste & Abuse, Litigation, Medicare
 After a protracted battle, Kaiser Foundation Health Plan, Inc. (Kaiser) recently settled a False Claims Act (FCA) qui tam case alleging that it falsely certified compliance with Medicare Advantage (MA) bidding instructions that relator claimed resulted in billions of dollars in damages to the United States. Crowell & Moring represented Kaiser in the litigation. Kaiser’s… Continue Reading

HHS, Labor, and Treasury Issue Flurry of Rulemakings and Guidance on Employee Benefits to Close 2014 with a Bang

Posted in Employee Benefits, Health Care Reform & ACA, Mental Health Parity
The last several weeks of 2014 brought with them a flurry of guidance from the Departments of Health and Human Services (“HHS”), Labor (“DOL”) and Treasury (collectively, the “Departments”) regarding group-health plan employee benefits issues, including issues under the Affordable Care Act (“ACA”), the Employee Retirement Income Security Act (“ERISA”) and the Mental Health Parity… Continue Reading

Federal Funds, States, and Health Care Reform: Innovation and Opportunity in 2015

Posted in Health Care Reform & ACA
States are on the front lines of health reform. The Affordable Care Act (ACA) acknowledged this by authorizing several grant programs for states to promote its implementation in addition to the many programs that already existed. Recently, the Department of Health and Human Services has awarded hundreds of millions of dollars in grants to states,… Continue Reading

Proposed Rule Would Broaden Rights for Same-Sex Couples at U.S. Hospitals

Posted in Medicaid, Medicare
On December 12, 2014, the Centers for Medicare & Medicaid Services (CMS) announced a proposed rule that would broaden rights for same-sex spouses at US hospitals. The proposed rule is aimed at “ensur[ing] that same-sex spouses in legally-valid marriages are recognized and afforded equal rights in Medicare and Medicaid participating facilities.” In its 2013 decision… Continue Reading

2016 Payment Notice Proposed Rule: Potential Changes to EHBs, Rate Review, and Other ACA Tweaks

Posted in Health Care Reform & ACA
On November 26, 2014, the U.S. Department of Health and Human Services (HHS) released its proposed Notice of Benefit and Payment Parameters for 2016, also known as the “Payment Notice.” Now that HHS has completed the majority of its major rulemakings implementing the Affordable Care Act, the annual Payment Notice has become the recurring opportunity… Continue Reading

HHS Delays Enforcement of Health Plan Identifier Rules

Posted in Health Care Reform & ACA
Health plans may continue to engage in healthcare transactions without using unique health plan identifiers (“HPIDs”)—at least for now. The Department of Health and Human Services (“HHS”) announced it would indefinitely delay enforcement of regulations that would have required health plans to obtain and use Health Plan Identifiers in HIPAA transactions as early as November… 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