First 100 Days LogoOn Tuesday, April 18, 2017, our Health Care Group will hold a webinar on the health care policy and transition challenges still at play as the Trump Administration nears the end of its 100 days in power.  During the webinar, participants will hear important insights and predictions on what a Trump-led Executive Branch will mean for health care industry stakeholders from:

  • Partner Xavier Baker, whose practice focuses on the regulatory and compliance aspects of commercial insurers’ participation in Medicare Advantage, Medicaid managed care, and the health insurance exchanges;
  • Counsel Gary Baldwin, the former deputy director of Plan and Provider Relations at the California Department of Managed Health Care (DMHC), with expertise in state insurance regulatory issues for commercial plans;
  • Partner Laura Cordova, the former assistant chief in the Fraud Section of the Criminal Division at the U.S. Department of Justice, who focuses primarily on counseling health care companies and executives in criminal, civil and administrative enforcement actions, which may still increase under a Trump administration; and
  • Counsel Stephanie Willis, who counsels health care entities in licensure and regulatory matters related to participation in health care reform incentive programs such as the Medicare Shared Savings Program and Meaningful Use.

Register for the webinar here.

On January 28, 2016, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would change the methodology used to evaluate and adjust the performance of Medicare Shared Savings Program (MSSP) Accountable Care Organizations (ACOs). The proposed rule is intended to improve long-term incentives for ACOs and create a path for long-term sustainability.

ACO performance is currently measured using a multi-step process that evaluates an ACO’s effectiveness in lowering expenditures for a group of assigned beneficiaries against a benchmark established based on an ACO’s historical costs. At the beginning of the ACO’s three-year agreement period, CMS sets an average per capita historical benchmark. CMS adjusts the historical benchmark on an annual basis based on projected growth in national per capita expenditures for Medicare Parts A and B services under the fee-for-service (FFS) program.

Continue Reading CMS Proposes New ACO Performance Measures

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 and conditions must be “reasonable and relevant.”  The sponsor’s standard terms and conditions establish the “floor” of minimum requirements that all similarly situated pharmacies must abide by (e.g., licensure requirements, minimum levels of liability insurance, etc.).

CMS expects Part D sponsors to make the standard contracting terms and conditions “readily available for requesting pharmacies no later than September 15 of each year for the immediately succeeding benefit year,” or 105 days prior to the start of the plan’s benefit year for non-calendar year plans.  The CMS guidance also requires that sponsors identify how pharmacies may obtain their standard terms and conditions, and provide the applicable terms and conditions to requesting pharmacies within two business days upon receipt of the request.  Part D sponsors must also provide the standard terms and conditions to CMS within two days of CMS’s request.

If the Part D drug plan sponsor requires a pharmacy to execute a confidentiality agreement, the sponsor is to provide the confidentiality agreement within two business days and then provide the standard terms to the pharmacy within two business days following the receipt of the executed confidentiality agreement.  CMS repeats that sponsors should not cause “any undue delay in executing” the any willing pharmacy agreement.

The guidance notes that sponsors may still modify some of their standard terms and conditions to encourage participation by particular pharmacies.  It does not alter or modify CMS regulations and guidance that permit Part D sponsors to establish networks of “preferred pharmacies.”