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Tag archives: Medicare

Centers for Medicare and Medicaid Innovation announces emergency transportation model

On February 14, 2019, the Center for Medicare and Medicaid Innovation (CMMI) announced the Emergency Triage, Treat, and Transport (ET3) Model that aims to transform the ambulance system.  Medicare-enrolled ambulance service suppliers and hospital-owned ambulance providers will participate in the model.   CMMI believes this model will improve quality and lower costs by reducing hospitalizations and … Continue reading

CMS rings in the new year with overhaul of MSSP ACOs

On December 21, 2018, CMS issued a mammoth 957 page “Pathways to Success” final rule, which overhauls shared savings/losses tracks for Medicare Shared Savings Program Accountable Care Organizations (MSSP ACOs) to push ACOs into shared risk models more quickly, among other program changes. Largely consistent with the proposed rule as we summarized here, the final … Continue reading

CMS significantly expands its Medicare site-neutral payment policy

We previously summarized certain provisions of CMS’s CY 2019 OPPS/ASC final rule published on November 2. See here. In this final rule CMS significantly expands its Medicare site-neutral payment policy beginning January 1, 2019. As we previously described, CMS did not finalize its proposal that an excepted off-campus provider-based department (PBD) will be paid under … Continue reading

CMS publishes CY 2019 changes to hospital outpatient prospective payment and ambulatory surgical center payment systems and quality reporting programs final rule

On November 2, CMS published its CY 2019 hospital outpatient prospective payment and ambulatory surgical center payment systems and quality reporting programs final rule. In the final rule CMS implements its proposal to pay clinic visit services performed in excepted off-campus provider-based departments (PBDs) a Medicare Physician Fee Schedule – equivalent payment rate. These services … Continue reading

CMS publishes CY 2019 Home Health and Home Infusion Therapy final rule

Earlier this summer the Centers for Medicare & Medicaid Services (CMS) published its Calendar Year (CY) 2019 home health agency (HHA) and home infusion therapy supplier payment updates proposed rule. On October 31, CMS published its CY 2019 final rule, which alters Medicare quality and payment reporting processes for HHAs under the Home Health Prospective … Continue reading

CMS proposes to expand payment for telehealth services

On July 12, 2018, CMS included three proposed changes to telehealth reimbursements within the CY 2019 Physician Fee Schedule (the “Proposed Rule”). Currently, subject to certain exceptions, Medicare reimbursements for certain telehealth services are statutorily limited by the type of health care professional providing the service, and the geographic location of the patient (namely, the … Continue reading

CMS further crystalizes Stark liberalizations

On July 12, 2018, CMS included within the CY 2019 Physician Fee Schedule (the “Proposed Rule”) two revisions to Stark Law regulations aimed at further clarifying any actual or perceived differences between current regulations and the recently enacted Bipartisan Budget Act of 2018 (“2018 BBA”). As we previously reported, Section 50404 of the 2018 BBA … Continue reading

CMS issues Pathway to Success ACO proposed rule

On August 9, 2018, CMS published the long-awaited Pathways to Success proposed rule.  CMS Administrator Seema Verma published a related  article on the Health Affairs Blog.  The proposed rule would usher in significant changes for Accountable Care Organizations (ACOs).  Groups of providers, such as doctors and hospitals, can join together to form an ACO and … Continue reading

CMS proposes significant Medicare OPPS and ASC payment system changes for 2019

On July 25, 2018, the Centers for Medicare & Medicaid Services published its 2019 Medicare hospital outpatient prospective payment system (OPPS) and ambulatory surgical center (ASC) payment system proposed rule.  A fact sheet describing the proposed rule is available here. The proposed rule can be accessed here. CMS proposes to update hospital OPPS payment rates … Continue reading

CMS issues CY 2019 home health proposed rule

On July 12, 2018, the Centers for Medicare & Medicaid Services (CMS) published its calendar year (CY) 2019 proposed rule for Medicare payment updates and proposed quality reporting changes for home health agencies (HHA) under the home health prospective payment system (HH PPS). CMS proposes certain changes to Medicare payment and quality reporting standards for … Continue reading

Status of Medicaid reform in Kentucky, Mississippi and Maine

On January 11, 2018, the Centers for Medicare & Medicaid Services (CMS) sent a letter to State Medicaid Directors that signaled their support of section 1115 demonstration projects that include work or community engagement requirements, as previously summarized in the Health Law Pulse. CMS prompted State Medicaid Directors to respond to this letter with proposals … Continue reading

US DOJ charges 601 individuals in nation’s largest healthcare fraud takedown

Last week, the U.S. Department of Justice announced charges against 601 individuals for their alleged participation in healthcare fraud schemes. According to the announcement, the alleged fraud is estimated to have resulted in more than $2 billion in losses to federal healthcare programs. This national healthcare fraud takedown is the largest in U.S. history, surpassing … Continue reading

MedPAC recommends to Congress a 30 percent reduction in Medicare payment rates for services provided in certain hospital off-campus emergency departments

In its June 2018 Report to the Congress the Medicare Payment Advisory Commission (MedPAC) recommends that Congress reduce Medicare Type A emergency department payment rates by 30 percent for services furnished in hospital off-campus emergency departments that are located within six miles of a hospital on-campus emergency department.  MedPAC also recommends that Congress should enable … Continue reading

U.S. Senate passes tax bill eliminating penalties for failure to comply with ACA individual health insurance mandate

On December 2, the U.S. Senate passed a tax bill by a 51-49 vote.  The legislation would not repeal the Affordable Care Act (ACA) individual health insurance mandate but instead would eliminate tax penalties for con-compliance with the mandate.  Senator Susan Collins (R-ME) announced her support for the bill in a press release in which … Continue reading

OIG rescinds advisory opinion to charity

For the first time, the OIG has rescinded an advisory opinion issued to a charity. According to the OIG, the advisory opinion – issued in 2006 and modified in 2015 –  was revoked because the charity “failed to comply with certain factual certifications” about independence from donors, potentially steering Medicare beneficiaries toward certain prescription drugs. … Continue reading

Third and Fifth circuits accept materiality arguments in throwing out qui tam cases

On November 16, 2017, the Third Circuit Court of Appeals affirmed the grant of summary judgment in favor of CVS Caremark, Corp. (“CVS Caremark”), finding that although the lower court’s reasoning was flawed, the whistleblower Anthony Spay failed to establish the requisite materiality element of a False Claims Act (“FCA”) lawsuit. In making its decision, … Continue reading

Senate tax bill would effectively repeal ACA individual mandate; House legislation to reverse 340B Drug Discount Program cuts; CMS addresses prescription drug costs and the opioid crisis

On November 14, Senate Finance Committee Chairman Orrin Hatch (R-UT) released the Chairman’s Mark to the Senate version of the Tax Cuts and Jobs Act. Hatch’s version of the tax plan effectively repeals the Affordable Care Act (ACA) individual mandate by reducing the associated penalty to $0. The ACA individual mandate requires individuals to buy … Continue reading

U.S. Senate Republican leadership decides against full Senate vote on Graham-Cassidy ACA repeal and replace legislation; HHS Secretary Tom Price resigns under pressure from the White House

On Tuesday, September 26, Senate Republican leadership decided not to hold a full Senate vote on the Graham-Cassidy Affordable Care Act (ACA) repeal and replace legislation. The previous day, Monday, September 25, the Senate Finance Committee held a hearing on the Graham-Cassidy bill. Following the hearing, Senator Susan Collins (R-ME) announced her opposition to the … Continue reading

US Senators Graham and Cassidy revise Affordable Care Act repeal legislation prior to Finance Committee hearing; AHA requests CMS guidance on hospital co-location and shared space arrangements

On Sunday evening, September 24, U.S. Senators Lindsey Graham (R-South Carolina) and Bill Cassidy (R-Louisiana) released a revised version of their Affordable Care Act (ACA) repeal legislation in advance of the Senate Finance Committee hearing scheduled for Monday, September 25, at 2 PM EST. The amended bill is similar to the legislation previously released in … Continue reading

CMS clarifies when hospitals are primarily engaged in inpatient care; U.S. Republican Senators introduce ACA repeal legislation while Democrats promote Medicare for all

The Centers for Medicare and Medicaid Services (CMS) recently issued Survey and Certification Letter 17-44, clarifying what it means for a facility to be “primarily engaged” in inpatient care for purposes of meeting the definition of a hospital and qualifying for reimbursement as a hospital under Medicare and Medicaid. A facility is primarily engaged in … Continue reading

U.S. Senators continue ACA stabilization and repeal efforts

The Senate Health, Education, Labor and Pensions (HELP) Committee has held three hearings in the past few days attempting to reach a bipartisan agreement on stabilizing the Affordable Care Act (ACA) insurance markets and will hold a fourth hearing later this week.  HELP Committee Chairman Lamar Alexander (R-TN) and Ranking Minority Member Patty Murry (D-WA) … Continue reading

CMS issues blanket waivers as a result of Hurricane Harvey; health care reform efforts continue

The Centers for Medicare & Medicaid Services (CMS) has issued several blanket waivers of Medicare requirements as a result of Hurricane Harvey.  Examples of requirements that CMS may waive include those relating to conditions of Medicare participation or certification, preapproval requirements, EMTALA requirements, Stark Law self-referral sanctions, and performance deadlines.  Providers do not need to … Continue reading

CMS extends deadline for health insurers to file 2018 rate requests; bipartisan group of experts advocates certain health reform initiatives

On August 11, the Centers for Medicare & Medicaid Services sent a memorandum to insurers announcing an extension of the deadline by almost three weeks until September 5 for insurers to file their 2018 rate requests.  Insurers are wrestling with whether to participate in the Affordable Care Act exchanges/marketplaces in 2018, and if so, the … Continue reading

Health care reform discussions continue in U.S. Senate; CMS issues multiple rules relevant to payments to and policies for hospitals, hospices, and skilled nursing facilities

On August 1, Chairman Lamar Alexander (R-Tenn.) and Ranking Minority Member Patty Murray (D-Wash.) of the U.S. Senate Committee on Health, Education, Labor and Pensions announced that the committee will hold hearings the week of September 4th on actions that Congress could take in an attempt to stabilize and strengthen the individual insurance markets in … Continue reading
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