Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Federal Regulation

CMS Proposes to Deregulate, Fast Track Medicaid Managed Care Programs

November 9, 2018 - CMS has proposed a new rule to reduce regulation around Medicaid managed care programs and allow states to contract with private payers to deliver managed care at faster rates. CMS developed the rule in coordination with the National Association of Medicaid Directors (NAMD) to address common administrative burdens for managed care programs. The agency explained that reducing...


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CMS to Audit Premium Subsidy Eligibility for Individual Health Plans

by Thomas Beaton

CMS has proposed a new rule that would audit premium subsidy eligibility for individual health plan beneficiaries and monitor premium assistance programs through the federal insurance exchanges. The Patient Protection and Affordable Care...

US District Court Denies Appeal to Resolve Risk Corridor Payments

by Thomas Beaton

Federal judges for the US Federal District Court of Appeals denied a request to reopen a case that could provide over $12 billion in risk corridor payments to payers. Moda Health Plan, BlueCross BlueShield of North Carolina, and Land of...

CMS Redesigns Medicare Home Health Payment with Case Mix Model

by Thomas Beaton

CMS has proposed a new rule that would recalculate Medicare home health payments using a case mix payment model.   In 2020, the agency plans to implement the Patient-Driven Groupings Model (PDGM) to compensate home health agencies...

CMS Extends Medicare Advantage Audit Program in 2019 Rule

by Thomas Beaton

CMS will be continuing its Medicare Advantage audit program, the agency indicated in a proposed 2019 rule, in an effort to ensure program integrity and reduce inappropriate payments to insurers. The changes are part of CMS’s new...

New Drug Pricing Model Could Save Medicare Part B $17.2 Billion

by Thomas Beaton

A new drug pricing model with an international component could save Medicare Part B approximately $17.2 billion over five years, CMS says.   The International Pricing Index (IPI) will test if using drug price benchmarks other...

Proposed Rule Alters HRAs to Allow Direct Reimbursement to Employees

by Thomas Beaton

The Departments of Labor, Treasury, and HHS have proposed a new rule that would allow employers to directly reimburse employees’ care costs through health reimbursement arrangements (HRAs) as an alternative to traditional insurance...

CMS Broadens ACA Waiver Scope for State Insurance Programs

by Thomas Beaton

CMS has issued federal guidance intended to expand the scope and availability of state-level waiver programs.   State governments can now apply for State Relief and Empowerment Waivers that may result in weaker consumer protections...

BCBS of TN Defrauded $2M in $2B Telemedicine Insurance Scheme

by Thomas Beaton

BlueCross BlueShield (BCBS) of Tennessee has been named a damaged party after it was defrauded $2 million as part of a larger $2 billion telemedicine insurance scheme, according to the Department of Justice (DOJ). The District Court for...

AMA, Industry Orgs Object to Short-Term Health Plan Expansion

by Thomas Beaton

The American Medical Association and other industry trade groups have filed amici curiae in support of a lawsuit contesting the legality of short-term health plans. The Association for Community Affiliated Plans (ACAP) contends that the...

FDA Recruits Payers to Submit Quality Feedback on Medical Devices

by Thomas Beaton

FDA has launched a new quality assurance program that leverages feedback from commercial payers about medical device coverage requirements in order to expedite approvals. The Private Payor Program (PPP) is a voluntary program for medical...

MedPAC to Explore if Hospital Consolidation Impacts Medicare Costs

by Thomas Beaton

The House Committee on Energy and Commerce has asked the Medicare Payment Advisory Commission (MedPAC) to investigate whether or not hospital consolidation increases Medicare spending. In a letter to MedPAC, Representatives Greg Walden...

Handful of States Propose Lower ACA Premium Rates for 2019

by Thomas Beaton

Several states have announced lower ACA premium rates for 2019, bucking a national trend brought on by unstable markets and regulatory changes.   While early proposals from a number of states, including Virginia, Maryland, and...

Payers Sue to Collect 2017 Cost Sharing Reduction Payments

by Thomas Beaton

Payer organizations are exercising their right to use the court system to collect cost sharing reduction (CSR) payments that were not provided in the last quarter of 2017. A number of lawsuits are challenging the government’s...

GOP Senators Propose to Reinforce Pre-Existing Condition Protections

by Thomas Beaton

Half a dozen Republican Senators have introduced a bill that would ensure the Affordable Care Act’s pre-existing condition protections would remain a federal law despite upcoming legal challenges. The Ensuring Coverage for Patients...

GAO Critiques HHS Actions on ACA Navigator Program Funding

by Thomas Beaton

The Government Accountability Office (GAO) has questioned the data-driven methodology behind significant reductions in funding for the ACA navigator program and subsequent declines in new enrollment in health insurance plans.   In a...

1115 Medicaid Demonstrations Should be Budget-Neutral, CMS Says

by Thomas Beaton

CMS has issued new guidelines for state officials around creating budget-neutral 1115 Medicaid demonstrations. CMS informed state governments that the agency will use a formalized methodology to determine if 1115 demonstrations are a...

CMS Provides $8.4M to Stabilize State Insurance Markets

by Thomas Beaton

CMS has awarded $8.4 million to 31 states in an effort to stabilize state insurance markets and increase the number of affordable health plan options for beneficiaries. Recipients are allowed to use the ACA-funded State Flexibility Grant...

New Jersey Gains CMS Approval for Reinsurance Program

by Thomas Beaton

New Jersey has received approval from CMS to implement a five-year reinsurance program that aims to lower individual health plan premiums by 15 percent. The program will operate from 2019 to 2023 and provide $218 million in reinsurance...

CMS Processes State Medicaid Requests, Approvals 23% Faster

by Thomas Beaton

CMS has announced that an agency initiative to streamline state Medicaid approvals and state plan amendments (SPAs) has increased approval processing speed by 23 percent. In 2017, CMS sent a bulletin to state Medicaid programs informing...

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