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Policy and Regulation News

HHS Sets Sights on Addressing Social Determinants of Health

November 19, 2018 - Speaking at the Hatch Foundation for Civility and Solutions in Washington, DC, early this month, Azar pointed to social determinants of health as “the root cause of so much of our health spending,” contributing to the $1 trillion in annual spending by the federal agency on the elderly and vulnerable Americans. While the head of HHS noted the federal government assumes the...


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Regulatory Uncertainty Continues to Disrupt ACA Marketplaces

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New research published by the Kaiser Family Foundation provides insight into the forces driving health payers to participate in certain ACA marketplaces while wholly quitting others. Insurer participation in the Affordable Care Act health...

HHS Looks to Medicaid Demonstrations to Improve Mental Health

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Medicaid beneficiaries with mental health conditions are the targets of recent CMS efforts to boost health outcomes. In recent remarks to the National Association of Medicaid Directors in the national capital, HHS Secretary Alex Azar said...

CMS Demonstrations Target Mental Health Services Under Medicaid

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Medicaid beneficiaries with serious mental illness (SMI) or serious emotional disturbance (SED) are the targets of recent CMS efforts to improve health outcomes. In a letter to Medicaid directors across the country, the federal agency...

Robocalls Targeted Consumers During Health Plan Enrollment Period

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Health insurance open enrollment’s kicked off, accompanied by a spike in automated calls with offers of Affordable Care Act or other health plans, much to the chagrin of consumers. “It’s at epidemic levels at this time...

CMS Proposes to Deregulate, Fast Track Medicaid Managed Care Programs

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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...

CMS to Audit Premium Subsidy Eligibility for Individual Health Plans

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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

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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

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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

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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

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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

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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

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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...

$36.9M in Medicare Fraud Leads to Federal Convictions, Sentencing

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New high-profile Medicare fraud cases have led to convictions and lengthy prison sentences for providers that attempted to defraud Medicare of $36.9 million. Federal agencies including HHS, the FBI, the Department of Justice (DoJ), and...

CMS: ACA Premiums to Decline in 2019 for Silver Plan Consumers

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CMS has announced it expects the average ACA health plan premium to drop by 1.5 percent for healthy consumers that purchase low-cost silver tier plans. The agency stated that it is the first time since 2014 that premiums in any part of...

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

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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...

OIG Finds Profits to Blame for Denied Medicare Advantage Claims

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Fifty-six percent of Medicare Advantage (MA) payers inappropriately denied claims from beneficiaries and providers to potentially profit from the capitated payment system, according to a report from the Office of Inspector General...

Medicare Advantage Premiums to Decrease by 6% in 2019

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CMS officially announced a six-percent decrease in Medicare Advantage premiums in 2019 as the result of MA enrollment, health plan options, and benefits increase. All signs point to the MA marketplace continuing to be a lucrative...

Montana Reinsurance Program May Cut Premiums Up to 20%

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Montana is moving ahead with the idea of creating a reinsurance program for the state’s health insurance market.  The program may reduce premiums between 10 and 20 percent, said Governor Steve Bullock and Department of...

Senators Propose Limits on Surprise Healthcare Billing

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A bipartisan group of Senators has introduced legislation that aims to end surprise healthcare billing, a practice which can lead to extremely high out-of-pocket costs for consumers. The Protecting Patients from Surprise Medical Bills Act...

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