Insights

On January 4, in its most recent effort to expand federal support for addressing health-related social needs (HRSNs), the Centers for Medicare & Medicaid Services (CMS) issued guidance to clarify an existing option for states to address HRSNs through the use of “in lieu of” services and settings policies in Medicaid managed care. This option is designed to help states offer alternative benefits that take aim at a range of unmet HRSNs, such as housing instability and food insecurity, and to help enrollees maintain their coverage and improve health outcomes. 

This summary of key lawsuits affecting managed care is provided by the Health Care Group of Crowell & Moring. If you have questions or need assistance on managed care law matters, please contact Chris Flynn, Peter Roan, or any member of the Health Care Group.

This summary of key lawsuits affecting managed care is provided by the Health Care Group of Crowell & Moring. If you have questions or need assistance on managed care law matters, please contact Chris Flynn, Peter Roan, or any member of the Health Care Group.

In Health Republic Insurance Co. v. U.S. (Jan. 10, 2017), the Court of Federal Claims (Court) rejected the Government’s motion to dismiss a lawsuit filed under the Tucker Act seeking to recover “risk corridors” payments pursuant to §1342 of the Affordable Care Act, holding that “HHS is required to make annual risk corridors payments to eligible qualified health plans” under the ACA, and that the “plaintiff’s claim for unpaid risk corridors payments is ripe for adjudication.” The Court’s decision was based on several factors, including the risk corridors program’s purpose of stabilizing insurance premiums in the ACA’s new and untested health insurance marketplace; notably, the Court held that even if the ACA were ambiguous and the court were to apply a Chevron deference analysis, HHS has interpreted the program to require annual payments, and the agency’s own actions (i.e., making partial annual payments) indicate it believes the program is annual in nature.

The Affordable Care Act (ACA) was enacted in 2010 and most of its provisions became effective by 2014. President Obama’s signature law ushered in nation-wide health insurance reforms and new pathways for coverage, but also created controversy over some of its key provisions—like the mandate to purchase insurance.

On Friday, October 14, 2016, the Centers for Medicare and Medicaid Services (CMS) released the pre-publication version of the final rule with comment period (Final Rule) that, beginning January 1, 2017, will implement the provisions of the Medicare Access and CHIP Reauthorization Act (MACRA) relating to the new Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). MIPS and APMs are collectively referred to as the “Quality Payment Program” or “QPP”. Physicians, physician assistants, nurse practitioners, clinical nurse specialists and certified registered nurse anesthetists (collectively, “MIPS-eligible clinicians”) are part of the QPP if they bill Medicare more than $30,000 a year or provide care for more than 100 Medicare patients a year (both higher thresholds than initially proposed by CMS in the notice of proposed rulemaking).

This summary of key lawsuits affecting managed care is provided by the Health Care Group of Crowell & Moring. If you have questions or need assistance on managed care law matters, please contact Chris Flynn, Peter Roan, or any member of the Health Care Group.

Under a recently proposed rule, the Centers for Medicare & Medicaid Services (CMS) would release on an annual basis data that Medicare Advantage (MA) organizations and Part D sponsors have typically considered to be proprietary and confidential.1 The proposed rule would also limit MA organizations to contracting with providers and suppliers that are enrolled in Medicare. This new network requirement could adversely affect some MA organizations’ ability to meet CMS network adequacy requirements. CMS solicits comments on several topics related to the proposed rule. Comments are due September 6, 2016.

The Medicare Access and CHIP Reauthorization Act (MACRA), enacted in April 2015, authorized the creation of the Medicare Quality Payment Program. Among other changes, MACRA provides for rewards for participation in Alternative Payment Models (APMs) to promote high-value rather than high-volume care. On May 9, 2016, the Centers for Medicare and Medicaid Services (CMS) published a notice of proposed rulemaking in the federal register to implement MACRA by creating the Quality Payment Program (MACRA Rule).

Yesterday, in U.S. House of Representatives v. Burwell, No. 14-1967 (RMC), D. D.C., May 12, 2016, the U.S. District Court for the District of Columbia held that the Affordable Care Act (ACA) does not authorize the administration to reimburse health plans operating on the ACA’s exchanges for cost-sharing reductions given to consumers as required by ACA Section 1402. As enacted, Section 1402 requires health plans on the ACA exchanges (so-called “Qualified Health Plans” or QHPs) to reduce the copayments and deductibles charged to consumers under certain income levels. The federal government, in turn, is required to reimburse QHPs for the amount of the reduction. Now, however, the district court has ruled that Section 1402 requires an annual appropriation to fund payments to health plans but Congress has never appropriated such funds, placing billions of dollars in government payments to health plans in jeopardy.

In a controversial move, HHS’ new rules for Medicaid Managed Care plans create a novel work-around for the prohibition on the use of Medicaid funds for mental hospital stays. One of the most venerable Medicaid rules—which was included in the original Act in 1965—is the exclusion of Medicaid assistance “for the care or services for any individual who has not attained 65 years of age and who is a patient in an institution for mental diseases” (IMD).1 An IMD is an institution “that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including medical attention, nursing care and related services.”2 The exclusion thus covers state and private mental hospitals, which have traditionally provided long-term care, often in locked wards, but not psychiatric wards in general med/surg hospitals.

Today the Centers for Medicare & Medicaid Services (CMS) published the Medicaid Managed Care final rule (the “Final Rule”) in the Federal Register. The Final Rule comes 14 years since the last Medicaid managed care rulemaking, when CMS promulgated the regulations implementing the Balanced Budget Act of 1997’s changes to the Medicaid program in 2002. The healthcare world has changed dramatically since then both through the enactment of the Affordable Care Act (ACA) and substantial growth in Medicaid managed care (the Final Rule notes that as of July 2013, 73.5 percent of Medicaid beneficiaries received at least some benefits through managed care).

This summary of key lawsuits affecting managed care is provided by the Health Care Group of Crowell & Moring. If you have questions or need assistance on managed care law matters, please contact Chris Flynn, Peter Roan, or any member of the health law group.

This summary of key lawsuits affecting managed care is provided by the Health Care Group of Crowell & Moring. If you have questions or need assistance on managed care law matters, please contact Chris Flynn, Peter Roan, or any member of the health law group.

This summary of key lawsuits affecting managed care is provided by the Health Care Group of Crowell & Moring. If you have questions or need assistance on managed care law matters, please contact Chris Flynn, Peter Roan, or any member of the health law group. Please click to view the full Crowell & Moring Managed Care Lawsuit Watch archive. Cases in this issue:

This summary of key lawsuits affecting managed care is provided by the Health Care Group of Crowell & Moring. If you have questions or need assistance on managed care law matters, please contact Chris Flynn, Peter Roan, or any member of the health law group. Please click to view the full Crowell & Moring Managed Care Lawsuit Watch archive. Cases in this issue:

This summary of key lawsuits affecting managed care is provided by the Health Care Group of Crowell & Moring. If you have questions or need assistance on managed care law matters, please contact Chris Flynn, Peter Roan, or any member of the health law group. Please click to view the full Crowell & Moring Managed Care Lawsuit Watch archive. Cases in this issue:

President Obama announced on November 14 that the Administration will allow health insurers to continue certain coverage in the individual and small group market which would have not otherwise met the market reform requirements of the Affordable Care Act (ACA). This change raises significant questions and operational problems for issuers, providers, employer sponsors of health plans, and other organizations operating in the health care industry. In conjunction with the President's announcement, the Centers for Medicare & Medicaid Services of the Department of Health and Human Services (CMS) has issued a letter to state insurance commissioners (CMS Letter) detailing the Administration's new "transitional policy" in regard to this issue. The CMS Letter provides some guidance regarding health insurance policies that now may be continued, and specifies the necessary conditions under which these policies may be continued. However, there remains much uncertainty as to whether issuers will be able to continue to offer these policies, as well as the overall impact on the insurance market.

This summary of key lawsuits affecting managed care is provided by the Health Care Group of Crowell & Moring. If you have questions or need assistance on managed care law matters, please contact Chris Flynn, Peter Roan, or any member of the health law group. Please click to view the full Crowell & Moring Managed Care Lawsuit Watch archive. Cases in this issue:

This summary of key lawsuits affecting managed care is provided by the Health Care Group of Crowell & Moring. If you have questions or need assistance on managed care law matters, please contact Chris Flynn, Peter Roan, or any member of the health law group. Please click to view the full Crowell & Moring Managed Care Lawsuit Watch archive. Cases in this issue: