Archives: Regulatory Developments

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HHS Posts Fall 2015 Regulatory Agenda Listing Rules in Pipeline

The Obama Administration has released its latest regulatory agenda, which lists major pending or planned regulatory actions and the anticipated timing of rulemaking activity. The agenda includes numerous pending HHS proposed and final rules affecting a wide range of policy areas, including Medicare payment rules, fraud and abuse authorities, the 340B drug pricing program, and … Continue Reading

Obama Administration Proposes 2017 ACA Marketplace Plan Benefit and Payment Parameters

On December 2, 2015, CMS is publishing its annual proposed Notice of Benefit and Payment Parameters, which would govern participation in the Affordable Care Act (ACA) Health Insurance Marketplaces for 2017. The wide-ranging rule includes a number of provisions intended to protect consumers enrolled in Marketplace plans, enhance transparency, improve marketplace premium stabilization programs, and … Continue Reading

Obama Administration Updates Rules for ACA Grandfathered Health Plans

On November 18, 2015, the Obama Administration published final regulations to update requirements for group health plans and health insurance issuers under the ACA, particularly with regard to the changes they can make to the terms of their plan/coverage while retaining their “grandfathered” status. The regulations also address preexisting condition exclusions, lifetime and annual dollar … Continue Reading

CMS Finalizes “Comprehensive Care for Joint Replacement” Model

On November 16, 2015, CMS released its final rule to establish a Medicare Comprehensive Care for Joint Replacement (CJR) model that will test whether bundled payments to acute care hospitals for lower extremity joint replacement surgery (LEJR) episodes of care will reduce Medicare expenditures while preserving or enhancing the quality of care for Medicare beneficiaries. … Continue Reading

CMS Finalizes Medicare Physician Fee Schedule Rates, Policies for 2016

Today the Centers for Medicare & Medicaid Services (CMS) published the final rule to update the Medicare physician fee schedule (MPFS) for calendar year (CY) 2016. Despite the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) establishing a 0.5% conversion factor (CF) update for 2016, the final 2016 CF of $35.8279 actually is a decrease … Continue Reading

CMS Publishes Final Rule on Medicaid Fee-For-Service Ratesetting for Assuring Access to Covered Medicaid Services

On November 2, 2015, CMS published a final rule with comment period that is intended to provide a transparent, data-driven process for states to follow when they set Medicaid provider payment rates, effective January 4, 2016. Under the Social Security Act, state plans must ensure that payment rates for Medicaid services “are consistent with efficiency, … Continue Reading

CY 2016 Medicare OPPS Spending to Drop by 0.4% under Final OPPS Rule; ASC Payments Get Small Boost

On November 13, 2015, the Centers for Medicare & Medicaid Services (CMS) is publishing its final rule updating the Medicare Hospital Outpatient Prospective Payment System (OPPS) and the Ambulatory Surgical Center (ASC) Payment System rates and policies for calendar year (CY) 2016. CMS estimates that total federal expenditures under the OPPS will drop by $133 … Continue Reading

Medicare Home Health PPS Payments to Fall by $260 Million in 2016

CMS published its final CY 2016 Medicare Home Health Prospective Payment System (PPS) rule on November 5, 2015.  CMS projects that overall Medicare payments to home health agencies (HHAs) will be reduced by 1.4% — or $260 million – in CY 2016 compared to 2015 levels as a result of the policies finalized in the … Continue Reading

Final ESRD PPS Rule to Boost Overall Medicare Payment by $10 Million in CY 2016

On November 6, 2015, CMS published its final rule to update the Medicare end-stage renal disease (ESRD) prospective payment system (PPS) for calendar year (CY) 2016. CMS estimates that the rule will increase overall Medicare payments to ESRD facilities by $10 million (0.2%) compared to CY 2015 payments, although the final CY 2016 ESRD PPS … Continue Reading

CMS Publishes Proposed Rule on Hospital/HHA Discharge Planning Requirements

Today the Centers for Medicare & Medicaid Services (CMS) published a proposed rule that would modify the discharge planning conditions of participation (COPs) for hospitals, including long-term care hospitals and inpatient rehabilitation facilities, critical access hospitals, and home health agencies (HHAs). The proposed rule would implement the discharge planning requirements of the Improving Medicare Post-Acute … Continue Reading

CMS/OIG Finalize Fraud Authority Waivers for Accountable Care Organizations (ACOs) under the Medicare Shared Savings Program (MSSP)

The Centers for Medicare & Medicaid Services (CMS) and the Office of Inspector General (OIG) have finalized a rule designed to “remove legal and regulatory barriers that can impede care coordination in furtherance of the Shared Savings Program” and “reduce burden on ACOs, ACO participants, and ACO providers/suppliers.”  Specifically, the rule allows ACOs, ACO participants, … Continue Reading

CMS Adopts Changes to Medicare & Medicaid EHR Policies

The Centers for Medicare & Medicaid Services (CMS) has published a sweeping final rule with comment period that specifies the requirements that eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) must meet in order to qualify for Medicare and Medicaid electronic health record (EHR) incentive payments and avoid downward payment adjustments under the … Continue Reading

CMS Provides More Time to Comment on MACRA Physician Payment Reforms

CMS has extended the comment period on its October 1, 2015 request for information (RFI) regarding implementation of the Merit-based Incentive Payment System and promotion of alternative payment models in accordance with MACRA. The comment period, which originally was scheduled to end on November 2, 2015, has been extended until November 17, 2015. CMS also … Continue Reading

CMS Expands Medicare Prior Authorization Model for Repetitive Scheduled Non-Emergent Ambulance Transport

As previously reported, CMS announced in November 2014 that it would test a Medicare prior authorization process for repetitive scheduled nonemergent ambulance transport services in New Jersey, Pennsylvania, and South Carolina. The three-year model began on December 1, 2014. As mandated by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), CMS is now … Continue Reading

CMS Proposes Funding Methodology for ACA Basic Health Program for 2017-2018

On October 22, 2015, CMS published a proposed methodology for determining federal payment amounts to states that elect to establish a Basic Health Program (BHP) to offer health benefits to low-income individuals otherwise eligible to purchase coverage through an Affordable Insurance Exchange/Marketplace in program years 2017 and 2018. The proposed notice uses the same methodology … Continue Reading

CMS Sends Long-Awaited Medicare 60-Day Overpayment Rule to OMB for Final Clearance

CMS is moving ahead on its much-anticipated final rule implementing Affordable Care Act (ACA) requirements on reporting and returning of Medicare overpayments.   Under the ACA, enrolled providers and suppliers (and certain other enrollees) receiving Medicare funds must report and return Medicare overpayments by the later of 60 days after the date on which the overpayment was … Continue Reading

CMS Sends Final 2016 Medicare Payment Rules to OMB for Review

This week CMS referred major final calendar year 2016 Medicare payment rules to the White House Office of Management and Budget (OMB) for regulatory clearance. Specifically, OMB is reviewing the final CMS rules to update the Medicare physician fee schedule, the hospital outpatient prospective payment system (PPS) and ambulatory surgical center payment update, the home … Continue Reading

CMS Posts CY 2016 Amount in Controversy Thresholds for Medicare Appeals

CMS has published a notice announcing the annual adjustment in the amount in controversy (AIC) threshold amounts for Administrative Law Judge (ALJ) hearings and judicial review under the Medicare appeals process. Specifically, the calendar year 2016 AIC threshold amounts are $150 for ALJ hearings (the same as 2015) and $1,500 for judicial review (compared to … Continue Reading

CMS Proposes Major Changes to Medicare Clinical Lab Test Payment Policy

On October 1, 2015, the Centers for Medicare & Medicaid Services (CMS) published its long-awaited proposed rule to base Medicare clinical laboratory fee schedule (CLFS) reimbursement on private insurance payment amounts beginning January 1, 2017. CMS estimates that the new policy, which was mandated by the Protecting Access to Medicare Act of 2014 (PAMA), will … Continue Reading

CMS Seeks Input on MACRA Physician Payment Reform Implementation

On October 1, 2015, CMS published a request for information (RFI) regarding implementation of Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) provisions that mandate significant reforms of the Medicare physician payment system. As previously reported, MACRA repealed the sustainable growth rate methodology (SGR) for updating the Medicare physician fee schedule, and after a … Continue Reading

CMS Corrects FY 2016 Medicare Payment Rules

CMS has released corrections to a number of fiscal year (FY) 2016 final Medicare payment rules. Specifically, on October 5, 2015, CMS is publishing corrections to: The final FY 2016 hospice payment update (to correct the hourly rate for continuous home care); The final FY 2016 hospital inpatient prospective payment system/long-term care hospital prospective payment … Continue Reading

CMS Extends Comment Period on Proposed Rule to Reform LTC Requirements

On September 15, 2015, CMS is publishing a notice extending by 30 days the comment period for its July 16, 2015 proposed rule entitled “Reform of Requirements for Long-Term Care Facilities.”  Specifically, the comment period has been extended from September 14, 2015 until October 14, 2015.  CMS notes that it is taking this step in response … Continue Reading