Policy Updates

No Surprises Act Implementation Yields Mixed Results

Is the No Surprises Act working? Is it protecting patients from surprise medical bills? Are providers and insurers happy? The Washington Post reports mixed results. On one hand, millions of people have been protected from surprise medical bills. But on the other hand… Experts thought that once the terms of the program were understood there would be only about 22,000 cases sent to arbitration – the law’s Independent Dispute Resolution process – in 2022. Instead, nearly 500,000 cases went that route, with nearly half of the requests for arbitration coming from physician staffing companies owned by private equity firms. At [...]

joe2024-02-14T16:33:47-05:00February 14, 2024|Uncategorized|

States Not Depending on Federal Action on Prior Authorization

Unwilling to leave the challenge of addressing the troubling prior authorization practices of many health insurers, officials in some states are trying to take matters into their own hands. Last year, lawmakers in 29 states considered 90 different bills to impose varying prior authorization requirements on health insurers serving their constituents. Among the changes these proposals seek: shorter response times for requests for authorization and mandatory public reporting of insurers’ prior authorization activity. In addition, last year five states required insurers to engage in a practice known as gold carding: waiving prior authorization for requested items and services for individual [...]

joe2024-02-13T16:56:53-05:00February 14, 2024|Uncategorized|

Millions Dropped From Medicaid Rolls

With the two-year “Medicaid unwinding” process nearly half complete, 9.5 million Americans have lost their Medicaid coverage – among them more than 3.7 million children. To date, 48 million of the 71 million people enrolled in Medicaid at pandemic’s end have had their eligibility reviewed. So far, many of those who were at first ruled ineligible were dropped for procedural reasons, such as failing to file paperwork on time, but many of those people eventually had their benefits restored. Still, estimates that 15 million people would lose their Medicaid eligibility by the time the process ended appear to be overlying [...]

joe2024-02-08T22:22:10-05:00February 13, 2024|Medicaid|

CMS Clarifies Medicare Advantage Rule

To help clarify its final Medicare Advantage rule for 2024, the Centers for Medicare & Medicaid Services has published an FAQ providing additional guidance to Medicare Advantage plans and Medicare-Medicaid plans about prior authorization for admission to post-acute-care facilities and plans’ future use of artificial intelligence (AI), algorithms, and other software tools in their coverage criteria and utilization management practices. The rule has broad implications for most health care providers but especially for post-acute-care providers, which the FAQ reflects by addressing major issues and long-running challenges for such providers, including prior authorization for discharge from acute-care hospitals into post-acute care, [...]

joe2024-02-08T21:14:52-05:00February 12, 2024|340b, Centers for Medicare & Medicaid Services, Medicare, Medicare post-acute care, Medicare regulations, Medicare reimbursement policy, post-acute care|

Federal Health Policy Update for February 8

The following is the latest health policy news from the federal government for February 2 - 8. Some of the language used below is taken directly from government documents. Congress Members of the Senate’s 340B bipartisan working group have released a discussion draft of legislation that would update the 340B prescription drug discount program. Last year the group sought stakeholder input on policy solutions that might provide stability and transparency to the 340B program to ensure that the program can continue to achieve its original intent of supporting entities serving eligible patients. Find a news release describing the discussion draft [...]

joe2024-02-08T20:43:44-05:00February 8, 2024|340b, Centers for Medicare & Medicaid Services, MACPAC, Medicaid, Medicaid and CHIP Payment and Access Commission, Medicare, Medicare post-acute care, Medicare regulations, Medicare reimbursement policy, post-acute care, Telehealth|

States Using Medicaid Money to Address Homelessness

Trusting in the adage that “an ounce of prevention is worth a pound of cure,” more and more states are using Medicaid funds to address homelessness. The theory, not fully tested, is that providing housing to the homeless, along with other social supports, will reduce their use of hospital emergency rooms, improve their overall health, and end up saving taxpayer money. Some are skeptical, believing health care money should be spent on health care services. Today, 19 states are using some of their Medicaid resources to provide housing to the homeless. Leading the way is California, which is spending $12 [...]

joe2024-02-07T17:56:09-05:00February 8, 2024|Medicaid, Medicaid and homelessness, Medicaid and housing|

Medicare ACO Participation Rising

Participation in Medicare’s various accountable care organizations is increasing, the Centers for Medicare & Medicaid Services reports. According to CMS, 50 new ACOs will participate in its Medicare Shared Savings Program in 2024 along with another 19 that will participate in a new, permanent payment option version of that program. Another 71 ACOs renewed their participation in the program, bringing the total number of ACOs in the program to 480 that together will serve nearly 11 million traditional Medicare beneficiaries. Other Medicare ACOs account for another three million participants. Among them are 2.6 million served by 122 ACOs in the [...]

joe2024-02-06T20:51:47-05:00February 7, 2024|Accountable Care Organization, ACO, Alternative payment models, Center for Medicare and Medicaid Innovation, Centers for Medicare & Medicaid Services|

Federal Health Policy Update for February 1

The following is the latest health policy news from the federal government for January 26 – February 1. Some of the language used below is taken directly from government documents. Centers for Medicare & Medicaid Services CMS has released its calendar year (CY) 2025 Advance Notice for the Medicare Advantage and Medicare Part D Prescription Drug Programs that would update payment and other policies for these programs. Under the notice, federal Medicare Advantage spending would increase an expected 3.7 percent, or more than $16 billion, but the agency also proposes reducing by 0.16 percent the program’s base rate. CMS also detailed [...]

joe2024-02-01T21:47:38-05:00February 1, 2024|Accountable Care Organization, Alternative payment models, Center for Medicare and Medicaid Innovation, Centers for Medicare & Medicaid Services, CMMI, COVID-19, Federal Update, health equity, hospitals, MACPAC, Medicaid, Medicaid and CHIP Payment and Access Commission, Medicare, Medicare regulations, Medicare reimbursement policy, Telehealth|

Preventable Medicaid Hospitalizations Vary Based on Race, Eligibility Path

Preventable hospitalizations among Medicaid patients vary based on the race of the patient and how that patient came to be eligible for Medicaid, according to a new analysis by the Urban Institute. According to a review of preventable hospitalizations in 21 states, the report concluded that: … the three most common types of potentially preventable hospitalizations for Medicaid-enrolled adults were asthma/COPD (0.2 percent of enrollees had at least one such hospitalization in 2019), diabetes (0.4 percent of enrollees had at least one such hospitalization in 2019), and heart failure (0.2 percent of enrollees had at least one such hospitalization in [...]

joe2024-01-29T19:09:49-05:00January 30, 2024|health equity, Medicaid|

Federal Health Policy Update for January 25

The following is the latest health policy news from the federal government for January 12 - 25. Some of the language used below is taken directly from government documents. Department of Health and Human Services – Funding Models HHS has announced a new model to test approaches for addressing the behavioral and physical health and health-related social needs of people with Medicaid and Medicare. The goal of the Innovation in Behavioral Health Model (IBH) is to improve the overall quality of care and outcomes for adults with mental health conditions and/or substance use disorders by connecting them with the physical, behavioral, [...]

joe2024-01-25T22:30:26-05:00January 25, 2024|Alternative payment models, Center for Medicare and Medicaid Innovation, Centers for Medicare & Medicaid Services, CMMI, health equity, hospitals, MACPAC, Medicaid, Medicaid and CHIP Payment and Access Commission, Medicaid regulations, Medicare, Medicare regulations, Medicare reimbursement policy, MedPAC, social determinants of health, Telehealth|