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On February 14, 2019, the Center for Medicare and Medicaid Innovation (CMMI) announced the Emergency Triage, Treat, and Transport (ET3) Model that aims to transform the ambulance system.  Medicare-enrolled ambulance service suppliers and hospital-owned ambulance providers will participate in the model.   CMMI believes this model will improve quality and lower costs by reducing hospitalizations and avoidable transports. Currently, Medicare provides payment for emergency ground ambulance services when a beneficiary is transported to a hospital, critical…
On January 22, 2019, the FDA released nonbinding guidance expanding the Abbreviated 510(k) program used to show the safety and efficacy of medical devices.  A new “safety and performance-based pathway” for certain, well understood device types, may be used by manufacturers to demonstrate substantial equivalency to devices already on the market. Under the 510(k) process, device manufacturers rely on predicate devices to demonstrate the safety and efficacy of a new device.  The guidance expands the…
On January 1, 2019, all hospitals are required to make public a list of their standard charges.  As a reminder, Section 2718(e) of the Public Health Service Act, as enacted by the Affordable Care Act, requires: “each hospital operating within the United States” to “make public (in accordance with guidelines developed by the Secretary) a list of the hospital’s standard charges for items and services provided by the hospital, including for diagnosis-related groups established under…
On Friday, December 14, Judge Reed O’Connor of the Federal District Court in the Northern District of Texas issued a declaratory judgment holding the shared responsibility provision (also referred to as the “Individual Mandate”), and with it, the entire Affordable Care Act (“ACA”), to be unconstitutional. The case is Texas v. United States and California (Civil Action No. 4:18-cv-00167) (previous HL Pulse discussion here). Judge O’Connor did not issue an injunction and the ACA…
On November 20, 2018, the Centers for Medicare & Medicaid Services (“CMS”) again approved the Kentucky HEALTH 1115 demonstration.  Kentucky HEALTH  was the first Section 1115 demonstration that CMS approved with a work and community engagement requirement as a condition of eligibility for coverage under Medicaid.  The demonstration requires certain Medicaid beneficiaries to engage in work or community engagement activities for at least 80 hours per month, or be locked out of coverage for six…
On November 2, 2018, CMS published its CY 2019 physician fee schedule final rule.  The final rule implements a number of significant changes to the way practitioners receive reimbursement for items and services provided to Medicare beneficiaries, including: Eliminating the requirement for a practitioner to document the medical necessity of a home visit in lieu of an office visit beginning with CY 2019. Reducing the documentation for established patient office and outpatient visits so that…
On August 9, 2018, CMS published the long-awaited Pathways to Success proposed rule.  CMS Administrator Seema Verma published a related  article on the Health Affairs Blog.  The proposed rule would usher in significant changes for Accountable Care Organizations (ACOs).  Groups of providers, such as doctors and hospitals, can join together to form an ACO and be held accountable for the quality and cost of care provided to a group of assigned beneficiaries.  If…
On August 1 the Departments of Treasury, Labor, and Health and Human Services (the Departments) published a final rule that will expand the availability of short-term limited duration insurance (STLDI).  A Health Law Pulse summary of the proposed rule may be read here.  STLDI is not required to comply with the Affordable Care Act (ACA) market reforms and consumer protections, such as the provision of essential health benefits and the elimination of lifetime and…
On July 25, 2018, the Centers for Medicare & Medicaid Services published its 2019 Medicare hospital outpatient prospective payment system (OPPS) and ambulatory surgical center (ASC) payment system proposed rule.  A fact sheet describing the proposed rule is available here. The proposed rule can be accessed here. CMS proposes to update hospital OPPS payment rates by 1.25 percent and update ASC payment rates using the hospital market basket rather than the consumer price…
CMS has issued a Final Rule to adopt the risk adjustment methodology for the 2017 benefit year.  The rule was issued without a notice and comment period and will become effective upon publication in the federal register.  The risk adjustment program is a premium stabilization program established by Congress in section 1343 of the Affordable Care Act.  The program transfers funds from plans with low-risk enrollees to plans with high-risk enrollees, in order to mitigate…