Jeff Wurzburg (US)

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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…
“In light of the district court’s decision in Stewart v. Azar,” CMS has opened a new 30-day comment period for the Kentucky HEALTH demonstration project that would implement work or community engagement requirements as a condition of eligibility.  On June 29, 2018, Judge James E. Boasberg of the U.S. Federal District Court for the District of Columbia struck down the program, finding the approval by CMS to be arbitrary and capricious (HL Pulse summary here
On July 11 the U.S. Department of Justice (DOJ)  announced a new Task Force on Market Integrity and Consumer Fraud.  The wide-ranging Task Force will be chaired by the Deputy Attorney General and work towards: [T]he investigation and prosecution of cases involving fraud on the government, the financial markets, and consumers, including cyber-fraud and other fraud targeting the elderly, service members and veterans, and other members of the public; procurement and grant fraud; securities…
On Saturday, July 7, 2018, the Centers for Medicare & Medicaid Services (CMS) announced the suspension of risk adjustment payments for the 2017 benefit year until the resolution of risk adjustment litigation following the decision in New Mexico Health Connections v. United States Department of Health and Human Services et al., in the United States District Court for the District of New Mexico (No.1:16-cv-00878).  CMS seeks a “quick resolution,” but in the meantime approximately $10.4…
On June 29 Judge James Boasberg of the United States District Court for the District of Columbia vacated the approval by the Secretary of Health and Human Services of Kentucky HEALTH.  Kentucky HEALTH was to be implemented on July 1.  Kentucky HEALTH is the state of Kentucky’s section 1115 demonstration project that would have required Medicaid beneficiaries to engage in work or community engagement activities to remain eligible for Medicaid coverage.  Judge Boasberg held that…