Government News of the Week
Medicare Compliance, HIPAA, Medicare Advantage and Part D,
Health Care Reform, and Other Federal and State Government Developments

November 21, 2016

Note: AIS's Government News of the Week will not be published Nov. 28 because of the Thanksgiving holiday.

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(1) A Republican ACA replacement could expand the individual market if it allows insurance carriers to design products tailored to young and healthy populations, suggested Matthew Borsch, an equities analyst at Goldman Sachs. While admitting he had a “glass-half-full” view, he said a bipartisan effort to replace the ACA could include some variation of insurance exchanges, significantly more product flexibility for carriers, 5:1 age-rating bands, a requirement for continuous coverage and the creation of high-risk pools for the most costly patients. He acknowledged such a scenario would be asking a lot of lawmakers. Borsch was one of three panelists at the 21st annual “Wall Street Comes to Washington” roundtable, which was held Nov. 15 at the Brookings Institution in Washington, D.C. Borsch warned that eliminating the federal premium subsidies and the individual mandate would lead to an individual market that resembles New York state’s market prior to the ACA. There would be far fewer covered lives and much more expensive coverage. Sheryl Skolnick, an analyst at Mizuho Securities, USA Inc., was less optimistic. Prior to the ACA, the individual market was expensive and didn’t work well, and nothing has changed, she said. “The fundamental problem is insurance is expensive because people who buy it are sick, and companies need to stay in business,” she said. “As soon as we talk about guaranteed issue and affordability — in the same sentence — we have an impossibility theorem,” she said .... (From Inside Health Insurance Exchanges' E-Alert)

(2) Memorial Hermann Health System in Texas agreed to pay $5.65 million in a civil monetary penalty (CMP) settlement over its alleged misuse of modifiers -59 and -91. .... (more)

(3) The Government Accountability Office (GAO) on Nov. 14 rejected every one of the nine protests challenging the Department of Defense’s (DoD) $58 billion TRICARE Awards for 2017 .... (more)

(4) Republican lawmakers have long pledged to eliminate the ACA’s unpopular individual mandate provision, along with the rest of the law, but any replacement will likely need a financial mechanism that gives healthy people a reason to buy health insurance, Kaiser Health News reported Nov. 15. The ACA imposes a tax penalty on people who don’t have health insurance. This year, the penalty is the greater of $695 per person or 2.5% of household income. President-elect Trump has indicated he would keep a rule that requires carriers to sell coverage to anyone, despite pre-existing conditions. The article points to a policy paper House Speaker Paul Ryan (R-Wis.) released last summer, in which he suggested those who decided to buy coverage outside of an open-enrollment period would face steeper premiums .... (From Inside Health Insurance Exchanges' E-Alert)

  From Congress and the Federal Agencies

(5) In the Medicare appeals backlog case before the U.S. District Court for the District of Columbia (Burwell v. American Hospital Association, No. 14-cv-00851), both parties have now filed motions and responses over whether the court should issue a writ of mandamus compelling CMS to resolve the backlog on a court-ordered schedule .... (more)

(6) CMS in its 2017 Physician Fee Schedule final rule (81 Fed. Reg. 80170, Nov. 15, 2016) finalized two controversial provisions that will for the first time make public certain pricing data from MA bids and medical loss ratio (MLR) reports from Parts C and D plan sponsors .... (more)

(7) Zwanger & Pesiri Radiology Group, Zwanger Radiology P.C. and Steven Mendelson, M.D., will pay $8.153 million to settle false claims allegations .... (more)

(8) During a Nov. 14 meeting at the White House, HHS Sec. Sylvia Burwell made an appeal to preserve the Affordable Care Act (ACA) in the wake of Donald Trump’s (R) surprise victory. She argued the ACA is “now woven into the fabric of our nation,” and indicated that Americans don’t want to return to the insurance market that existed before the law. Instead, she said, they want to see Republican and Democratic lawmakers come together to improve the six-year-old law. While President-elect Trump ran on the platform of immediately repealing and replacing the ACA, he already has indicated some provisions — such as not denying coverage to people with pre-existing conditions, and allowing young adults to remain on a parent’s policy until age 26 — are likely to remain. Another Obama administration official suggested that the large number of people who buy 2017 coverage on the exchanges will make it more difficult for the new president and Congress to eliminate coverage or the federal subsidies that make it affordable, The Washington Post reported .... (From Inside Health Insurance Exchanges' E-Alert)

(9) CMS on Nov. 16 said more than 1 million people had signed up for exchange plans during the first 12 days of open enrollment for the 2017 plan year .... (more)

(10) CMS will for the third time delay enforcement of Medicare Part D prescriber enrollment requirements that were included in a final rule in May 2014 and an interim final rule in May 2015 .... (more)

(11) In an Emergency Medical Treatment and Labor Act (EMTALA) case (Friedrich v. South County Hospital Healthcare System, C.A. No. 14-353 S), the U.S. District Court for the District of Rhode Island has denied South County Hospital Healthcare System’s motion for partial summary judgment .... (more)


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