6th Circuit Affirms District Court Ruling On Medicaid DSH FAQs While Upholding Underlying Policy
On November 14, 2018, in a 2-1 decision, the 6th Circuit affirmed a summary judgment ruling that CMS Medicaid DSH third party payer FAQs are procedurally invalid, while holding that CMS has the statutory authority to require the inclusion of Medicare and commercial...
CMS Announces New Waiver Opportunity for Inpatient Mental Health Services
On November 13, 2018, CMS notified state Medicaid directors of a new 1115 waiver opportunity for adults and children with serious mental health conditions. This new authority, similar to the agency’s substance use disorder waiver authority issued in November 2017,...
CMS Released Proposed Medicaid Managed Care Rule
On November 8, 2018, CMS released proposed regulations to amend the 2016 Medicaid Managed Care Rule. The proposed rule would allow states to establish new 3-year pass-through payments for populations transitioning into managed care, streamline the approval process for...
CMS Issues 2018 OPPS Final Rule
On November 2, 2018, CMS issued its Hospital Outpatient and Prospective Payment System (OPPS) final rule. Of particular note, the agency finalized the proposal to extend the reduced payment rate provided under Section 603 of the Bipartisan Budget Act of 2015 (BBA) to...
HRSA Proposes Earlier Effective Date for Long-Pending 340B Ceiling Price Rule
Facing a legal challenge from the hospital industry, the Health Resources and Services Administration has proposed a January 1, 2019 effective date of a rule to establish a system to verify ceiling prices for 340B drugs, to provide web site access to the ceiling...
CMS Approves Innovative Pilot Program to Address Social Determinants of Health as Part of North Carolina’s New Medicaid Waiver
For a printer-friendly version, click here. The Centers for Medicare and Medicaid Services (CMS) approved a Section 1115 waiver for North Carolina on October 19, 2018 that includes an innovative new pilot program. Embedded in the larger waiver, which is focused...
CMS Releases Guidance on 1332 Waivers
On October 22, 2018, CMS released guidance for states seeking to implement State Innovation Waivers. The guidance provides additional clarification on the requirements that must be met for CMS to approve a 1332 waiver, including application review procedures,...
Supreme Court Agrees to Hear $4B Medicare DSH Case
On September 27, 2018, the Supreme Court granted certiorari in Azar v. Allina Health Services, et al. The Court will hear arguments on whether HHS was required to go through notice and comment before implementing a rule that altered the Medicare reimbursement formula...
Trump Administration to Consider Medicaid and Other Public Programs to Assess Public Charge
On September 22, 2018, the Trump administration issued a proposed rule that would newly consider an immigrant's use of Medicaid, SNAP, Medicare Part D Low-Income Subsidy program and several housing programs to determine whether an individual is a "public charge" for...
CMS issues SMDL Letter on Budget Neutrality Calculation for 1115 Waivers
On August 22, 2018, CMS issued a State Medicaid Directors letter outlining how states should calculate their budget neutrality expenditure limits for Medicaid 1115 Waivers.
CMS Issues Proposed Rule to Restructure the Medicare Shared Savings Program
On August 9, 2018, CMS released a proposed rule to restructure the Medicare Shared Savings Program (MSSP). The proposal seeks to reduce the amount of time ACOs can remain in the program without assuming risk by eliminating the one-sided shared savings option...
GAO Report Details Covered Entity Use of Contract Pharmacies and Related Compliance Issues, Including Audits and Corrective Action Plans
On June 28, 2018, the GAO released a report detailing how covered entities use contract pharmacies and relevant compliance issues.
CMS Releases New Medicaid Program Integrity Initiatives
On June 26, 2018, CMS announced a new set of initiatives seeking to promote program integrity throughout the Medicaid program. The initiatives focus on strengthening the audit process, increasing oversight of state contracts with provide health plans, increasing...
Trump Administration Releases Blueprint to Lower Drug Prices
On May 11, 2018, President Trump and HHS Secretary Alex Azar introduced their "American Patients First" initiative, described as a blueprint to lower drug prices and reduce out-of-pocket costs for patients. The plan also included a request for information (RFI)...
CMS Releases RFI on Stark Law
On June 25, 2018, CMS published a request for information (RFI) to seek input on how the agency could address the "undue regulatory impact and burden" of the physician self-referral, or "Stark," law.
CMS Rejects Kansas’ Request to Impose Lifetime Limits on Medicaid Beneficiaries
On May 7, 2018, CMS official Seema Verma announced that the agency would not approve Kansas’ request to impose a 3-year lifetime limit on certain Medicaid beneficiaries. Verma stated that while CMS is committed to transitioning people out of poverty, "we also...
CMS Publishes IPPS Extension for FY 2018
On April 26, 2018, CMS published an extension of the hospital Inpatient Prospective Payment Systems (IPPS) payment adjustments, effective April 24, 2018.
GAO Releases Report on CMMI Models
On April 25, 2018, GAO released a report on the performance results of various models implemented by CMS Innovation Center. The Report found that the models met goals targeting delivery and payment improvements, but only partially met the goals of reducing overall...