Effective January 1, 2019, The Affordable Care Act has required each hospital to publish, update, and make public a list of its standard charges for items and services provided by each hospital; this includes diagnosis related groups (DRGs). In CMS’ 2019 Proposed Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals (IPPS) Rule and 2019 […]
Read MoreOverview This evening, the Centers for Medicare and Medicaid Services (CMS) released a proposed rule entitled “Modernizing Part D and Medicare Advantage to Lower Drug Prices and Reduce Out-of-Pocket Expenses.” CMS believes that the changes proposed in this rule will give plans more tools to negotiate lower drug prices. The proposed rule discusses the definition [...] Read More
Today, the Centers for Medicare and Medicaid Services (CMS) finalized its CY 2019 Home Health Prospective Payment System Rate Update and CY 2020 Case Mix Adjustment Methodology Refinements. The rule implements a payment update, changes to the Home Health Value-based Purchasing Model (HHVBP), a new alternative case-mix model, and provisions related to home infusion therapy [...] Read More
On September 17, 2018, the Centers for Medicare and Medicaid Services (CMS) released a proposed rule entitled “Regulatory Provisions to Promote Program Efficiency, Transparency, and Burden Reduction.” The proposed rule was developed in response to President Trump’s executive order that instructed agencies to look for ways to reduce regulatory burden. The agency also notes that [...] Read More
In the Bipartisan Budget Act of 2018 the Congressional Budget Office underestimated – by $4 billion – the amount Medicare would save due to changes in Medicare Part D. Instead of saving $7.7 billion, Medicare will actually save $11.8 billion. The savings come from an increase in the government mandated discount that drug manufacturers must offer enrollees [...] Read More
Here are some reimbursement related reasons why access to biosimilars has been slower than hoped, even though patient out-of-pocket costs are lower. Current System Is an Improvement Over Earlier System, But Could Be Better Part B Is For Biologics (and Some Drugs) When I was working at the Senate Legislative Counsel’s office drafting the Average [...] Read More
CMS has released the risk adjustment summary report for the 2017 benefit year for the individual and small-group markets. The program, included as a permanent fixture of the Affordable Care Act (ACA), is designed to discourage adverse selection by health plans by providing transfer payments to plans with higher-than-expected health care costs. On a summer […]
Read MoreEvery year, thousands of Americans hear the devastating news that they have Alzheimer’s disease. This diagnosis carries with it a certain future of declining mental and behavioral capabilities, and the eventual need for round-the-clock end-of-life care. The financial costs can be staggering, and the emotional costs immeasurable. While the impact of Alzheimer’s can be slowed, […]
Read MoreOn April 2, 2018, the Center for Medicare and Medicaid Services (CMS) released a pre-publication version of a final regulation impacting both the Medicare Advantage (MA) and Medicare Part D prescription drug benefit programs. The provisions of the rule will be effective for the 2019 plan year. Update: CMS released the final version of the […]
Read MoreOn December 27, CMS issued a State Medicaid Director letter to explain new limitations on federal financial participation for durable medical equipment (DME) in Medicaid. Beginning on January 1, 2018 (as required by Section 5002 of the 21st Century Cures Act), federal reimbursement to states for DME expenditures in Medicaid will be limited to the […]
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