Bipartisan efforts to lower prescription drug costs remains a core focus for the US Congress. Effective October 1, 2024, the Centers for Medicare and Medicaid Services (CMS) has announced the follow-on cohort for its coinsurance savings program under the Medicare Prescription Drug Inflation Rebate Program.
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Legal Insights and Perspectives for the Healthcare Industry
The Medicare program is broken down into four parts. Part A covers the cost of healthcare items and services provided during inpatient hospital stays as well as skilled nursing facility, hospice, and some home health care. Part B covers certain physician services, outpatient care, medical supplies, and preventive services. Together, Parts A and B are commonly referred to as traditional Medicare or fee-for-service (FFS) because claims for each item or service are submitted to the Centers for Medicare & Medicaid Services (CMS) for reimbursement through its Medicare Administrative Contractors.
Since our publication on disenrollments caused by the “unwinding” of Medicaid’s continuous enrollment condition, the Centers for Medicare and Medicaid Services (CMS) issued an interim final rule on December 6, 2023 implementing the requirement under the Consolidated Appropriations Act for CMS to withhold federal Medicaid funding from states that do not report monthly unwinding data.
Estimates show that Medicaid enrollment grew by more than 20 million (approximately 31%) during the public health emergency (PHE) and the top Medicaid managed care organizations (MCOs) experienced a 44.1% increase in managed care enrollment between March 2020 and March 2023. This increase has been largely attributed to the continuous enrollment condition, which conditioned certain federal funding on maintaining all Medicaid enrollments during the PHE. In spring of 2023, the continuous enrollment condition ended and states were given a year to redetermine the eligibility of 94 million Medicaid enrollees.
The Centers for Medicare & Medicaid Services (CMS) proposed on April 23, 2023 two rules that would affect Medicaid managed care: Ensuring Access to Medicaid Services (CMS 2442-P) and Medicaid and Children’s Health Insurance Program (CHIP) Managed Care Access, Finance, and Quality (CMS-2439-P). The proposed rules recognize the growth of managed care, which currently constitutes more than 70% of the Medicaid population.
Medicaid enrollment grew significantly during the public health emergency (PHE). States implemented expanded eligibility and enrollment as well as reduced cost sharing and premiums based on Medicaid program regulatory flexibilities available during the PHE, but many of those will expire on May 11, 2023 and December 11, 2023.
On October 3, the Office of Inspector General (OIG) of the US Department of Health and Human Services issued a report titled “UPICs Hold Promise to Enhance Program Integrity Across Medicare and Medicaid, But Challenges Remain.” This report detailed OIG’s findings related to the efficacy of the Unified Program Integrity Contractor (UPIC) program.
The US Department of Health and Human Services, Office of Inspector General (OIG) recently transmitted a memorandum to the Center for Medicaid and CHIP Services detailing the findings of the Massachusetts state auditor's report on the commonwealth’s controls around dual-eligible hospice patients and weaknesses related to election statements and potential MassHealth overpayments for curative items and services related to hospice patients that should have been covered by the hospices.
Members of our healthcare team recently published a LawFlash highlighting the American Rescue Plan Act of 2021 (ARPA). ARPA provides $1.9 trillion in relief funding to address the COVID-19 pandemic, support the US economy, and provide relief for impacted Americans, and includes provisions specifically affecting healthcare providers remaining on the frontlines.
Our healthcare team recently published a LawFlash covering President Joe Biden’s two new health-focused executive actions, the Strengthening Medicaid and the Affordable Care Act and the Protecting Women’s Health at Home and Abroad memorandum.