HealthCheck, December 2018

Academy activities, legislative/regulatory updates, and more.

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December 19, 2018

Academy Activities

On Dec. 18, the Individual and Small Group Markets Committee submitted comments about the October guidance from the Department of the Treasury and the Department of Health and Human Services (HHS) on State Relief and Empowerment Waivers under Section 1332 of the Affordable Care Act (ACA), focusing on three areas: evaluation of coverage comprehensiveness and affordability, evaluation of coverage, and waiver funding. Read the related Academy alert.

The Health Practice Council (HPC) provided comments to the Centers for Medicare and Medicaid Services (CMS) in response to its request for comments on proposed rules pertaining to the Medicare Advantage program. The proposed rules include provisions to revise the risk adjustment data validation payment error calculation methodology and process. CMS also released an accompanying study and technical appendix regarding the fee for service adjuster.

The Health Practice Employee Benefits Committee and the Individual and Small Group Markets Committee submitted comments to the administration on Dec. 13 on the proposed rule regarding Health Reimbursement Arrangements (HRAs), issued jointly on Oct. 29 by the IRS, the Employee Benefits Security Administration of the Department of Labor, and CMS. The proposed rule would create two new types of HRAs—Integrated HRAs and Excepted Benefit HRAs—which would allow employers to provide HRAs that could be used to pay for individual plan premiums and out-of-pocket health costs.

Legislative/Judicial/Regulatory Updates

check markA federal judge for the U.S. District Court for the Northern District of Texas issued a decision in Texas v. Azar on Dec. 14 declaring the individual mandate for health insurance coverage to be unconstitutional and further cannot be severed from the rest of the ACA, thus making the entire law invalid. Read the Academy alert.

check markCMS on Dec. 7 released a final rule on the methodology for the risk-adjustment program operated by HHS for the 2018 benefit year. Read the Academy alert.

check markCMS’ Office of the Actuary released data on U.S. national health expenditures for 2017 on Dec. 6. Read the Academy alert.

check markThe Maine Business and Consumer Court issued an order on Dec. 6 in response to a motion from Gov. Paul LePage requesting a stay on a Nov. 21 ruling that the state’s Department of Health and Human Services begin implementing a voter-approved expansion of the state’s Medicaid program by Dec. 5. The court’s order extended the deadline for implementation of the Medicaid expansion to Feb. 1, but noted that the central determinations made in its Nov. 21 ruling have not changed. LePage’s term expires on Jan. 2. The court stated the extension will give the new state legislature an opportunity to review the expansion.

check markSens. Ron Wyden and Chuck Grassley introduced a bill on Dec. 4 that would allow HHS to fine drug companies participating in the Medicaid program that knowingly misclassify products and recover rebate payments that are due. The bill gives HHS the ability to correct such misclassifications.

check markCMS sent a letter to the Minnesota Department of Commerce on Nov. 30 announcing that it would provide the state an estimated $84.7 million in federal pass-through funding for its state-based reinsurance program in 2019, down from an estimated $130.7 million in federal pass-through funding for 2018. 

check markHHS’ Dec. 10 final rule on risk adjustment cited the HPC’s issue paper on the ACA risk adjustment program.

check markA Section 1115 Medicaid waiver request from New Hampshire was approved by CMS on Nov. 30. Under the waiver, Medicaid enrollees will be required to perform 100 hours of work or community engagement activities each month as a condition of Medicaid eligibility.

check markA proposed rule released by CMS would make several changes to the Medicare Advantage and Part D programs with the intention of lowering drug costs. The proposed changes include providing Part D plans with greater flexibility to negotiate discounts for drugs in “protected” therapeutic classes; requiring Part D plans to provide enrollees with a patient’s out-of-pocket cost obligations when a prescription is written; allowing “step therapy” for Part B drugs; and implementing a statutory requirement, recently signed by President Trump, prohibiting pharmacy “gag” clauses in Part D. Comments on the proposed rule are due Jan. 25.

check markCMS reapproved a Section 1115 Medicaid waiver request from Kentucky on Nov. 20. The waiver, which was originally approved by CMS in January, was vacated by the U.S. District Court for the District of Columbia in June in response to a lawsuit filed by a group of Kentucky Medicaid enrollees. Following the court’s ruling, CMS exposed the waiver’s provisions for a new public comment period. The reapproved waiver includes requirements for work or community activities as a condition of Medicaid eligibility.

check markSen. Bernie Sanders and Rep. Ro Khanna announced on Nov. 20 that they would introduce companion bills in Congress aimed at reducing prescription drug prices. The legislation would require the HHS secretary to make sure Americans don’t pay more for prescription drugs than the median price in Canada, the United Kingdom, France, Germany, and Japan. The bill allows for the federal government to approve cheaper generic versions of drugs that fail to meet that threshold, regardless of any patents or market exclusivities in place on other drugs.

In the News / Media Activities

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