flag_160540827On Monday, March 6, 2017, House Republicans released the long awaited proposed legislation to replace the Affordable Care Act (ACA).

The GOP bill, the “American Health Care Act” (AHCA), repeals or significantly changes major portions of the ACA involving the individual and employer mandates, subsidies, and Medicaid expansion, among others. The AHCA, which is already facing political headwinds and healthcare industry objections, has not yet been scored by the Congressional Budget Office (CBO), so the economic effect and the potential change to the number of people covered by health insurance have not been officially quantified. However, the AHCA’s overall philosophy and goals are clear, and it signals areas of concern for healthcare providers and Medicaid expansion States. In this article in our series on the effect of a “slow repeal” of the ACA, this week’s discussion focuses on the significant aspects of the proposed AHCA, potential concerns for healthcare providers, and likely next steps.

Continue Reading Slow Repeal of the ACA – Proposed Replacement Legislation Released

flag_160540827This is the fifth article in our series on the effect of the “slow repeal” of the Affordable Care Act (ACA). This week’s article focuses on the potential impact of the slow repeal of the ACA on rural communities and healthcare.

Continued Fragile System Leads to Uncertainty or Closure Causing Economic Ripple Effect Throughout Rural America

There are nearly 5,000 short-term, acute care hospitals in the United States, half of which are in rural areas. About four in 10 rural hospitals are located in the South. More than half of rural hospitals are Critical Access Hospitals (CAHs) (53.5%); a smaller share of rural hospitals are designated as Sole Community Hospitals (SCHs) (13%), Medicare Dependent Hospitals (MDHs) (8%), and Rural Referral Centers (RRCs) (11%). All of these designations provide enhanced or supplemental reimbursement under Medicare, using different formulas. Rural hospitals that do not qualify for these Medicare programs are reimbursed as standard Medicare Prospective Payment System (PPS) hospitals. Continue Reading Slow Repeal of the ACA and Its Impact on Rural Healthcare and Communities

Group of Children in a CircleOn January 6, 2017, several new regulatory exceptions to the beneficiary inducement statute went into effect. These regulations, published by the Department of Health and Human Services Office of Inspector General (OIG) in a final rule dated December 7, 2016,1 bring long awaited closure to many of the outstanding issues raised in the statutory versions of the exceptions implemented by the Affordable Care Act (ACA) and in the proposed regulations issued by the OIG on October 3, 2014.2 Several exceptions that may be of particular interest to children’s hospitals are highlighted below. Continue Reading New Regulatory Exceptions to the Beneficiary Inducement Statute

Traffic lights over blue skyGov. John Bel Edwards signed an executive order Jan. 19, 2016, to make Louisiana the 32nd state to adopt Medicaid expansion under the Affordable Care Act. Montana’s Medicaid expansion became effective Jan. 1, and South Dakota, Virginia and Wyoming are including Medicaid expansion in upcoming state budget proposals.

This is reflective of a growing trend of so-called “red” states that are nevertheless adopting provisions of the Affordable Care Act that subsidize healthcare costs for new groups of citizens who cannot afford commercial or exchange insurance products and do not qualify for Medicare. To sweeten the pot, the Obama administration announced its 2017 budget proposal will include a legislative proposal to provide any state that expands Medicaid coverage under the Affordable Care Act with the same three years of full federal funding that states that expanded their Medicaid programs in 2014 enjoyed. Continue Reading Red states see green: Opportunities for children’s hospitals

gavel-scales2013%20052[A New York district court issued the first judicial opinion Monday, Aug. 3 on the Affordable Care Act’s “60-day rule,” which requires that a Medicare or Medicaid overpayment be reported and returned within 60 days of the date on which the overpayment was “identified.” The decision by Judge Edgardo Ramos provided a definition of what it means to “identify” an overpayment and thus begin the 60-day time period in which overpayments must be reported and returned. Given that the 60-day rule maintains that any person who knowingly fails to comply with this obligation within the 60-day timeframe has violated the False Claims Act (“FCA”), the potential implications of Judge Ramos’s decision are significant. Continue Reading District court interprets ‘identification’ of overpayment under 60-day rule

TexasFlagOn Thursday, July 16, 2015, the Texas Health and Human Services Commission (HHSC) held a public meeting regarding its request to seek an extension of its Section 1115 Medicaid Transformation Waiver. The current waiver covered a five year period ending September 30, 2016. Under the waiver Texas has expanded Medicaid managed care, created a funding pool to offset uncompensated care and provided incentives for hospitals and other providers to develop delivery system infrastructure in Texas. Over the waiver period, Texas will commit $29 Billion to the uncompensated care and delivery system payment pools (approximately 58% or $16.82 Billion represent federal funds).

Continue Reading Texas 1115 Waiver Extension

The Texas Health & Human Services Commission’s (HHSC) final rules regarding physician billing for services provided by an APRN or PA became effective Jan. 1, 2015, and include limitations on such billing arrangements. See 39 Tex. Reg. 9884 (Dec. 19, 2014). The adopted rule requires that a physician billing for services provided by an APRN or PA under the physician’s Medicaid billing number must make a decision regarding the patient’s care or treatment on the same date of service as the billable medical visit and documented that decision in the patient’s recordSee Tex. Admin. Code Tit. 1 §354.1062. If a physician billing for such services does not make a decision regarding the patient’s care or treatment on the same date of service, the physician must note on the claim that the services were provided by a supervisee. See Tex. Admin. Code Tit. 1 §354.1001. Continue Reading Update: Texas Medicaid ‘incident to’ rule now in effect

Pursuant to the Affordable Care Act, the Centers for Medicare and Medicaid Services recently adopted a final rule implementing $1.1 billion in cuts to the Medicaid disproportionate share hospital (DSH) program in 2014 and 2015.  The new rule reduces Medicaid DSH payments by $500 million in 2014 and $600 million in 2015. 

There are several factors that impact how CMS will implement these reductions across the states.  CMS will apply smaller reductions to hospitals in low-DSH states.  States with fewer uninsured individuals and states that do not direct Medicaid DSH payments to hospitals with high Medicaid and uncompensated care volumes will absorb larger cuts.

The Medicaid DSH program reimburses hospitals that serve significant Medicaid and uninsured populations.  Supporters of ACA believe that Medicaid DSH payments will be less necessary because fewer people will be uninsured.  In states that do not expand Medicaid, however, safety net hospitals may receive cuts in their Medicaid DSH funding without corresponding reductions in their uninsured populations.

Between 2016 and 2020, ACA mandates further cuts totaling $17 billion.