PPACA Impact and Opportunities : Health Care Lawyer & Attorney : Epstein Becker Green Law Firm : Insurance & Costs : Health Reform Musings Blog

by Lynn Shapiro Snyder,  Shawn M. Gilman,  Adam C. Solander, and Constance A. Wilkinson

On June 16, 2011, the Office of Personnel Management (“OPM”) released the Request for Information (“RFI”) regarding Section 1334 of the Affordable Care Act, which requires OPM to contract with health insurers to offer multi-state qualified health plans (“MSQHPs”). The purpose of the RFI is to provide OPM with information that will allow it to better understand the “interests and capabilities” of health insurance issuers that will offer MSQHPs through Health Insurance Exchanges. This alert summarizes the substantive information requested by OPM in the RFI.  Additionally, this alert provides the statutory context in which OPM is operating pursuant to Section 1334 of the Affordable Care Act.

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David C. Gibbons, a Summer Associate (not admitted to the practice of law) in EpsteinBeckerGreen's Washington, DC, office, contributed significantly to the preparation of this alert.

by Patricia M. Wagner and Ross K. Friedberg

Among the criteria that the “Proposed Statement of Antitrust Enforcement Policy Regarding Accountable Care Organizations Participating in the Medicare Shared Savings Program” (“Proposed Statement”) uses to evaluate an accountable care organization’s (“ACO’s”) risk of an antitrust challenge is the ACO applicant’s “market share” within each of its service lines. The market share is a measure of the share of services an ACO participant provides in its Primary Service Area (“PSA”) relative to other providers. The share of services that each ACO participant provides in its PSA is the key factor that the agencies are proposing to use for determining whether an ACO will receive “Safety Zone” protection from the antitrust laws or be subject to mandatory expedited review from the agencies in order to participate in the Medicare Shared Savings Program. To assist with the PSA analysis, we have provided in this alert a step-by-step description of the proposed method for calculating PSA shares as well as an illustration of the steps involved in calculating PSA shares.

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by Patricia M. Wagner and Ross K. Friedberg

On April 19, 2011, the “Proposed Statement of Antitrust Enforcement Policy Regarding Accountable Care Organizations Participating in the Medicare Shared Savings Program” (“Proposed Statement”) was published in the Federal Register. As noted in the Proposed Statement, the antitrust enforcement agencies (the Department of Justice Antitrust Division and the Federal Trade Commission issued the Proposed Statement in response to a perceived preference by potential accountable care organization (“ACO”) participants to operate in both the Medicare and commercial markets. In order to “maximize and foster opportunities for ACO innovation, the Agencies wish both to clarify the antitrust analysis of newly formed collaborations among independent providers that seek to become ACOs in the Shared Savings Program and to coordinate the antitrust analysis with CMS review of those ACO applications.” This alert provides an overview of the Proposed Statement.

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