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

by Lynn Shapiro Snyder and Lesley R. Yeung

On December 16, 2011, the Center for Consumer Information and Insurance Oversight ("CCIIO") within the Centers for Medicare & Medicaid Services ("CMS") released a "bulletin" to provide information and solicit comments on the regulatory approach that the Department of Health and Human Services plans to propose to define essential health benefits ("EHB") under section 1302 of the Affordable Care Act. The "bulletin" provides information to stakeholders (i.e., consumers, states, employers, and health insurance issuers) about what benefits are likely to be required under the EHB package. CCIIO is proposing to give states a significant role in defining the EHB package by allowing them to select from one of four benchmark health plan types that will serve as the standard for the health plans offered through the new state exchanges starting in 2014. Public comments may be submitted to CMS by January 31, 2012. Comments should be sent to EssentialHealthBenefits@cms.hhs.gov. Stakeholders interested in the EHB package definition process should consider submitting comments and actively engaging in public dialogue with HHS on the process now.

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Expansion of the DMEPOS Competitive Bidding Program; Legislative Inquiry Related to Fraud and Abuse Enforcement Actions; and Automated Pre-Enrollment Provider Screening

by George B. Breen, Amy F. Lerman, Emily E. Bajcsi, Deepa B. Selvam

In order to be prepared for upcoming changes and to respond to new initiatives, providers and suppliers participating in Medicare must be aware of recent Congressional activity that would hold the federal government accountable for its intended enforcement efforts designed to curb health care fraud, waste, and abuse, as well as an effort by the Centers for Medicare & Medicaid Services (“CMS”) to implement automated pre-enrollment provider and supplier screening in January 2012. One example of the pressures that providers and suppliers face in this enhanced regulatory and enforcement climate is the upcoming expansion of the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (“DMEPOS”) Competitive Bidding Program, which is targeted to launch in July 2013 and for which the Round 2 bidding timeline was announced on November 30, 2011.

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by Lynn Shapiro Snyder and Lesley R. Yeung

The Early Retiree Reinsurance Program (“ERRP”) was created by the Patient Protection and Affordable Care Act to provide financial assistance to employers, unions, and state and local governments to help them maintain health insurance coverage for early retirees age 55 and older. A report published by the Department of Health and Human Services on March 2, 2011, states that almost 5,500 plan sponsors have been approved to participate in the ERRP and that $535 million in ERRP reimbursement payments have been made to date. It is important for plan sponsors and third-party administrators to understand that the health benefit claims that qualify for ERRP reimbursement are only those for medical services that would be covered by the Medicare program. Compliance is essential for those participating in the ERRP, especially when Medicare rules are relevant to this federal program.

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by George B. Breen, Carrie Valiant, Emily E. Bajcsi, Anjali N.C. Downs, and Amy F. Lerman

On February 2, 2011, the Centers for Medicare and Medicaid Services ("CMS") published new rules ("Final Rule") authorized by the Affordable Care Act ("ACA") creating a vigorous screening process for new and existing Medicare, Medicaid and the Children's Health Insurance Program ("CHIP") providers and suppliers; giving CMS authority to temporarily stop enrollment of new providers and suppliers; expanding the ability of CMS and States to temporarily suspend payments to providers and suppliers; establishing requirements for States to terminate providers from the Medicaid and CHIP programs; and adding several other enrollment-related provisions. Generally, the new rules are effective March 25, 2011.

Publication of the Final Rule follows the recent announcement that the federal government recovered more than $4 billion in FY 2010 from health care fraud prosecutions and settlements – the largest annual amount ever recovered in health care fraud cases. Significantly, the 2010 recoveries from civil health care matters brought under the False Claims Act were more than $2.5 billion, reportedly the largest in the history of the Department of Justice ("DOJ"). These results, and the Final Rule, are further evidence of the increased focus the government will place on enforcement efforts in 2011 and beyond.

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by Shawn Gilman and Frank C. Morris, Jr.

A little-noticed provision of the Patient Protection and Affordable Care Act (PPACA) will significantly impact both health care manufacturers and providers.  The provision amends the Rehabilitation Act of 1973 to require regulations by March 23, 2012, mandating that all medical diagnostic equipment and health care provider locations be able to accommodate the needs of individuals with disabilities.  This requirement would mean a redesign of both diagnostic equipment and locations for patient interactions to assure that individuals with disabilities who could not utilize currently available diagnostic equipment or provider locations will, in the future, have access to the care and services available to individuals without disabilities.  They must be able to have access to—and independently be able to enter, use, and exit—the equipment to the maximum extent possible.  This is significant because of the often high cost of diagnostic equipment and space requirements at provider locations.

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Now that we have sweeping new health care legislation, the Patient Protection and Affordable Care Act ("the Act"), let's look at the rollout of the accountable care provisions--i.e., those changes to the payment and delivery system that hold the most long-term promise of improving quality and cost-efficiency. They are discussed in my most recent article: "The Timeline for Accountable Care: The Rollout of the Payment and Delivery Reform Provisions in the Patient Protection and Affordable Care Act and the Implications for Accountable Care Organizations," published last week in the BNA's Health Law Reporter.  Click here to read the full article (PDF).

In my most recent article in the series I have been writing for the BNA's Health Law Reporter on payment and delivery system reform, accountable care organizations and bundled payments, I comment on where things are now that federal reform has stalled. The article, titled "Payment and Delivery System Reform: It's Only a Matter of Time," argues that changes in payment and delivery are on the horizon regardless of the pace of federal reform and that providers (and payers as well) should continue their efforts toward accountable care to meet the cost and quality challenges that are no less daunting today than they were a month ago. Please click here to view. I hope you find it of interest.

Thursday's White House Forum on Health Reform brought together people who have a stake in our health care system with people who have the ability to change it. Prior to his inauguration, President Obama called on Americans to hold community discussions about health care. More than 9,000 Americans signed up to host discussions in all 50 states and more than 30,000 Americans attended these discussions. These community groups submitted reports to the White House that detailed their concerns about the health care system and their suggestions for reform. At the Forum, several of these community participants joined health care experts to participate in the Forum discussions.

Did these community representatives have any meaningful impact on Thursday’s discussion? Let’s hope so – engaging members of our nation’s communities adds a necessary human element to these debates as they begin to take shape and hopefully will demonstrate to those who can effect change that every ordinary person must be involved in this important national discussion. The President expressed his desire see change by the end of this year. We should harness the energy generated by yesterday's discussions to promote actions that result in health reform efforts and engage all Americans - all "stakeholders" - in these efforts.