Medicare and Medicaid Archives - HEALTH & LIFE SCIENCES NEWS

CMS Advises Preparatory Steps for Anticipated PrEP Coverage Transition to Medicare Part B

by Monica Wallace, Emily Jane Cook and Gregory E. Fosheim | Apr 25, 2024 | Life Sciences

On April 15, the Centers for Medicare & Medicaid Services (CMS) released a fact sheet on the potential national coverage determination (NCD) for pre-exposure prophylaxis (PrEP) using antiretroviral drugs to prevent HIV. CMS did not announce any coverage changes in the fact sheet but is providing advance information to avoid any possible disruptions to beneficiaries should the NCD be issued.

We are closely monitoring this issue and will provide further updates regarding the coverage details and additional guidance in the NCD once it is issued.

Under the proposed NCD, PrEP drugs (which may be covered under Medicare Part D and subject to beneficiary cost-sharing obligations) would be transitioned to Medicare Part B, with no beneficiary cost-sharing obligations. CMS also proposes to cover HIV screening tests and counseling visits under Medicare Part B. This would be consistent with most commercial health insurance and Medicaid plans, which, under the Affordable Care Act, must cover PrEP drugs (oral or injectable), laboratory tests and related clinical visits without cost sharing when prescribed by a healthcare provider.

If the proposed change for PrEP drugs occurs, pharmacies will need to be enrolled in Medicare Part B as either a durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) supplier (CMS-855S) or as a Part B pharmacy supplier (CMS-855B). Pharmacies not already enrolled should consider doing so in preparation for the final NCD, as Part B coverage will be effective at the time the final NCD is posted. Pharmacies enrolled in Part B with the provider type [...]

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VBC Symposium 2023 | Innovations in Value-Based Care for Complex Populations

by McDermott Will & Emery | Jul 6, 2023 | Uncategorized

During this session, Partner Jeremy Earl moderated a panel that discussed how value-based care models are delivering care to individuals with complex conditions and those with significant healthcare and social needs. The panel also provided perspectives from executives at companies that are revolutionizing the delivery of care to high-needs populations and demonstrating how doing good can also be a successful business model.

Session panelists included:

Christopher Aguwa, Executive Vice President & Head of Growth and Business Development, Cityblock
Benjamin Kornitzer, MD, Chief Medical Officer, agilon health
Hank Watson, Chief Development Officer, American Health Partners
Lea Tompsett, Head of Provider Enablement, Waymark

Top takeaways included:

Focus on Empowering and Elevating Providers. The companies that are successfully delivering care to complex populations are those that are focused on empowering and elevating providers to fill in gaps in care; such entities also succeed on cost and outcome goals as a result. These companies primarily focus on primary care providers (PCPs), nursing homes and related front-line providers. The panelists who focus their efforts on primary care do so in the belief that primary care can have the greatest impact on outcomes. Traditionally, primary care has been delivered within the four walls of a PCP’s office, with fee-for-service (FFS) reimbursement. Companies take different approaches to moving outside of this traditional model: Some focus on extending services outside of the PCP’s office to fill in gaps in care, such as deploying nurses to the home. Others seek to enable PCPs with data and [...]

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PPM ASC Symposium 2023 | Washington Outlook: Evolving Federal Policy Impacting Reimbursement, Operations and Deal Strategies

by McDermott Will & Emery | Jun 12, 2023 | PPM/ASC

In this session, panelists discussed the political shifts in Washington that are impacting healthcare reimbursement, operations, and deal strategies, including Centers for Medicare & Medicaid Services (CMS) policies on reimbursement, recent activity regarding non-competes and consolidation, and the end of the COVID-19 public health emergency (PHE).

Session panelists included:

Brian Fortune, President, Farragut Square Group
Deborah Godes, Vice President, McDermott+Consulting
Katharine O’Connor, Partner, McDermott Will & Emery
William Prentice, Chief Executive Officer, Ambulatory Surgery Center Association
Moderator: Eric Zimmerman, Principal, McDermott+Consulting, and Partner, McDermott Will & Emery

Top takeaways included:

Eight years after the passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), CMS continues to make adjustments to calibrate physician reimbursement. As they do so, budget neutrality requirements continue to hamper progress. Providers may have to look to the US Congress to get involved and implement an inflation adjustment factor to the fee schedule.
Ambulatory Surgery Centers (ASCs) may face challenges in obtaining favorable reimbursement as they enter the fifth year of a pilot program in which they have been receiving the same inflation adjustments as hospitals. At the end of the pilot program, it is unclear whether ASC reimbursement will continue to receive the hospital market basket adjustments or go back to Consumer Price Index (CPI) adjustments, which have historically been less favorable than hospital inflation adjustments.
Site neutrality continues to be a hot topic as CMS and Congress looks for ways to minimize incentives to refer patients to one setting over [...]

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Proposed Changes to DSH Payment Calculation Regulations Could Impact 340B Hospitals

by Emily Jane Cook, Caroline Reignley and Katie Waldo | Mar 10, 2023 | 340B

On February 28, 2023, the Centers for Medicare and Medicaid Services (CMS) released a proposed rule that would change how Medicare disproportionate share hospital (DSH) payments are calculated with respect to the counting of days associated with Section 1115 demonstrations in the Medicaid fraction of the DSH calculation. This proposed rule is a follow-up to the FY 2022 and FY 2023 Inpatient Prospective Payment System (IPPS) proposed rules, which initially included similar proposed revisions to the treatment of certain Section 1115 waiver days for purposes of the Medicare DSH adjustment.

Comments on the proposed rule are due May 1, 2023.

Read the full article here.

HPE New York 2021: Prepare for Tomorrow

by McDermott Will & Emery | Oct 26, 2021 | Health Private Equity, Uncategorized

Kevin Miller—a partner at McDermott Will & Emery whose practice largely focuses on the securities, tax and regulatory aspects of complex transactions—moderated a panel during HPE New York 2021 that looked at how government actions will impact the market. The panel feature: