Week in Washington MA Rulings, Legislation Moving, and Uninsured Rates

Week in Washington is brought to you by Michael Cohen, PhD. Tune in each week to read the latest on healthcare policy and get a glimpse of what’s on the horizon.


September 14, 2018:  MA Rulings, Legislation Moving, and Uninsured Rates

Things you may have missed this week

United Wins Case Against CMS

A federal judge ruled against CMS and vacated the Medicare overpayment rule. As background, CMS audits diagnoses submitted by MA plans to determine if the diagnoses are valid. If they are invalid, MA plans need to pay back the “overpayment”.  The judge’s decision ruled that the overpayment rule is invalid because it violates the requirement that payments be actuarially equivalent to fee for service provider payments. The judge also concluded that CMS violated the Administrative Procedures Act (APA) by how it finalized rule.   

What happens next? As John Commins lays out here, CMS can either appeal the ruling or put forward a new rule that satisfies the judge’s critiques. In particular, a new rule could move away from tying overpayments to diagnosis codes and/or improve the definition of “identify” as part of the rule-making process.

Legislation Watch

There are a number of pieces of legislation that bear watching as Congress rushes to tie up loose ends before effectively skipping town until after the November election. Anything not handled in the next few weeks could be taken up in a lame duck session (after the election).

  • Opioid LegislationAn opioid treatment bill is expected to be passed in the Senate next week. A House bill on opioids passed earlier this year so before the bill can be finalized a negotiation between the House and Senate will happen. One key difference between the House and Senate bill is about IMD exclusion. The house version eliminates the restriction on Medicaid while the Senate version continues to not allow Medicaid to pay for addiction treatment in bigger facilities.  
  • Mandate Delays –The House is poised to pass a moratorium of the employer mandate requirements as well as make it less likely firms will be required to pay the mandate penalty.
  • Spending Bill-  HHS operating budget appears to be on track to be passed into legislation in the coming weeks. This would be passed on a bipartisan basis and therefore large cuts to the agency are unlikely.
  • HIT Watch – The House passed a two year delay for the health insurance tax (2020, 2021). The Senate has yet to vote on its own version of this. If it happens it is likely.

Uninsured Rate Stable

The US Census released its annual findings on health coverage. They found overall that the uninsured rate was stable relative to 2016, with the uninsured rate not changing. Most experts expect the uninsured rate to increase next year when the effects of the mandate repeal and potential work requirements go into effect.

 Navigator Funding Cut

CMS announced that the amount of funds and the number of navigators receiving funds would be reduced. Navigators help sign up enrollees to the ACA Exchanges. At the end of the Obama Administration, Navigator funding was at $100 million. For the 2019 benefit year that amount was announced at $10 million.




Previous editions:

08/31/2018:  Uninsured Rate Steady?

08/23/2018:  Maryland Joins Approved 1332 Waivers

08/16/2018:  Odds and Ends

08/10/2018:  ACO Rule is Out

08/02/2018:  Short Term Plans & more

07/26/2018:  Risk Adjustment is Back













07/19/2018:  HHS Regs are Coming

07/13/2018:  Risk Adjustment Roller Coaster

06/22/2018:  AHP Regulations, Budgets, and More  

06/15/2018:  Risk Corridor Lawsuits and More Lawsuits

06/06/2018:  Medicare Trustees Report

05/31/2018:  Mandates and Medical Expansion










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