In May 2023, the Texas Legislature passed Senate Bill No. 14 (SB 14), which prohibits physicians and other licensed medical professionals from providing gender-affirming medical care to minors. The bill faced numerous legal challenges but ultimately went into effect on September 1, 2023. The case challenging the bill remains pending before the Texas Supreme Court.
Amidst the legal challenges, the Texas Office of the Attorney General has used its investigative and enforcement powers under the Texas Deceptive Trade Practices Act to initiate investigations of a hospital and telehealth clinic based outside of Texas in connection with their provision of gender-affirming care to minors.
On January 31, 2024, the US Centers for Medicare & Medicaid Services (CMS) released the Advance Notice of Methodological Changes for Calendar Year (CY) 2025 for Medicare Advantage (MA) Capitation Rates and Part C and D Payment Policies. CMS also released a press release and fact sheet. The advance notice is released on an annual basis and includes proposed updates to the capitation and risk adjustment methodologies used to calculate payments to MA plans, as well as other payment policies that impact Part D. The final CY 2025 rate announcement will be published no later than April 1, 2024.
The advance notice discusses several updates the Inflation Reduction Act of 2022 (IRA) made for 2025, including:
Newly defined Part D benefit design composed of three phases: annual deductible, initial coverage and catastrophic coverage
Lower out-of-pocket threshold of $2,000
Sunset of the Coverage Gap Discount Program and establishment of the Manufacturer Discount Program, and
As a result of the IRA, CMS proposes updates to the Part D risk adjustment model to reflect the Part D benefit design.
CMS is annually required to update the parameters for the defined standard Part D drug benefit. This is meant to ensure that the actuarial value of the drug benefit tracks changes in Part D expenses. For non-low-income subsidy beneficiaries, the advance notice outlines the benefit parameters for defined standard benefits in 2025 as follows:
In an apparent attempt to shield physician practices from perceived abuses of close association with physician practice management (PPM) companies, a pending Oregon law could undermine a broad range of structures and transactions between physicians and laypersons, including loans, real estate leases, practice sales, national virtual care platforms, investor sponsored practice roll-ups and payor-provider joint ventures.
Oregon House Bill 4130 prohibits several relationships and control structures which would materially constrain the typical PPM structure utilized by hospitals, private equity sponsors, virtual care providers, managed care companies and others to create a more integrated approach to care delivery, to take advantage of efficiencies and, in many instances, simply to operate.
If the US Supreme Court strikes down the established doctrine of significant judicial deference to certain government agency interpretations in two upcoming fishing boat cases, this decision could have ripple effects on employee benefit plan sponsors and fiduciaries. Such a decision would rock the boat and create more uncertainty in administering employee benefits.
On January 9, 2024, the Centers for Medicare and Medicaid Services (CMS) approved the New York State (NY) 1115 Medicaid waiver “Medicaid Redesign Team” (MRT). The MRT is a long-standing waiver in NY that has continuously evolved to improve the administration, structure and financing of the NY Medicaid program; enhance Medicaid beneficiaries’ access to services; and improve health outcomes across the state. The recently approved waiver represents the next step in Medicaid redesign in NY and builds on the previous Delivery System Reform Incentive Payment (DSRIP) program.
This article reviews the major initiatives included in the MRT, components of the MRT that were excluded from the approval, implications for stakeholders and more.
Group health plan sponsors, third-party administrators and other health plan service providers must navigate a shifting legal landscape as they determine how to offer gender-affirming benefits, including whether − and to what extent − group health plans must cover gender-affirming medical or surgical treatments, especially regarding minors. In this On the Subject, we discuss recent legal developments impacting gender-affirming care and approaches to group health plan coverage.
The rules and regulations on workplace and employee speech, interpretation and enforcement are rapidly changing. Companies must carefully factor legal and business implications into their strategy to reach the desired outcomes for their customers, workforce and brand.
In this Law360 article, Michael Sheehan, Michelle Strowhiro and Alexander Randolph examine important considerations for companies as they navigate the complexities of workplace and employee speech.
The US Department of Health and Human Services and the US Department of Justice recently published new proposed rules that update and create various requirements under Section 504 of the Rehabilitation Act of 1973 and Title II of the Americans with Disabilities Act of 1990. What are some of the biggest changes?
What are some of the major health policy topics on Congress’s plate this year? In this report, our McDermott+Consulting team looks at some of the most popular topics, including physician payment reforms, site-neutral policies, rural healthcare and Medicaid regulations.
This post continues our consideration of comments submitted in response to proposed regulations under the Mental Health Parity and Addiction Equity Act (MHPAEA). Our previous MHPAEA content is available here.
Under current law, if a plan provides any mental health or substance use disorder (MH/SUD) benefits in any classification of benefits, benefits for that condition or use disorder must be provided in every classification in which medical/surgical (M/S) benefits are provided. Classifications for this purpose include inpatient, in-network; inpatient, out-of-network; outpatient, in-network; outpatient, out-of-network; emergency care; and prescription drugs. The proposed regulations modify this standard by providing that a plan does not provide benefits for MH/SUD benefits in every classification in which M/S benefits are provided unless the plan provides meaningful benefits for treatment for the condition or disorder in each such classification “as determined in comparison to the benefits provided for medical/surgical conditions in the classification.”
The term “meaningful benefits” is nowhere defined. The regulators nevertheless “recognize that the proposal to require meaningful benefits [ ] is related to scope of services.” “Scope of services” for this purpose generally refers to the types of treatments and treatment settings that are covered by a group health plan or health insurance issuer. The preamble to the proposed regulation invites comments on how the meaningful benefits requirement “would interact with the approach related to scope of services adopted under the 2013 final regulations.” The preamble of the 2013 final regulations addressed an issue characterized as ‘‘scope of services’’ or ‘‘continuum of care’’ but otherwise failed to provide any substance. Two examples from the proposed regulations do, however, give us a sense of what the regulators have in mind.
A plan that generally covers treatment for autism spectrum disorder (ASD), a mental health condition, and covers outpatient, out-of-network developmental evaluations for ASD but excludes all other benefits for outpatient treatment for ASD, including applied behavior analysis (ABA) therapy, when provided on an out-of-network basis. (ABA therapy is one of the primary treatments for ASD in children.) The plan generally covers the full range of outpatient treatments and treatment settings for M/S conditions and procedures when provided on an out-of-network basis. The plan in this example violates the applicable parity standards.
In another example, a plan generally covers diagnosis and treatment for eating disorders, a mental health condition, but specifically excludes coverage for nutrition counseling to treat eating disorders, including in the outpatient, in-network classification. Nutrition counseling is one of the primary treatments for eating disorders. The plan generally provides benefits for the primary treatments for medical conditions and surgical procedures in the outpatient, in-network classification. The exclusion of coverage for nutrition counseling for eating disorders results in the plan failing to provide meaningful benefits for the treatment of eating disorders in the outpatient, in-network classification, as determined in comparison to the benefits provided for M/S conditions in the classification. Therefore, the plan violates the proposed rules.
Notably, the newly proposed meaningful benefits requirement is separate from, [...]
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