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Photo of Posts by Charles B. Oppenheim Charles B. Oppenheim
Partner
coppenheim@health-law.com
310.551.8110
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Showing 13 posts by Charles B. Oppenheim.

California’s Department of Managed Health Care (“DMHC”) recently finalized regulations that significantly expand what it means to take on “global risk,” which triggers the requirement to obtain a Knox-Keene license or an exemption. Historically, the requirement to obtain a Knox-Keene license has been reserved for health maintenance organizations (“HMOs”) or other organizations that are paid on a capitated basis in exchange for providing or arranging health care services.

The new regulation will disrupt this status quo by sweeping in a range of value-based payment arrangements – potentially including independent practice association (“IPA”) participation in hospital risk pools and some accountable care organizations (“ACOs”) – that providers have historically entered into without needing to be licensed as a Knox-Keene plan. California-based providers that engage in these types of payment arrangements should therefore pay special attention to these new rules as they are implemented. Read More ›

On Friday, January 25, 2019, the Department of Managed Health Care (DMHC) published its latest draft of a proposed regulation that will dramatically expand the scope of arrangements subject to licensure under the Knox-Keene Act. The regulation breaks with the DMHC’s longstanding policies and threatens to disrupt common provider payment arrangements in California, including hospital risk pools, bundled payment arrangements, and accountable care organizations (ACOs), and to stifle innovation in the area of value-based payments.

Under the proposed regulation, a Knox-Keene license would be required for an entity to accept “global risk,” which is defined as the acceptance of a “prepaid or periodic charge” in exchange for assuming “both professional and institutional risk.” (28 C.C.R., proposed § 1300.49, subds. (a) & (b)(1).) The statute has long defined health care service plans in reference to providing or arranging for health care services in exchange for a “prepaid or periodic charge.” However, the regulation provides a new definition of that term that encompasses payments made “at the start or end of a predetermined period… that may be fixed either in amount or percentage of savings or losses in which the entity shares.” (28 C.C.R., proposed § 1300.49, subd. (a)(4).) Providers that engage in shared risk arrangements, which involve fee-for-service payments with shared savings payable after a set period of time, even those involving upside risk only, may be subject to licensure under the new rule. Read More ›

On Friday, December 21, 2018, CMS issued a final rule, referred to as “Pathways for Success,” that makes significant changes the Medicare Shared Savings Program. Issued just before the holidays, various stakeholders will likely have varying opinions about whether this final rule constituted an early gift or lump of coal. Among other things, the final rule overhauls the current track system for participating accountable care organizations, or ACOs, and requires a more rapid transition to assumption of downside risk. The two new tracks available to participating ACOs will go into effect for agreement periods commencing on or after July 1, 2019. Read More ›

On October 24, 2018, President Trump signed into law the bipartisan SUPPORT for Patients and Communities Act (H.R. 6 or the “Act”), which aims to combat opioid abuse with increased attention to treatment. The wide-reaching compromise legislation combines elements from a number of opioid bills, addressing issues from access to treatment and prevention programs to expanded law enforcement efforts to curtail drug trafficking. The Act, however, does omit several items that have been part of the national dialogue on opioid abuse. For example, it does not include amendments to 42 U.S.C. § 290dd-2 and the associated regulation at 42 C.F.R. Part 2 (“Part 2”) that would align the Part 2 substance use treatment privacy law with the Health Insurance Portability and Accountability Act (“HIPAA”) privacy rules to better facilitate the sharing of a patient’s substance use disorder information among providers. In addition, the Act does not provide for a significant increase in spending for the opioid crisis. Read More ›

The Department of Managed Health Care (DMHC) recently published a regulation that could dramatically expand the scope of arrangements that are considered health care service plans for which a license is required under the Knox-Keene Act, the legal framework for managed care in California. Read More ›

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