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Photo of Posts by Stephanie  Gross Stephanie Gross
Associate
sgross@health-law.com
415.875.8509
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Showing 5 posts by Stephanie Gross.

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, April 5, 2019, the Centers for Medicare & Medicaid Services (“CMS”) finalized its fall 2018 proposal to expand coverage of telehealth benefits for Medicare Advantage beneficiaries, creating a new category of benefits entitled “additional telehealth benefits.” This brief alert highlights what this development means for healthcare providers, before reviewing the various ways in which Congress and CMS have expanded the telehealth benefits available to Medicare beneficiaries throughout 2018 and 2019.

Background: Telehealth Coverage by Medicare and Medicare Advantage

Medicare Coverage of Telehealth. Historically, Medicare has only covered telehealth services delivered to Medicare fee-for-service (“FFS”) beneficiaries when the services at issue satisfy the requirements for “Medicare telehealth services” set forth in § 1834(m) of the Social Security Act, and codified at 42 U.S.C. § 1395m(m). In order to be eligible for payment, such services must satisfy five requirements: the services must be rendered to a patient in a rural health professional shortage area (“HPSA”) or in a county which is not included in a metropolitan statistical area (“MSA”) (unless an exception applies); the patient must be located at an approved “originating site;” the services must be delivered through an approved telecommunications system; the service must be rendered by an approved type of provider; and the service provided must be included on CMS’ list of approved “Medicare telehealth services,” which it updates annually. In the past few years, Congress and CMS have broadened the authority to offer telehealth based services both in Medicare FFS and in Medicare Advantage. 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 ›

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 ›

For media assistance, please contact Maura Fisher at 202-580-7714.