Last Friday the Centers for Medicare and Medicaid Services (CMS) released the 2020 Part C and Part D Program Audit and Enforcement Report. The purpose of program audits is to evaluate Medicare Advantage (MA) and Part D plan sponsors’ compliance with core program requirements, including ensuring that sponsors provide beneficiaries with access to medically necessary services and medications. The annual program audit and enforcement report provides background information on the program audit process, a summary of the 2020 program audits, as well as enforcement actions taken by CMS in the last year.
The answer to that question is not as straightforward as you might think. Chiquita Brooks-Lasure is the nominee to serve as the next CMS Administrator, but she has yet to assume the role. The previous CMS Administrator, Seema Verna, resigned effective January 20, 2021, as is customary in an administration transition. Elizabeth Richter then became Acting Administrator of CMS, after having served at CMS since 1990, and continues in that interim role due to the holdup of the confirmation of President Biden’s appointee.
One theme that bubbled to the surface of cultural conversations around healthcare over the last year is the notion that “mental health is health.” Whether you’re a parent of children who struggled with isolation during a year of virtual school, a person who relied on in-person support for mental and behavioral health issues before the pandemic, or a healthcare professional trying to meet the needs of patients who are in increasing need of services for mental illness and substance use disorders, you know that COVID-19 has had an enormous, negative impact on mental health.
This week marks the anniversary of the World Health Organization declaring COVID-19 to be a pandemic, the United States entering a state of national emergency, and the Centers for Disease Control and Prevention (CDC) issuing the first set of restrictions in the United States. As we acknowledge these dates, and ruefully reflect on the emails from colleagues and signs hanging on the doors of our favorite restaurants saying, “Stay safe, we’ll see you in two weeks,” it is impossible not to reflect on how much our lives have changed in the last year, and to evaluate how many of those changes will be with us for the long term. We may disagree on when restaurants should reopen and kids should go back to school, but one thing on which patients, providers, plans, and lawmakers seem to agree is that telehealth is not going away.
As a health plan lawyer for over two decades, I have seen the intricacies—and curiosities—of our healthcare financing and regulatory system up close. Before I studied political science, law, and theology, I learned from my history teacher father that knowledge of the past is critical to making sense the present. My dad taught me to try to place what I observe in historical perspective to understand it better.
At first glance, surprise billing seems like an issue that should have been straightforward to address. Patients, health plans, providers, and legislators of both parties supported legislation to protect consumers from unexpected medical bills from out-of-network providers. Nevertheless, lawmakers continued to debate the issue for years. In December, in the midst of a pandemic, during which some patients received substantial bills related to their COVID-19 care, Congress enacted federal legislation to rein in unexpected bills with the No Surprises Act, a ban on surprise billing tucked into the year-end spending bill passed on December 21, 2020. The prohibition goes into effect on January 1, 2022. Before that, we will see new rules from the Department of Health and Human Services (HHS) establishing processes for resolving out-of-network payment disputes between providers and those health plans subject to the new law.
In 2004, when I started focusing on Medicare plans in preparation for the 2006 implementation of Medicare Part D prescription drug benefits, only a small percentage of Medicare beneficiaries—just 13 percent or roughly 5.3 million people—were enrolled in what were then called Medicare+Choice plans. Fast-forward 16 years, now 39 percent of all Medicare beneficiaries, or 24.1 million people out of roughly 62 million Medicare beneficiaries overall, are enrolled in Medicare Advantage (MA) plans. The Congressional Budget Office projects the share of beneficiaries enrolled in MA plans will rise to over 50 percent by 2030.
We witnessed a peaceful transfer of presidential power in the United States last week. Following an inauguration in which President Biden pledged to take on a “raging virus” and “make health care secure for all,” the new administration dug in and got to work. Indeed, on the first day in office, President Biden issued seventeen executive orders, memoranda, and proclamations covering issues ranging from the environment to immigration to the economy.
Medicare Advantage (MA) organizations have a unique relationship with the federal government. Like all healthcare companies, they interact with the government as a regulator, the industry’s rule-maker and watchdog. This is a familiar aspect of the industry-government relationship, consistent with insurers’ experience with state and federal agencies in commercial lines of business.
The most successful MA plans, however, adopt a broader picture of their relationship with the government. The Centers for Medicare & Medicaid Services (CMS) is also their customer, a valuable and demanding public group health plan, responsible for safeguarding the benefits of tens of millions of Medicare beneficiaries administered by private insurers.
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