Tag Archives: medicare

Will Addiction Treatment Be Eliminated from Obamacare Requirements?

The federal Centers for Medicare & Medicaid Services (CMS) proposed a federal rule late Friday aimed at giving states more flexibility in interpreting the Affordable Care Act’s “Essential Health Benefits” mandate as a way “to lower the cost of individual and small group health plans.”

Perhaps most notably, CMS’ proposed rule would allow states to alter their essential health benefits benchmark plan annually, beginning as early as 2019.

The Affordable Care Act set forth ten (10) categories of essential health benefits, including mental health and substance use disorder treatment.

“Consumers who have specific health needs may be impacted by the proposed policy,” the agency said. “In the individual and small group markets, depending on the selection made by the state in which the consumer lives, consumers with less comprehensive plans may no longer have coverage for certain services. In other states, again depending on state choices, consumers may gain coverage for some services.”

The agency in 2017 proposed standardized health plan options as a way to simplify shopping for consumers on the federally run marketplaces. The CMS said it would eliminate standardized options for 2019 to maximize innovation. “We believe that encouraging innovation is especially important now, given the stresses faced by the individual market,” the proposed rule states.

The Trump administration hopes to relax the ACA’s requirements and provide as much state flexibility as possible through administrative action, following the collapse of congressional Republican efforts this year to make those changes legislatively.

However, the EHB benchmark plans for mental health/substance abuse must comply with the Mental Health Parity and Addiction Equity Act of 2008 (“Parity Act”).

While we do not believe that any state can eliminate or reduce benefits for drug and alcohol treatment, by reducing benefits for other medical health care counterparts, they could strategically and effectively compromise reimbursements, even under the Parity Act.

The 2019 Notice of Benefit and Payment Parameters (PDF), released Friday.

Alabama-based Lab Pays $24.5 million penalty in kickback scheme

From our friends at PathologyBlawg.com

“Alabama-based Infirmary Health System (IHS), Infirmary Medical Clinics (IMC), Diagnostic Physicians Group P.C. (DPG) and two clinics run by IMC have agreed to pay $24.5 million to settle allegations they violated the Stark Law and Anti-Kickback Statute by engaging in a scheme to compensate physicians for laboratory and radiology referrals… The government alleged IHS, through its subsidiaries and clinics, paid physician-owned DPG ‘a percentage of collections on items and services performed or referred by DPG physicians’ to IHS-affiliated clinics that performed clinical laboratory and diagnostic imaging tests from 2005 to 2011. DPG then compensated individual physicians for their referrals.”

Read more here.

Note from Jeffrey C Lynne:

Cases such as this are, for the time being, prosecuted based upon the fact that Medicare and/or Medicaid was implicated, as the Stark Laws only pertain to these federal health insurance programs. The Federal Anti-Kickback Statute (AKS) is more broad. However, to date, we are not aware whether the federal government, or any state government, has sought prosecution against a provider who only seeks reimbursement from private pay insurance.