Articles and Blogs

On May 21, 2025, the Centers for Medicare & Medicaid Services (“CMS”) announced a substantial expansion of its Risk Adjustment Data Validation (“RADV”) audit program for all Medicare Advantage (“MA”) plans. Effective immediately, CMS will audit all eligible MA plans annually and aims to complete outstanding audits for prior payment years (“PY”) 2018-2024 by... READ MORE

On July 3, 2024, a federal court in Texas (“the Court”) issued a stay related to certain provisions of CMS’s Contract Year 2025 Medicare Advantage and Part D (“MAPD”) Final Rule (“2025 Final Rule”), which would change how agents and brokers are paid by Medicare Advantage (“MA”) and Part D plans. Specifically, the Court... READ MORE

Could it be that CMS is implementing changes in the Medicare Communications and Marketing standards that will change the content and tone of the omnipresent television and radio advertisements targeted at potential enrollees? On the heels of publishing a final rule modifying the regulations for Medicare communications and marketing in April, on May 10,... READ MORE

On May 11, 2020, the Centers for Medicare & Medicaid Services (“CMS”) released the 2021 Inpatient Prospective Payment System (“IPPS”) Proposed Rule (“Proposed Rule”). One of the most significant updates is the proposed addition of a new requirement to the Medicare cost report submission process. Specifically, hospitals would be required to provide the median... READ MORE

Section 3709 of the Coronavirus Aid, Relief, and Economic Security Act of 2020 (“CARES Act”) temporarily suspends Medicare sequestration for the period of May 1 through December 31, 2020. As a result, health care providers can expect to receive an increase in fee-for-service Medicare payments by approximately 2% as compared to what they would... READ MORE

Thanks to a final rule issued by the Centers for Medicare & Medicaid Services (“CMS”) this spring, Medicare Advantage (“MA”) plans will now be able to offer additional telehealth benefits to enrollees starting in 2020. Historically, MA plans have been able to offer more telehealth services compared to Original Medicare as part of their... READ MORE

The Centers for Medicare & Medicaid Services (“CMS”) recently published a final rule (“Final Rule”) revising the procedures that CMS uses to administer its Preclusion List. As outlined below, CMS now requires Medicare Advantage, Medicare Part D and other designated plans to deny payment for items or services provided by or prescribed by a... READ MORE

On August 7, 2018, the Centers for Medicare & Medicaid Services (“CMS”) issued a Memorandum (“Memorandum”) announcing a policy change to allow Medicare Advantage (“MA”) plans to implement step therapy programs for physician-administered and other Part B drugs. Step therapy is a type of prior authorization for drugs in which a health plan requires... READ MORE

Nearly a decade has passed since the U.S. Congress enacted the Patient Protection and Affordable Care Act (the “ACA”). Since March 2010, we have seen federal court rulings on numerous challenges to the ACA itself and the executive branch’s efforts to enforce the ACA. One such challenge resulted on September 7, 2018 in the... READ MORE

The Centers for Medicare & Medicaid Services (“CMS”) recently enacted a Final Rule removing certain compliance training requirements previously applicable to first tier, downstream and related entities (“FDRs”) of Medicare Advantage and Part D Plan Sponsors (“Plan Sponsors”). Specifically, beginning in plan year 2019, health care providers that participate in Medicare Advantage and Part... READ MORE