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The Weekly Scan

Last Updated: 1:00 PM EST

Medicare & Medicaid

  • On Tuesday, CMS proposed to update its national coverage policy for Transcatheter Aortic Valve Replacement (TAVR), a procedure for a condition known as “aortic stenosis” in which the heart valve that propels blood from the heart to the rest of the body becomes narrowed. The current national coverage determination, effective May 1, 2012, established CMS coverage for TAVR under Coverage with Evidence Development (CED). Since the finalization of the 2012 national coverage determination, TAVR programs have been established in over 500 hospitals across the country. Under the coverage proposal announced today, CMS would continue to cover TAVR under CED when furnished according to an FDA-approved indication. However, CMS is updating the coverage criteria for hospitals and physicians to begin or maintain a TAVR program. The proposed decision provides more flexibility in how providers can meet the requirements for performing TAVR, while continuing to ensure good health outcomes for patients receiving the procedure. (CMS.gov)

  • Centene Corporation and WellCare Health Plans, Inc. announced Wednesday that Centene will acquire WellCare in a cash and stock transaction for $305.39 per share based on Centene's closing stock price on March 26, 2019 for a total enterprise value of $17.3 billion pursuant to the terms of a definitive merger agreement. The transaction, which has been unanimously approved by the Boards of both companies, will create a premier healthcare enterprise focused on government-sponsored healthcare programs and a leader in Medicaid, Medicare and the Health Insurance Marketplace. (Centene.com)

  • On Monday, CMS released the Health Insurance Exchanges 2019 Open Enrollment Report. Key findings from this report include:

  • Plan Selections: Approximately 11.4 million consumers selected or were automatically re-enrolled in an Exchange plan during the 2019 OEP in the 50 states, plus DC. This is a decrease from 11.8 million consumers during the 2018 OEP.

  • New Consumers: Nationally, 24 percent of consumers with a plan selection during the 2019 OEP were new to the Exchange through which they enrolled. This is a decrease from 27 percent during the 2018 OEP.

  • Average Premiums: Among all consumers in the 39 states that use the HealthCare.gov platform, the average premium before application of the tax credit was $612 in the 2019 OEP. This is a decrease from $621 in the 2018 OEP.

  • Financial Assistance: Eighty-seven percent of consumers in states that use the HealthCare.gov platform received APTC in the 2019 OEP, compared to 85 percent in the 2018 OEP; the average premium after application of APTC for these consumers was $87 in the 2019 OEP, compared to $89 in the 2018 OEP. (CMS.gov)

  • The Government Accountability Office (GAO) released a new report on Wednesday titled: "Medicare and Medicaid: CMS Should Assess Documentation Necessary to Identify Improper Payments." Among other things, GAO examined: (1) Medicare and Medicaid documentation requirements and factors that contribute to improper payments due to insufficient documentation; and (2) the extent to which Medicaid reviews provide states with actionable information. GAO found that although Medicare and Medicaid pay for similar services, the same documentation for the same service can be sufficient in one program but not the other. The substantial variation in the programs’ improper payments raises questions about how well the programs’ documentation requirements help identify causes of program risks. As a result, CMS may not have the information it needs to effectively address program risks and direct program integrity efforts. Four recommendations were made to assess effectiveness of documentation requirements going forward. (GAO.gov)


  • The Department of Justice (DOJ) announced on Monday in a brief that it is siding with a district court ruling that found the Affordable Care Act unconstitutional. The move is an escalation of the Trump administration's legal battle against the health care law. The DOJ previously argued in court that the law's pre-existing condition protections should be struck down. Now, the administration argues the entire law should be invalidated. (TheHill.com)

  • Purdue Pharma LP and the Sackler family will pay $270 million to settle Oklahoma’s claims that illegal marketing of the Oxycontin painkiller devastated local communities, an accord that could influence the results of thousands of lawsuits faced by the company and others. The settlement comes two months before the scheduled start of a trial against Purdue, Johnson & Johnson and Teva Pharmaceutical Industries Ltd.and other opioid makers in Norman. Oklahoma is the first state in the nation to try such claims and the trial against the other companies will proceed. The settlement resolves a sliver of the massive legal liability that has led Purdue to threaten bankruptcy protection as a way of managing its legal costs. The drugmaker is owned by the billionaire Sackler family, and states and local governments have recently targeted the family’s wealth to recoup billions spent on the social costs of opioid addiction. (Bloomberg.com)

  • In two closely watched cases, US District Court Judge James Boasberg Wednesday voided the Trump administration's approvals of requests by Kentucky and Arkansas to mandate that low-income people work for benefits and kicked the matter back to the Department of Health & Human Services for further review. Boasberg also suspended the program in Arkansas, which began in June. In both cases, the approvals did not address how the requests would align with Medicaid's core objective of providing Medicaid coverage to the needy, the judge said. However, Boasberg also said that it's not impossible for the agency to justify its approvals, but it has yet to do so. (CNN.com)

  • A federal judge has struck down a small-business health insurance plan widely touted by President Donald Trump. U.S. District Judge John D. Bates wrote in his opinion late Thursday that so-called “association health plans” were “clearly an end-run” around consumer protections required by the Obama-era Affordable Care Act. The plans at issue in Bates’ ruling Thursday allow groups of small businesses and sole proprietors to band together to offer lower-cost coverage that doesn’t have to include all the benefits required by the ACA, often called “Obamacare.” They also can be offered across state lines, an attempt to deliver on a major Trump campaign promise. (CNBC.com)

#Medicaid #Medicare #Litigation


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