Category Archives: Health Reform

New York Implements Federal Requirements Suspending Medicaid Payments for “Credible Allegations of Fraud”

Under Section 6402 of the Affordable Care Act, State Medicaid programs are required to suspend all Medicaid payments to providers under investigation for a “credible allegation of fraud”. After more than a year of delay and discussion, on August 22, New York adopted regulations implementing this requirement, joining a number of other states who have already done so. Prior to enactment of the new regulations in New York, the decision on whether to withhold payments was discretionary. Continue reading

Veterans On Waiver Programs Get Larger Personal Allowance

On June 18, 2012, Judge Sandra Beck of the US District Court for the Southern District of Ohio sided with a group of  Veterans Affairs (VA) pension recipients in Ledford, et al., vs. Michael B. Colbert, director, Ohio Department of Job and Family Services, Case No. 1:10-cv-706.

Judge Beck  found that the Ohio Department of Job and Family Services (ODJFS) violated federal law by not providing recipients of the Medicaid assisted living waiver a $90 Personal Needs Allowance (PNA) in the patient liability calculation of their Medicaid budget when the individual is a recipient of VA Aid and Attendance benefits. Continue reading

The U.S. Supreme Court Rules on the ACA – The Individual Mandate is Constitutional

This morning, June 28, 2012, the United States Supreme Court released its decision upholding the constitutionality of the individual mandate – the centerpiece of President Obama’s health care law.

The individual mandate requires that all Americans maintain “minimum essential” health insurance coverage. Beginning in 2014, individuals that do not comply with the mandate must make a “shared responsibility payment” to the Federal Government. The amount of the payment varies with household income, subject to a floor and a ceiling based on the average annual premium that the individual would have to pay for private health insurance.

Interestingly, the Supreme Court rejected the Obama administration’s argument that the individual mandate was permissible under the Commerce Clause, instead concluding that the individual mandate was permissible under Congress’ taxing authority.

Another key provision of the Affordable Care Act is the expansion of the Medicaid program. The Affordable Care Act expands the scope of the Medicaid program and increases the number of individuals that states must cover. For example, the Act requires state programs to provide Medicaid coverage to adults that earn up to 133 percent of the federal poverty level. Many states only provide Medicaid to individuals whose incomes are significantly lower.

While the Act increases federal funding to cover the states’ costs in expanding coverage, it also threatened to withdraw all federal Medicaid funds for failure to comply. This morning, the Supreme Court ruled that while it was permissible to expand the Medicaid program, the Act could not withdraw existing Medicaid funds for states that opt out of the expansion.

A copy of the full opinion can be found here–> USCT ACA Opinion

For more information on the U.S. Supreme Court’s decision,  please feel free to contact any member of our health care practice group for a further discussion.

Please all check back here often for further posts on the decision.

GAO Report – Medicare Program Integrity – CMS Continues Efforts to Strengthen the Screening of Providers and Suppliers

On April 10, 2012, the GAO released a report (GAO-12-351) entitled Medicare Program Integrity – CMS Continues to strengthen the Screening of Providers and Suppliers. The report focusses on many of the ongoing Medicare program integrity initiatives that CMS has been implementing and that are required by the Patient Protection and Affordable Care Act (“PPACA”).

The GAO specifically looked at  Medicare provider enrollment procedures. The GAO report focused on: (1) how CMS and its contractors use provider and supplier enrollment information to prevent improper payments and factors that may affect the usefulness of this information, and (2) the extent to which CMS has implemented new provider and supplier enrollment screening procedures since the enactment of PPACA.  Continue reading