Jeremy Earl

Jeremy Earl

McDermott Will & Emery

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CMS Releases Guidance on Coverage Criteria, Use of AI and More

On February 6, 2024, the US Centers for Medicare & Medicaid Services (CMS) released a set of frequently asked questions (FAQs) related to Medicare Advantage (MA) coverage criteria and utilization management (UM) requirements....more

2/20/2024  /  Artificial Intelligence , Centers for Medicare & Medicaid Services (CMS) , Health Insurance , Healthcare , Healthcare Reform , Medicare Advantage , New Guidance , Regulatory Requirements

CMS Interoperability and Prior Authorization Rule Significantly Impacts Payers’ Approval and Denial Practices

On January 17, 2024, the Centers for Medicare & Medicaid Services (CMS) issued the CMS Interoperability and Prior Authorization final rule (Final Rule) (fact sheet, CMS’ interoperability website), which aims to improve prior...more

1/26/2024  /  Application Programming Interface (APIs) , Centers for Medicare & Medicaid Services (CMS) , Children's Health Insurance Program (CHIP) , Denial of Insurance Coverage , Federally Facilitated Exchanges , Final Rules , Health Care Providers , Health Insurance Portability and Accountability Act (HIPAA) , Medicaid , Medicare Advantage , MIPS , Patients , Qualified Health Plans , Single-Payer

CMS Proposes to Prohibit Overrides in Medicare Advantage

On November 6, 2023, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule regarding Contract Year (CY) 2025 Policy and Technical Changes to the Medicare Advantage (MA) and Medicare Prescription Drug...more

11/10/2023  /  Centers for Medicare & Medicaid Services (CMS) , Health Care Providers , Managed Care Contracts , Medicare , Medicare Advantage , Medicare Advantage Organizations (MAOs) , Medicare Part D , Proposed Rules

CMS Announces Request for Applications for Participation In the ACO REACH Model

On February 24, 2022, the Centers for Medicare and Medicaid Services (CMS) Innovation Center announced a Request for Applications (RFA) for the Accountable Care Organization (ACO) Realizing Equity, Access, and Community...more

3/4/2022  /  ACOs , Centers for Medicare & Medicaid Services (CMS) , Health Care Providers , Medicare , Medicare Shared Savings Program , Patients , Payment Systems , REACH

CMS Unveils Geographic Direct Contracting Model

The Centers for Medicare & Medicaid Services (CMS) Innovation Center announced a Letter of Interest (LOI) for a new geographic model option within the Direct Contracting portfolio. The geographic model would transfer full...more

12/7/2020  /  ACOs , Centers for Medicare & Medicaid Services (CMS) , Department of Health and Human Services (HHS) , Health Care Providers , Health Insurance Portability and Accountability Act (HIPAA) , HMOs , Medicare , Medicare Advantage

[Webinar] CMS Direct Contracting Model: Evaluating Participation and Managing Risk - December 1st, 1:30 pm - 2:30 pm EST

The Centers for Medicare and Medicaid Services (CMS) Direct Contracting Model presents an exciting move towards value-based care with benefits for participants, providers and patients alike. However, the model raises a number...more

11/18/2020  /  ACOs , Capital Requirements , Centers for Medicare & Medicaid Services (CMS) , Health Care Providers , Hospitals , Medicare , Medicare Advantage , Medicare Shared Savings Program , Physicians , Risk Assessment , Risk Management , Value-Based Care , Webinars

CMS Guidance and Waivers for MA and Part D Plans’ Response to COVID-19

Over the past week, the Centers for Medicare & Medicaid Services (CMS) has made a number of announcements related to Medicare coverage in connection with the Coronavirus (COVID-19) outbreak. Several of those announcements...more

3/22/2020  /  Centers for Medicare & Medicaid Services (CMS) , Coronavirus/COVID-19 , Cost-Sharing , Medicare , Medicare Advantage , Medicare Part D , New Guidance , Public Health Emergency , State of Emergency , Waivers

Special Report - 2019 Hospital and Health Systems Year in Review

Hospitals and health systems are facing consumer demand for innovation, the need to expand and enhance streams of revenue and the push for improved quality, all while navigating changing regulations, federal enforcement,...more

2/6/2020  /  Antitrust Litigation , Centers for Medicare & Medicaid Services (CMS) , CMIA , Cyber Attacks , Cybersecurity , Department of Health and Human Services (HHS) , Department of Justice (DOJ) , Federal Trade Commission (FTC) , Health Care Providers , Health Insurance Portability and Accountability Act (HIPAA) , Hospitals , Medicare , No-Poaching , OCR , Popular , Ransomware

CMS Seeks to Provide Flexibility and Facilitate Innovation in Medicare Advantage and Part D

The Centers for Medicare and Medicaid Services (CMS) recently released several significant Medicare Advantage (MA) and Part D guidance documents outlining new Center for Medicare and Medicaid Innovation (CMMI) programs and...more

2/8/2019  /  Advance Notice , Bipartisan Budget Act , Call Letter , Centers for Medicare & Medicaid Services (CMS) , CMMI , GAO , Medicare Advantage , Medicare Part D , Opioid , Prescription Drugs , Risk Adjustment Formula , Social Security Act

Administration Offers Up New Proposals to Cut Drug Costs

On November 26, CMS released a notice of proposed rulemaking, “Modernizing Part D and Medicare Advantage to Lower Drug Prices and Reduce Out-of-Pocket Expenses,” which includes provisions that aim to reduce overall drug...more

12/3/2018  /  Centers for Medicare & Medicaid Services (CMS) , Drug Pricing , Life Sciences , Medicaid , Medicare Advantage , Medicare Part B , Medicare Part D , Pharmaceutical Industry

CMS to Allow Medicare Advantage Organizations to Utilize Step Therapy for Part B Drugs

The Centers for Medicare & Medicaid Services recently announced that, in a reversal of prior policy, it will begin to allow Medicare Advantage organizations (MAOs) to implement step therapy for Part B drugs and services as of...more

8/16/2018  /  Centers for Medicare & Medicaid Services (CMS) , Medicaid , Medicare , Medicare Advantage , Medicare Advantage Organizations (MAOs) , Medicare Part B

CMS Opens Module for MA Plans to Report MACRA Other Payer Advanced APM Information

The other payer advanced alternative payment model (APM) option is intended to give eligible clinicians an additional option to meet MACRA’s escalating participation thresholds to qualify for the 5 percent advanced APM bonus....more

6/1/2018  /  Alternative Payment Models (APM) , Centers for Medicare & Medicaid Services (CMS) , Medicare Access and CHIP Reauthorization (MACRA) , Medicare Advantage , Payment Systems , Quality Payment Program (QPP)

Flurry of Medicare Advantage and Part D Changes Includes Significant Policy Shifts

Last week, CMS released new regulations and guidance for Medicare Advantage Organizations (MAOs) and Part D Sponsors. These documents—along with the Bipartisan Budget Act of 2018 that was passed in January—reflect significant...more

4/13/2018  /  Centers for Medicare & Medicaid Services (CMS) , Medicare , Medicare Advantage Organizations (MAOs) , Medicare Part D

CMS Aims to Stabilize Exchanges but Does Not Address Issuers’ Biggest Questions

CMS recently released a final rule with the goal of stabilizing Exchange markets for 2018. The agency also issued several significant guidance documents where CMS extended the deadlines for 2018 rate and Exchange qualified...more

4/26/2017  /  Affordable Care Act , Centers for Medicare & Medicaid Services (CMS) , Filing Deadlines , Final Rules , Good Faith , Healthcare Reform , Qualified Health Plans , Trump Administration

Trump Administration Takes First Steps to Support Exchanges, but Key Questions Remain

In an effort to stabilize the Exchanges and encourage issuer participation, the Centers for Medicare & Medicaid Services (CMS) recently extended the federal Exchange application and rate filing deadlines and published a...more

2/27/2017  /  Affordable Care Act , Centers for Medicare & Medicaid Services (CMS) , De Minimis Claims , Department of Health and Human Services (HHS) , Enrollment , Executive Orders , Filing Deadlines , Health Insurance , Healthcare Reform , Medicaid , Medicare , Open Enrollment , Proposed Rules , Qualified Health Plans , Trump Administration

21st Century Cures: Congress Enacts Medicare Advantage and Small Business Insurance Market Reforms

The 21st Century Cures Act encourages biomedical research investment and facilitates innovation review and approval processes, but also serves as a vehicle for a wide variety of other health-related measures, including...more

12/12/2016  /  21st Century Cures Initiative , Affordable Care Act , Centers for Medicare & Medicaid Services (CMS) , ESRD , Handbooks , HRA , Medicare Advantage , Open Enrollment , Risk Assessment , Star Ratings

Managing the Transition to Transformation: Implementing a CJR Collaborator Agreement

Summary - McDermott’s Managing the Transition to Transformation series is designed to help health systems and other health care industry leaders address the many challenges presented by the transformation in payment and...more

8/3/2016  /  BPCI , Bundled Payments , Centers for Medicare & Medicaid Services (CMS) , Collaboration , Fee-for-Service , Gainsharing , Payment Systems , Waivers

CMS’s Final Medicaid Rule Creates a Medicaid MLR Framework but Leaves Room for State Variation

In Depth - The final Medicaid managed care rule issued by the Centers for Medicare & Medicaid Services (CMS) on April 25, 2016, (the Final Rule) establishes a new federal medical loss ratio (MLR) standard for Medicaid...more

5/12/2016  /  Centers for Medicare & Medicaid Services (CMS) , Children's Health Insurance Program (CHIP) , Managed Care Contracts , Medicaid , Medical Loss Ratio

Medicaid Managed Care Update: CMS Proposes a National Medicaid MLR Standard

States would have the option to create binding Medicaid MLR requirements modeled after existing commercial market MLR standards. This article is part of a series that takes an in-depth look at several proposals that...more

6/11/2015  /  Centers for Medicare & Medicaid Services (CMS) , Health Care Providers , Managed Care Contracts , Medicaid , Medical Loss Ratio

2015 Notice of Benefit and Payment Parameters

The Centers for Medicare & Medicaid Services (CMS or the agency) kicked off a flurry of springtime regulatory activity for health insurance issuers with publication of the final Notice of Benefit and Payment Parameters for...more

3/24/2014  /  Affordable Care Act , Centers for Medicare & Medicaid Services (CMS) , Employee Benefits , Health Insurance Exchanges , Healthcare , Healthcare Reform

CMS Indicates Select Controversial Part D Proposals Will Not Be Finalized

Acknowledging concerns regarding some proposals in the January 2014 proposed rule for the Medicare Advantage and Part D Programs, the Centers for Medicare & Medicaid Services states it does “not plan to finalize” certain...more

3/17/2014  /  Centers for Medicare & Medicaid Services (CMS) , Healthcare , Medicare , Medicare Part D

CMS Proposes Significant Changes to Medicare Part D Program’s Administration

The Centers for Medicare & Medicaid Services proposes significant changes to several key Medicare Part D Program components, such as the “any willing pharmacy” contracting requirement, that will affect all industry...more

1/24/2014  /  Centers for Medicare & Medicaid Services (CMS) , Healthcare , Healthcare Reform , Medicaid , Medicare , Medicare Part D , Pharmacies

CMS Proposed Rule Reflects Increased Sophistication in Administration of MA/Part D Programs

Addressing issues ranging from participation in Part D Plan pharmacy networks to compliance training for so-called first-tier, downstream and related entities, the Proposed Rule covers numerous topics with varying degrees of...more

1/22/2014  /  Centers for Medicare & Medicaid Services (CMS) , Healthcare , Medicare , Medicare Part D

CMS Announces CY 2014 MA and Part D Rates with Change to Growth Rate Estimates

The Centers for Medicare & Medicaid Services (CMS) released the announcement of CY 2014 payment rates on April 1, which included its change in position regarding the assumption of the "doc fix" in estimates of Medicare...more

4/5/2013  /  Centers for Medicare & Medicaid Services (CMS) , Fee-for-Service , Fees , Medicare , Medicare Advantage , Pharmacies , Risk Assessment

CMS Releases 2014 Advance Notice and Proposed MA and Part D Program MLR Regulations

On February 15, 2013, the Centers for Medicare & Medicaid Services released for comment two key documents affecting the Medicare Advantage (MA) and Part D Programs: (1) the Advance Notice of Methodological Changes for...more

2/25/2013  /  Centers for Medicare & Medicaid Services (CMS) , Fee-for-Service , Medicaid , Medical Loss Ratio , Medicare , Medicare Advantage , Medicare Part D , MLR Rebate
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