HealthCare Roundtable e-News – December 15, 2021

Health Professionals, Hospitals, and Lobbies Sue to Block Surprise Billing Rule

Health professionals and lobbying groups have filed a suit in federal courts to block a controversial piece of the Biden Administration’s most recent surprise billing rule, arguing that the interim final rule (IFR) illegally limits what an arbitrator can consider when resolving a payment dispute. The American Hospital Association and several other organizations argued that the latest IFR conflicts with the statutory language of the No Surprises Act and violates the Administrative Procedure Act.

Lawmakers passed the IFR in an effort to protect consumers after reports that nearly 1 in 5 hospital visits resulted in patients receiving unexpectedly large hospital bills because doctors or other providers weren’t part of their insurer’s network. In response to the IFR, the American Medical Association, American Hospital Association, and individual hospitals and doctors filed a lawsuit in an attempt to stall the bill, claiming that insurers will rely on the arbitration rules to get an “unfairly low rate”. The groups claim that the IFR offers little incentive to include higher-cost providers in their network, “all to the detriment of patients.”

The plaintiffs emphasized in the suit that while they are in protest of the language in the IFR that directs arbitrators to primarily consider the qualifying payment amount (QPA), or median in-network rate, when deciding which party will win a payment dispute, they otherwise support shielding patients from surprise bills and say their challenge will not stop those core protections from going into effect in the new year. Other organizations have challenged the QPA language in separate district courts prior to the AHA’s suit, including the Texas Medical Association (TMA) and the Association of Air Medical Services. A hearing in the TMA case has been scheduled for Feb. 4, 2022 at the U.S. District Court Eastern Division of Texas, Tyler. (InsideHealthPolicy)

CMS Touts Latest ACA Enrollment Numbers Heading into 2022

Last week, CMS announced that Medicare enrollment is up by 5% this year in the 33 states using the exchange, with some state-based exchanges reporting increases by more than 15%. The agency also confirmed that nearly 4.6 million Americans have signed up for coverage either through or a state-based exchange since the November launch of the plan year 2022 open enrollment.

In the past year, the agency has invested heavily in targeted outreach to encourage Americans to enroll during the designated enrollment period. CMS confirmed that the agency has been various formats of advertising as well as “micro-targeting” communities in Texas and Florida, offering specific information on available plans and costs so consumers can better understand their options. Other factors, like affordability of coverage, have played a role in the increase of enrollees.

“Affordability continues to drive enrollment during this Open Enrollment period, and we are excited to see so many individuals and families taking advantage of the many affordable and quality plans available,” says CMS Administrator Chiquita Brooks-LaSure. The agency confirmed that 95% of consumers are receiving tax credits, and the number of consumers getting coverage for $10 or less has doubled from last year.

The Biden administration has made it clear that it’s difficult to make accurate predictions on final enrollment numbers before the period is over, noting that automatic renewals have not yet been included in the final count. CMS will continue its outreach programs through the enrollment period this year for January 1 coverage. (InsideHealthPolicy)

Private Health Insurers Press White House for Answers as Biden Administration Plans to Have Groups Cover At-Home Testing Reimbursements

Questions from insurers are piling in around the White House’s plan to require private health insurers to cover at-home COVID-19 tests purchased over the counter, a proposal that the administration announced last week. Some details of the plan have not yet been released, and many insurers are wondering how the administration is planning to address the costs of tests, potential fraud, and whether Medicaid and Medicare plans will also be required to cover the tests.

As Omicron threatens to spread across the U.S. as it has in Europe and other parts of the world, the Biden administration continues to re-evaluate making testing more accessible and urging Americans to get their vaccinations and booster shots. According to industry groups, the Biden administration did not consult insurance stakeholders on the at-home testing proposal and gave them fewer than 24 hours’ notice that it would be part of Biden’s broader COVID-19 blueprint. The White House had previously discussed building a broader national testing apparatus earlier in the year, though talks had paused once the COVID-19 vaccination plan was rolled out. After the rise of Delta, it became clearer that continued discussions around investing in a larger testing program may be necessary.

At a press conference, White House Press Secretary Jen Psaki told reporters that the administration would clarify whether the government plans to help private health insurance companies by funding the reimbursements of over-the-counter tests, though the White House later confirmed the government will not reimburse insurers, commenting that insurers were required to cover diagnostic testing for COVID-19 “without any cost-sharing requirements during the public health emergency.”

Kristine Grow, a spokesperson for insurance industry lobby AHIP, confirmed that industry groups are working with the White House to address questions and make sure the impact of any testing plan is fully understood. According to Grow, areas of concern include price gouging on these tests, higher premiums, clear rules, and guidance for implementation, among others.

Senate Passes Medicare Sequester and Provider Relief Legislation

On Thursday (Dec. 9), Senate lawmakers passed legislation to phase in Medicare sequester cuts and allow for other provider relief. After much debate around Medicare sequesters in recent weeks, the bill heads to the president’s desk to be signed as providers are already lobbying for longer-term relief next year.

The bill, known as the Protecting Medicare and American Farmers from Sequester Cuts Act, would phase in the cuts starting in March 2022 with a 1% cut through the end of June, after which the cuts would return to 2%. Additionally, the bill will defer the cost of the American Rescue Plan to the 2023 so-called PAYGO scorecard and mitigate some cuts tied to changes in CMS’ evaluation. Sens. Jeanne Shaheen (D-N.H.) and Susan Collins (R-Maine), who both pushed for the bill’s passing and wrote a bipartisan letter to Senate leadership on the legislation, praised the outcome and thanked Leadership for prioritizing the bill.

“As we face a new, highly contagious variant, we need to ensure that Congress is responding to needs and conditions on the ground,” said Shaheen in a statement. “Delaying these Medicare payment cuts is crucial so our providers have the breathing room and financial resources necessary to get to the other side of the pandemic. I’m glad Congress got this done and look forward to the President swiftly signing it into law.” (InsideHealthPolicy)

Many providers have also praised the passing of the bill. In a statement, Anders Gilberg, Medical Group Management Association Senior Vice President for Government Affairs, said that the MGMA “looks forward to working with Congress to create permanent workable solutions rather than annual legislative workarounds,” a sentiment that has been shared by other groups pushing for longer-term reforms. (InsideHealthPolicy)