Tag: District of Columbia (DC)

CMS Announces Comment Period for National Expansion of Prior Authorization Process

On October 29, 2019, the Centers for Medicare and Medicaid Services (CMS) posted a notice in the Federal Register announcing an opportunity for the public to provide comments on the proposed national expansion of the prior authorization process for repetitive, scheduled non-emergent ground ambulance transportation.  CMS refers to this process as its “RSNAT Prior Authorization…

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CMS Announces Extension of Prior Authorization Program

On September 16, 2019, CMS published a notice in the Federal Register that it would be extending the prior authorization demonstration project for another year. The extension is limited to those states where prior authorization was in effect for calendar year 2019. The affected states are Delaware, Maryland, New Jersey, North Carolina, Pennsylvania, South Carolina,…

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Federal District Court Judge Strikes Down the ACA

On December 14, 2018, a federal district court judge for the Northern District of Texas issued a ruling striking down the Affordable Care Act (ACA) on the grounds that the Individual Mandate was unconstitutional, and that the rest of the law cannot withstand constitutional scrutiny without the Individual Mandate.

District Court Judge Reed O’Connor’s decision relates to a lawsuit filed earlier this year by 20 states and two individuals. The plaintiffs argued that the Tax Cuts and Jobs Act of 2017 — which amended the Individual Mandate to eliminate the penalty on individuals that failed to purchase qualifying insurance effect January 1, 2019 — rendered the Individual Mandate unconstitutional. The plaintiffs further argued that the Individual Mandate was inseverable from the rest of the ACA, and, therefore, that the entire ACA should be struck down.

The defendants in this case were the United States of America, the U.S. Department of Health and Human Services (HHS), Alex Azar, in his capacity as the Secretary of HHS, and David J. Kautter, in his capacity as the Acting Commissioner of the Internal Revenue Service (IRS). 16 states and the District of Columbia intervened as additional defendants.

In order to properly understand the district court’s ruling, it is necessary to revisit the Supreme Court’s 2012 decision on the constitutionality of the ACA, National Federal of Independent Business v. Sebelius (NFIB). In that case, 26 states, along with several individuals and a business organization challenged the ACA’s Individual Mandate and Medicaid expansion provisions as exceeding Congress’ enumerated powers. In a complicated decision, the majority of Justices ruled that the Individual Mandate was unconstitutional under Congress’ authority to regulate interstate commerce, but that the provision could be salvaged under Congress’ authority to lay and collect taxes. In reaching this conclusion, the majority of Justices focused on the “shared responsibility payment” aspect of the Individual Mandate, which imposed a tax on those individuals that failed to purchase or otherwise obtain qualifying health insurance. The majority of Justices concluded that the shared responsibility payment was a “tax.” It was therefore constitutional under the Congress’ general taxing authority.

In sum, the Supreme Court ruled that Congress lacked the power to compel individuals to buy qualifying health insurance, but that it could constitutionally impose a tax on those that failed to purchase or otherwise obtain qualifying health insurance.

In the current case, the court was asked to reconsider the Individual Mandate in light of the TCJA, which “zeroed” out of the shared responsibility payment, effective January 1, 2019. The plaintiffs argued that the Individual Mandate could no longer be justified as a valid exercise of Congress’ taxing authority. The federal government and its agents did not necessarily contest the plaintiffs’ argument with respect to the Individual Mandate. By contrast, the intervening states and the District of Columbia argued that the Individual Mandate could continue to be construed as a tax because it continues to satisfy the factors set forth by the Supreme Court in NFIB.

Judge O’Connor sided with the plaintiffs, holding that, because the Individual Mandate would no longer trigger a tax beginning in 2019, the Supreme Court’s ruling on this point in NFIB was no longer applicable. He therefore concluded that the Individual Mandate could no longer be upheld under Congress’ taxing authority. Judge O’Connor then fell back on the Supreme Court’s previous holding that the Individual Mandate, as a stand-alone command, remained unconstitutional under the Interstate Commerce Clause. Judge O’Connor then ruled that the Individual Mandate could not be severed from the rest of the ACA. On this point, the judge cited the express provisions of the ACA, as well as the Supreme Court’s decisions in NFIB and King v. Burwell.

What this decision means

On its face, the decision strikes down the Affordable Care Act in its entirety. However, the ruling is likely to be appealed to the Fifth Circuit Court of Appeals. Most legal experts expect that, regardless of the decision at the Circuit Court, the case is likely to make its way up to the Supreme Court.

Pending the resolution of these appeals, the Administration has adopted a “business as usual” approach. The White House has already indicated that it will not attempt to enforce the ruling during the appeals process. CMS Administrator Seema Verma recently tweeted that the decision will have “no impact to current coverage or coverage in a 2019 plan.”

The American Ambulance Association will continue to monitor this case as it makes its way through the appeals process, and we will notify our members of any new developments.

CMS Announces Extension of Prior Authorization Program

On November 30, 2018, CMS issued a notice on its website that it would be extending the prior authorization demonstration project for another year. The extension is limited to those states where prior authorization was in effect for calendar year 2018. The affected states are Delaware, Maryland, New Jersey, North Carolina, Pennsylvania, South Carolina, Virginia…

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AAA moved! Would you please direct all future communication to our new office?

American Ambulance Association
202.802.9020 (NEW!)
info@ambulance.org

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Washington DC, 20005

Thank you for your continued support.

Talking Medicare: CMS Implements Further Dialysis Cuts

Talking Medicare: CMS Implements Further Cuts in Reimbursement for Dialysis Services; Medicare Payment Data Shows Continued Reduction in Overall Spending on Dialysis Transports, but Net Increase in Dialysis Payments in Prior Authorization States On October 1, 2018, CMS implemented an additional thirteen (13%) cut in reimbursement for non-emergency BLS transports to and from dialysis. This cut…

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Talking Medicare: Prior Authorization Spending Update

Prior Authorization Data Shows Continued Reduction in Overall Spending on Dialysis Transports; Pendulum Swings Back Slightly in New Jersey and Pennsylvania In May 2014, CMS announced the implementation of a three-year prior authorization demonstration project for repetitive scheduled non-emergency ambulance transports. This demonstration project was initially limited to the states of New Jersey, Pennsylvania, and…

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The Future of Prior Authorization

In May 2014, CMS announced the creation of a three-year demonstration project that calls for the prior authorization of repetitive scheduled non-emergency ambulance transports. The demonstration project was first implemented in the states of New Jersey, Pennsylvania, and South Carolina. These states were selected based on their higher-than-average utilization rates for repetitive ground ambulance transportation….

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MAC Novitas March 2016 Updates to Ambulance Services

On March 4, Novitas Solutions, Medicare Administrative Contract managers for several jurisdictions, asked AAA to share the following information with ambulance services.

March 4, 2016 – Letter to Ambulance Providers | March 4, 2016 – Letter to Beneficiaries

Jurisdictions Covered By Novitas

  • The Medicare Administrative Contract (MAC) Jurisdiction L (JL), which spans Pennsylvania, New Jersey, Maryland, Delaware and Washington D.C.;
  • The Medicare Administrative Contract (MAC) Jurisdiction H (JH), which spans Colorado, Oklahoma, New Mexico, Texas, Arkansas, Louisiana, Mississippi, Indian Health Service (IHS) and Veterans Affairs (VA); and
  • The payment processing for the Federal Reimbursement of Emergency Health Services Furnished to Undocumented Aliens contract, as authorized under Section 1011 of the 2003 Medicare Modernization Act.

Summary of CMS Ambulance Open Door Forum of November 5, 2015

By David M. Werfel, Esq. | Updated November 6, 2015 On November 5, 2015, the Centers for Medicare and Medicaid Services (CMS) conducted its latest Ambulance Open Door Forum.  As usual, CMS started with announcements, which were as follows: As required under the Medicare Access and CHIP Reauthorization Act (HR 2), the pilot program for…

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Prior Auth Expansion to MD, DE, DC, NC, VA, WV

CMS Announces Expansion of Prior Authorization Program for Repetitive Scheduled Non-Emergent Ambulance Transports October 26, 2015 CMS has announced that consistent with the requirements of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), it will expand the current prior authorization demonstration program for repetitive scheduled non-emergent ambulance transports beginning on January 1, 2016,…

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Novitas Issues Guidance for Ambulance Providers, Facilities and Beneficiaries Regarding Expansion of Prior Authorization Project for Repetitive Patients

September 17, 2015 Novitas Solutions, Inc. (Novitas) recently issued a series of guidance documents on the expansion of the prior authorization demonstration project for repetitive scheduled non-emergency ambulance transports. This demonstration project is currently operating in the states of New Jersey, Pennsylvania, and South Carolina. The Medicare Access and CHIP Reauthorization Act of 2015 (Pub….

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Spotlight: Kathy Lester

Kathy Lester, MPH, JD
Washington, DC
Healthcare Consultant to AAA

Tell us a little about yourself, please.

I am from Indianapolis, Indiana.  I graduated from Warren Central High School, best known for being the high school of Jane Pauley and Jeff George.  My undergraduate degree is from DePauw University.  I had a double major in biology and English literature, with a minor in violin performance.  I also loved philosophy and political science course and was the editor-in-chief of the college newspaper.  I received my JD from Georgetown University Law Center and my Master of Public Health (MPH) from The Johns Hopkins School of Public Health and Hygiene, now known as the Bloomberg School of Public Health.

After law school, I clerked on for The Honorable Michael S. Kanne on the U.S. Court of Appeals for the Seventh Circuit.  I have also worked in all three branches of government.  In addition to the courts, I worked on the Hill for Sen. Richard G. Lugar (R-IN) and in the General Counsel’s Office at the Department of Health and Human Services.

My husband and I met while both working for Senator Lugar.  He retired from the Senate after 20+ years.  We have two children and are trying to succeed in having tropical fish survive for more than a few months.

When and how did you get involved with AAA?

I began working with the AAA several years ago when we began developed recommendations for a quality program.  I believe my first meeting with the group was in Las Vegas.

How do you help AAA?

Currently, I assist on the public policy issues.  This includes working with the Congress to protect the add-ons, as well as develop payment reforms to create stability for Medicare rates.  I help to draft materials for the Hill and legislative language.  As part of this effort, I help with developing more comprehensive Medicare reform recommendations.  I also assist with the regulatory agenda and engage with Centers for Medicare and Medicaid Services (CMS) and other federal agencies.  In addition, I continue to work on quality structural and measurement issues.

What is your typical day like?

Unpredictable and fun!  My days vary greatly.  I can find myself on the Hill or driving to Baltimore to meet with CMS.  I also spend a lot of time talking with AAA members and the staff team.

What are the biggest challenges you foresee for our industry?Any tips or last thoughts?

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It is more important than ever to understand the cost of services and to be able to articulate why these services are necessary.

[/quote_left]All of healthcare is at a crossroads.  While federal policymakers have successfully reduced spending in the Medicare program, the focus for the foreseeable future will be how to reduce the cost of providing services.  It is more important than ever to understand the cost of services and to be able to articulate why these services are necessary.

For ambulance providers and suppliers in particular, there is great promise in the innovative payment models, because they would most likely recognize the high quality of health care services provided by ambulance providers and suppliers.  However, there is also the potential that ambulance services could become subordinate to larger provider organizations.  As this debate unfolds, it is critically important that data drive any reforms and that the industry look carefully at how programs such as value-based purchasing, the Medicare quality reporting programs (facility compare websites and the five star rating programs), and coordinated/integrated care models have worked for other Medicare providers.  At the end of the day, ambulance providers and suppliers need to understand their care and cost models and articulate use these data points to develop meaningful and sustainable reform options.