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Missouri Pharmacy and Clinical Services Management Solution RFI; Kentucky Pharmacy Benefit Manager RFP

This week, our In Focus sections reviews the Missouri HealthNet Pharmacy and Clinical Services Management Solution request for information (RFI) and the Kentucky Medicaid Managed Care Organization (MCO) Pharmacy Benefit Manager request for proposals (RFP).

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CMS Finalizes Policy to Use Hospital Negotiated Charge Data to Set Payment Rates

This week, our In Focus section reviews the policy changes included in the Centers for Medicare & Medicaid Services (CMS) Fiscal Year (FY) 2021 Medicare Hospital Inpatient Prospective Payment System (IPPS) and Long-Term Acute Care Hospital (LTCH) Final Rule (CMS-1735-F). This year’s IPPS Final Rule includes several important policy changes that will change hospitals’ administrative procedures and may alter hospitals’ Medicare margins, beginning as soon as October 1, 2020.

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California Releases Medi-Cal Managed Care RFI

This week, our In Focus section reviews the California request for information (RFI) regarding the Medi-Cal Managed Care Plan (MCP) contract and the upcoming Medi-Cal MCP procurement. The California Department of Health Care Services (DHCS) is seeking information to update boilerplate contracts and develop the request for proposals (RFP) scheduled for release in 2021.

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Health Management Associates Acquires Health Policy Consulting Firm Burns & Associates

Today, Jay Rosen, founder and president of Health Management Associates (HMA), announced the firm’s acquisition of Burns & Associates, Inc., an Arizona-based health policy consulting firm that specializes in innovative approaches to the financing and delivery of health care and human services.

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HMA Summary of Democratic Nominee Joe Biden’s Healthcare Plan

This week, our In Focus section reviews Democratic Nominee Joe Biden’s healthcare plan to protect and build on the Affordable Care Act (ACA). On August 18, 2020, Biden was officially nominated as the presidential candidate. Biden vowed at the 2020 Democratic National Convention (DNC) that if elected, he would strengthen the ACA and provide a Medicare-like public option. HMA summarizes Biden’s official plan below.

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HMA Summary of Medicare Fee-For-Service (FFS) Proposed Rules

This week, our In Focus section reviews two Medicare fee-for-service (FFS) proposed rules recently issued by the Centers for Medicare & Medicaid Services (CMS). On August 3, 2020, CMS released a proposed rule that includes updates to services furnished under the Medicare Physician Fee Schedule (PFS). On August 4, CMS released the Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System proposed rule. These proposed regulations include payment rate and policy changes for the upcoming calendar year. Key features in this year’s PFS proposed rule include: policies to retain, extend, or end certain telehealth flexibilities implemented in response to the novel COVID-19 public health emergency (PHE), changes to enable certain health care professionals to practice at the top of their licenses, modifications to opioid treatment programs (OTPs), and updates to the Medicare Shared Savings Program (MSSP). Additional information on the PFS Proposed Rule can be found here. Among the most notable policy changes in the OPPS and ASC proposed rule are: 1) transitioning services to lower cost settings by eliminating the inpatient-only list to enable more services to be provided in the outpatient settings and increasing the scope of procedures that can be provided in ASCs, 2) further reducing payments for the 340B drug program, and 3) modifying the formula for calculating Hospital Star Ratings, and expand the use of prior authorization for outpatient services. Additional information about these proposals can be found here.

Read MoreHMA Summary of Medicare Fee-For-Service (FFS) Proposed Rules

Regulatory Changes to Medicare in Response to COVID-19

This week, our In Focus section examines how the federal government implemented changes to the Medicare program in response to COVID-19.  As the COVID-19 pandemic began in the United States, Congress and the Administration responded with a series of legislative, regulatory, and sub-regulatory changes to the Medicare program that were designed to provide relief from certain Medicare rules to assist health care providers, Medicare Advantage organizations, and Part D plans in responding to the pandemic. Some of these changes waived conditions of Medicare participation to enable patients to be treated in alternative care settings. Others permitted physicians and other providers to receive Medicare reimbursements for telemedicine services.

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Hawaii Releases Quest Integration Reprocurement RFI

This week, our In Focus section reviews the Hawaii request for information (RFI) regarding reprocurement of the state’s QUEST Integration (QI) Medicaid managed care program, released on July 21, 2020. QI covers approximately 360,000 individuals, including pregnant women, children, parents/caretakers, adults, and individuals who are aged, blind, or disabled (ABD). The state had awarded contracts earlier this year, however, the contracts were rescinded as the state focused on their response to COVID-19.

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