Court decisions on ACA marketplace rules affect key coverage provisions
As CMS moves ahead with Medicaid funding limits for gender-affirming care in minors, Democratic state leaders used litigation to block restrictions in the Affordable Care Act (ACA) insurance marketplaces. The ACA policy, established in 2025 regulations, would remove the essential health benefit (EHB) designation from gender-affirming care. EHB status allows ACA consumer protections, such as…
No Surprises Act QPA calculations set to change after appeals court ruling
An appeals court sided with providers in a case about the No Surprises Act’s qualifying payment amount (QPA), a key benchmark in out-of-network payment determinations. The U.S. Court of Appeals for the Fifth Circuit issued a ruling that QPA calculations must not include ghost rates, referring to non-negotiated rates listed in contracts for services a…
Guilty plea in UnitedHealthcare CEO killing comes amid sustained focus on obstacles to care
Luigi Mangione pleaded guilty Aug. 14 to federal stalking charges in the 2024 fatal shooting of UnitedHealthcare’s CEO, potentially bringing resolution to an incident that spurred introspection by insurers and the healthcare industry. The charges, stemming from the killing of Brian Thompson on Dec. 4, 2024, carry a maximum penalty of life in prison. Prosecutors…
HHS report raises scrutiny of gender-affirming care billing and coding
HHS followed up its final rule blocking Medicaid funding for gender-affirming care in minors by publishing a commissioned report alleging “potentially fraudulent” billing and coding among providers of the services. The report, released Aug. 13, alleges that financial incentives drove hospitals and physicians to expand access to the care, and that deceitful billing practices took…
CMS ends Medicaid coverage of gender-affirming care for minors
Federal Medicaid funding no longer will be available to cover gender-affirming healthcare for minors, according to a CMS final rule issued Aug. 11. The rule blocks Medicaid and Children’s Health Insurance Program (CHIP) federal matching funds from reimbursing providers for what the rule refers to as “sex-rejecting procedures” in beneficiaries younger than 18 in Medicaid…
CMS proposes new 340B reporting and HOPD attestation requirements
Recently published editions of two annual Medicare proposed rules both included provisions creating new administrative tasks for hospitals. CMS’s proposed rule for hospital outpatient care would formalize a system of required attestation for off-campus hospital sites starting in 2028, while the rule for physician payments would establish obligatory submission of 340B-related data to a centralized…
Medicare DSH payments ruling could boost hospital reimbursement under 1115 waivers
Hospitals obtained a victory in a case about Medicare disproportionate share hospital (DSH) payments, with potentially significant reimbursement implications. In a July 27 ruling in Covenant Medical Center v. Kennedy, a judge with the U.S. District Court for Northern Texas struck down an HHS rule that excluded certain patients from the DSH formula if they were…
Senate Medicaid hearing highlights the debate over federal spending cuts
Cuts to federal Medicaid spending are necessary to streamline the program and don’t necessarily portend tough times for providers, conservative policymakers and analysts argued during a Senate hearing. The Aug. 4 hearing of the Senate Budget Committee included discussion of whether healthcare policies in the One Big Beautiful Bill Act (OBBBA) should be scaled back…
SUSTAIN 340B Act proposes major changes for hospitals and pharmacies
A bipartisan working group in Congress released a preliminary legislative draft that attempts to resolve some of the most disputed aspects of the 340B Drug Pricing Program. One noteworthy provision in the legislation would curtail the 340B rebate model, which was finalized by the Health Resources and Services Administration on July 31 and is scheduled to begin Jan.…
CJR-X mandatory bundled payment model begins for hospitals in 2028
Hospitals have 17 months to prepare for the first mandatory nationwide alternative payment model, as established in Medicare’s FY27 final rule for the Inpatient Prospective Payment System (IPPS) and long-term care hospitals (LTCHs). The final rule makes no major changes to the proposal issued earlier this year for the CJR-X Model, which will require most…