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…
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…
How healthcare providers can understand and mitigate FWA risk
Many healthcare providers believe they could readily explain their billing and charging practices — until a government review requires them to do so. What feels routine internally can look quite different when examined externally, particularly in today’s fraud, waste and abuse (FWA) environment, where attention is increasingly focused on patterns, processes and governance. Providers may…
MultiPlan antitrust litigation gains momentum after rulings for providers
Healthcare providers obtained two favorable rulings over the last month in their massive antitrust litigation against a vendor’s repricing algorithm. The case entails allegations that MultiPlan — which since has rebranded as Claritev — conspired to set out-of-network (OON) payment rates by gathering competitively sensitive information from roughly 700 health plans and using that information…
House bill would increase tax-exempt hospital reporting requirements
A bill that advanced out of a House committee Wednesday would add significant reporting requirements for tax-exempt hospitals. As passed by the Ways and Means Committee, the Tax-Exempt Hospital Transparency Act includes increased reporting obligations in areas such as community benefit, charity care, the 340B Drug Pricing Program and service-line spending. Requirements would be more…
340B claims data requirements put hospital discounts under stress
June 18 update Eli Lilly has followed through with cutting off 340B discounts for certain hospitals that have yet to submit the required claims data (see the original story below), provider advocacy groups said Thursday. “As a result of Lilly’s decision to deny hospitals access to 340B pricing for the company’s products unless they submit…
Healthcare compliance risks rise as CMS expands fraud enforcement
With recent developments highlighting the Trump administration’s emphasis on healthcare fraud prevention, providers should ensure their compliance processes are working optimally. The administration has taken various steps in 2026, including this month. On May 13, CMS announced it was withholding $1.3 billion in Medicaid funding from California. During media availability at the White House that…
DOJ brings antitrust lawsuits challenging hospital contracting practices
June 4 update NewYork-Presbyterian responded to the lawsuit brought by the U.S. Department of Justice alleging anticompetitive business practices in the organization’s contracting with insurers (see the original story below). The health system is arguing for a dismissal of the government’s case. Partially echoing OhioHealth’s defense against similar allegations, NYP said the contractual provisions at…