OBBBA Medicaid cuts increase credit risk for NFP hospitals
Looming healthcare cuts as legislated in the One Big Beautiful Bill Act (OBBBA) constitute the biggest risk to the not-for-profit (NFP) hospital industry, according to insights from experts with the leading credit-rating agencies. The OBBBA is set to hit Medicaid over the next few years, bringing potentially sizable reductions to enrollment along with direct cuts…
Medicaid work requirement rule adds significant wrinkles to program eligibility criteria
For state agencies and potentially healthcare providers, CMS’s regulatory guidance on implementing the Medicaid work requirement imposes responsibilities that go beyond language seen in the underlying statute. CMS published an interim final rule with comment period late Monday, just barely meeting the June 1 deadline established in the 2025 reconciliation law known as the One…
Medicaid revenue cutbacks, plus the healthcare fraud landscape
Nick Hut is joined by HFMA Policy Director Katie Gilfillan to discuss fraud, waste and abuse as well as state-directed Medicaid payments. Further reading: CMS Medicaid state-directed payment rule | HFMA
Medicaid Managed Care State Directed Payments and FFS Targeted Medicaid Practitioner Payments Proposed Rule Summary
HFMA provides a detailed summary of the rule that includes proposals to implement the provisions of the “Working Families Tax Cut” legislation, which modify the limit on the total payment rate and other requirements for State directed payments (SDPs) in Medicaid managed care with respect to certain service types and SDPs, and the proposals to expand application of the modified limit to all SDPs and all service types and to set a limit for certain targeted Medicaid payments in Medicaid fee-for-service.
Final rule lowers No Surprises Act IDR fees, adds requirements
Regulations issued Thursday to update the No Surprises Act’s independent dispute resolution (IDR) process represent an effort to improve access while also streamlining the volume of cases. CMS and the Departments of Labor and Treasury published a final rule that significantly lowers IDR fees but includes more requirements of the insurers and providers that seek to use…
News Briefs: CMS proposes a modest increase to hospital inpatient payments for FY27
CMS projects an average Medicare inpatient payment increase of 2.4%, totaling $1.4 billion industrywide, when the new fiscal year begins Oct. 1. The update, described in a proposed rule for inpatient care and long-term care hospitals (LTCHs), is based on a 3.2% increase to the market basket and a 0.8% reduction via a mandatory economywide productivity adjustment.…
340B lawsuits against CVS allege $250M in underpaid hospital reimbursement
CVS Health’s pharmacy benefit manager (PBM) under-reimbursed three health systems by almost $250 million over five years in connection with the 340B Drug Pricing Program, according to new lawsuits. Filed in three separate federal courts, the complaints describe how CVS Health and its subsidiaries retained a large share of the savings generated through the 340B…
CMS moves to curb MA plans’ unfair payment advantage
In April, CMS published its annual Medicare Advantage (MA) rate announcement for 2027.a For most years in recent memory, this would be a routine event, accompanied by no small amount of headshaking from the provider community. Hospitals and physicians would be perpetually perplexed at why CMS would give MA plans generous payment increases, while giving hospitals…
Off-campus outpatient billing rules could extend to commercial claims
Hospitals preparing for new off-campus outpatient department (OPD) billing requirements in Medicare may soon face a parallel mandate for commercial claims. The House Education and Workforce Committee on May 21 unanimously passed the Transparency in Billing Act, which would prohibit commercial health plans from paying claims that do not include a unique identifier for the…
CMS’s Medicaid state-directed payment rule would expand limits beyond hospitals
CMS’s proposed rule on Medicaid state-directed payments (SDPs) would implement limits authorized by the One Big Beautiful Bill Act (OBBBA) while applying restrictions to a broader swath of Medicaid, including certain fee-for-service (FFS) supplemental payments. Essentially, the agency issued proposed regulations that would take some of the OBBBA’s Medicaid provisions a step further. Services previously…