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CMS Finalizes Guidelines for Medicare Drug Price Negotiation Program, Permanent by 2029

CMS Finalizes Guidelines for Medicare Drug Price Negotiation Program, Permanent by 2029

The Centers for Medicare & Medicaid Services (CMS) has finalized the guidelines for the Medicare Drug Price Negotiation Program, which is set to become a permanent fixture starting in 2029. This program, established by the Inflation Reduction Act of 2022, empowers CMS to directly negotiate drug prices with manufacturers for high-cost medications covered under Medicare's Part B and Part D programs. Under the finalized rule, CMS will identify and publish a list of up to 20 selected drugs for negotiation or renegotiation. The agency will then enter into agreements with participating manufacturers to establish maximum fair prices for these drugs and will publish these agreed-upon prices. The program also includes provisions for imposing civil monetary penalties when necessary. This initiative aims to reduce the cost of prescription drugs for Medicare beneficiaries, though it will not apply to all drugs, take immediate effect, or eliminate all differences between Medicare plans. The implementation of this progr...

US gives states another 6 months before they have to remove people from Medicaid for not working

US gives states another 6 months before they have to remove people from Medicaid for not working

President Donald Trump's administration is giving states another six months before they must remove beneficiaries from Medicaid rolls for failing to meet new work requirements

Elevance Health's Anthem Brand Faces Network Changes with Sentara Facilities in 2027

Beginning in 2027, certain Anthem health plans will no longer consider Sentara facilities as in-network providers. This change impacts Anthem Medicare Advantage, ACA Exchange plans, and Medicaid plans, with effective dates starting January 1, 2027, and January 28, 2027, respectively. Commercial or employer-sponsored Anthem plans are also expected to be affected starting January 1, 2027, though negotiations are ongoing. This development means that patients with these Anthem plans who seek care at Sentara facilities, including The CarePlex Orthopaedic Ambulatory Surgery Center, may face out-of-network costs. Tidewater Orthopaedics, while continuing to see Anthem patients at its clinic locations, notes that surgical procedures at The CarePlex Orthopaedic Ambulatory Surgery Center will be impacted. Patients are advised to contact Anthem directly to confirm their specific plan's coverage and network status for 2027.

College of American Pathologists Urges Members to Participate in Virtual Hill Day for Medicare Reimbursement Advocacy

College of American Pathologists Urges Members to Participate in Virtual Hill Day for Medicare Reimbursement Advocacy

The College of American Pathologists (CAP) is calling on its members to participate in its Virtual Hill Day, scheduled for next Wednesday, November 18th. This initiative is crucial for pathologists to advocate directly to members of Congress regarding legislation that could impact Medicare reimbursement for physicians and laboratories before the end of the year. During Virtual Hill Day, CAP members nationwide will engage in online meetings with congressional representatives and their staff. These meetings are designed to be brief, lasting less than 30 minutes, and CAP will manage the scheduling and provide all necessary talking points. No prior advocacy experience is required for participation. Additionally, CAP leaders will host a webinar on Tuesday, November 17th, to provide a comprehensive overview of the Centers for Medicare and Medicaid Services (CMS) 2027 Medicare Physician Fee Schedule and Quality Payment Program Final Rule, detailing its impact on pathologists and CAP's advocacy efforts.

Congressman Bentz Announces $197.3 Million for Oregon's Rural Healthcare in 2027

Congressman Bentz Announces $197.3 Million for Oregon's Rural Healthcare in 2027

Congressman Cliff Bentz (R-OR) has announced that the Centers for Medicare & Medicaid Services (CMS) has awarded $197.3 million for fiscal year 2027 to enhance and modernize rural healthcare in Oregon. This funding is a continuation of the 'Big Beautiful Bill’s Rural Health Transformation Program,' which provided a similar amount to Oregon in the previous year. Congressman Bentz was the sole member of Oregon’s congressional delegation to vote in favor of this funding measure. In 2026, the program distributed $16.4 million across 42 'Immediate Impact Award' projects addressing urgent needs, and $80.1 million to 103 'Catalyst Award' projects aimed at improving healthcare access in areas such as maternity, primary, and senior care. Additionally, $21.7 million was allocated to Oregon's nine federally recognized Tribes, $35 million to its 35 rural hospitals, and $10 million to its 100 rural health clinics.

CMS Finalizes 2027 Medicare Physician Payment Cuts and Policy Reforms

CMS Finalizes 2027 Medicare Physician Payment Cuts and Policy Reforms

The Centers for Medicare & Medicaid Services (CMS) has released its Medicare Physician Fee Schedule, finalizing significant payment cuts and policy reforms for 2027. Physicians participating in qualifying Advanced Alternative Payment Models (APMs) will face a conversion factor cut of -1.83%, while those not in qualifying APMs will see a larger reduction of -2.31%. These cuts are primarily driven by the expiration of a temporary 2.5% payment increase provided by Congress for 2026. Additionally, CMS is continuing its multi-year trend of reforming Medicare payments, including changes to evaluation and management (E/M) reimbursements and practice expense methodology. A notable change is the reduction in reimbursements for separately identifiable E/M visits furnished on the same day as a 0-day global procedure. CMS also announced that the traditional Merit-based Incentive Payment System (MIPS) will end in 2030, requiring physicians to transition to MIPS Value Pathways (MVPs) by 2031. Furthermore, new restrictio...

Reps. Smith and Dingell Introduce Bipartisan Bill to Expand Medicare Care at Home Options

Reps. Smith and Dingell Introduce Bipartisan Bill to Expand Medicare Care at Home Options

Congressman Adrian Smith (R-NE) and Congresswoman Debbie Dingell (D-MI) have introduced the 'Bringing Rehabilitation, Integrated Delivery, and Greater Extended (BRIDGE) Care at Home Act.' This bipartisan bill aims to modernize Medicare by allowing beneficiaries to receive skilled nursing and rehabilitation services in their homes after a qualifying hospital stay. The proposed legislation would establish a five-year Medicare 'SNF-at-Home' pilot program. This program would enable the Department of Health and Human Services Secretary to compare the costs, outcomes, and patient characteristics of home-based care versus facility-based care. Supporters of the bill view it as a means to expand patient choice, alleviate pressure on hospitals and nursing facilities, and potentially reduce healthcare costs.

National Health Law Program Brief Examines AI Use in Medicaid Prior Authorization, Citing Equity and Due Process Concerns

National Health Law Program Brief Examines AI Use in Medicaid Prior Authorization, Citing Equity and Due Process Concerns

The National Health Law Program has released a brief titled 'Prior Authorization in Medicaid: Regulating Artificial Intelligence.' This publication delves into the application of artificial intelligence (AI) within Medicaid's prior authorization processes. The brief highlights specific concerns regarding equity and due process that arise from the use of AI in this context. It argues that existing safeguards are insufficient to address these issues. Furthermore, the brief reviews recent regulatory efforts by individual states to manage AI in healthcare and discusses the current federal administration's actions, which it characterizes as undermining state autonomy on this matter. The document aims to shed light on the complexities and potential pitfalls of integrating AI into critical healthcare authorization systems, particularly for vulnerable Medicaid populations.

Medicare's Maximum Fair Prices Influence Payer Negotiations and Manufacturer Strategies

Medicare's Maximum Fair Prices Influence Payer Negotiations and Manufacturer Strategies

Medicare's Maximum Fair Prices Influence Payer Negotiations and Manufacturer Strategies

CDC Updates Respiratory Illness Guidance for Nursing Homes, Shifts COVID-19 Testing Strategy

CDC Updates Respiratory Illness Guidance for Nursing Homes, Shifts COVID-19 Testing Strategy

The Centers for Disease Control and Prevention (CDC) has updated its guidance for managing COVID-19 and other viral respiratory illnesses in healthcare settings, significantly altering recommendations for nursing homes. The CDC's previous COVID-19 guidance, last updated in 2023, has been archived. Relevant recommendations are now integrated into Appendix A of the 'Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings.' A key change is the shift in COVID-19 testing strategy: the CDC now primarily recommends testing at the onset of respiratory illness symptoms to identify the specific pathogen, which informs treatment and transmission-based precautions. However, recommendations for testing asymptomatic individuals after exposure or for serial testing have been removed. Testing to end isolation is now advised only for individuals who are moderately to severely immunocompromised, with nursing home admission alone not qualifying an individual for this designati...

Congressman Mike Bost Applauds Over $190 Million Federal Funding for Illinois Rural Healthcare

Congressman Mike Bost Applauds Over $190 Million Federal Funding for Illinois Rural Healthcare

U.S. Representative Mike Bost (IL-12) has commended an announcement from the Centers for Medicare and Medicaid Services (CMS) detailing over $190 million in federal funding allocated to Illinois. This funding is specifically aimed at bolstering rural healthcare systems and addressing critical workforce shortages in underserved communities across the state. The allocation comes through the Rural Health Transformation Program, an initiative that Congressman Bost supported and voted to create last year. This program is designed to distribute a total of $50 billion nationwide over five years, with $10 billion being awarded annually until fiscal year 2030. This recent investment, part of the Trump administration's efforts, elevates Illinois's total awards from this program to approximately $384 million over a two-year period. Congressman Bost emphasized that this fund serves as a vital resource for rural communities in Southern Illinois, enhancing patient services locally and providing essential support for hea...

Charta Health Secures $55 Million Series B Funding Led by Insight Partners to Standardize Healthcare Billing Accuracy

Charta Health Secures $55 Million Series B Funding Led by Insight Partners to Standardize Healthcare Billing Accuracy

Charta Health Secures $55 Million Series B Funding Led by Insight Partners to Standardize Healthcare Billing Accuracy