HRI regulatory center

HRI regulatory center

HRI regulatory spotlight: CMS proposes ‘two-midnight’ hospital payment compromise
HRI regulatory spotlight: CMS proposes ‘two-midnight’ hospital payment compromise
New regulations proposed by the Medicare program will give hospitals flexibility to determine the medical appropriateness of a patient’s inpatient stay by relying more on physician judgment.
HRI regulatory spotlight:CMS final rule establishes flexibility for Medicare ACOs
HRI regulatory spotlight: CMS final rule establishes flexibility for Medicare ACOs
Medicare Accountable Care Organizations (ACOs) now have more flexibility in administrative requirements, additional choices around shared savings options, and new performance and quality metrics that they must meet as part of a final rule effective August 3, 2015.
HRI regulatory spotlight: New Medicare physician payment formula will reward risk, quality care
HRI regulatory spotlight: CMS draft rule revamps Medicaid managed care
Federal health officials are proposing to update decade old regulations, to better align rapidly growing Medicaid managed care programs with Medicare Advantage and private health insurance offerings.
HRI regulatory spotlight: New Medicare physician payment formula will reward risk, quality care
HRI regulatory spotlight: New Medicare physician payment formula will reward risk, quality care
After 18 contentious years, Medicare’s sustainable growth rate formula—intended to determine yearly payment rate updates for doctors who care for Medicare patients—will be replaced by a series of new reimbursement models that more closely reflect broader healthcare trends, such as growing consumerism and rewards for high-quality, low-cost care.
FDA announces landmark biosimilar approval
FDA announces landmark biosimilar approval
FDA’s first biosimilar approval – an event described as “historic” by agency leadership – marks an important step toward the drug cost savings intended by the ACA’s Biologics Price Competition and Innovation Act.
HRI regulatory spotlight: Regulatory action may strengthen telehealth take-off
HRI regulatory spotlight: Regulatory action may strengthen telehealth take-off
State and federal governments are playing a role in driving telehealth expansion. New York is the latest in over 20 states already mandating private insurer reimbursement, and more than 40 states have expanded Medicaid to cover telehealth.

For more information, click here to download HRI's overview presentation on telehealth.

 

HRI regulatory spotlight: Understanding the 3Rs – risk adjustment, risk corridors, and reinsurance
HRI regulatory spotlight: Understanding the 3Rs – risk adjustment, risk corridors, and reinsurance

The 3Rs were created to balance insurer risks in the insurance exchanges and incentivize health plans to participate in this new market.
HRI regulatory spotlight: Managing antimicrobial resistance: More than just medicine
HRI regulatory spotlight: Managing antimicrobial resistance: More than just medicine
Antimicrobial resistance is a threat to the nation’s health and security. To help reduce this threat, President Obama recently proposed a $1.2 billion investment for research and development of new antibiotics.
HRI regulatory spotlight: States use rate approval authority to manage individual health insurance premium prices for 2015
HRI regulatory spotlight: States use rate approval authority to manage individual health insurance premium prices for 2015
The individual health insurance market has received much attention as consumers enroll in plans for 2015. In the months leading up to the 2015 open enrollment period, PwC’s Health Research Institute (HRI) analyzed insurers’ rate filings and found that premium increases over 2014 varied widely from state to state.
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The Affordable Care Act has entered its most pivotal year since being signed into law in 2010. About 20 million Americans gained coverage during the ACA’s inaugural open enrollment period, and hospitals and physicians are beginning to reorient how they deliver care to align with new payment models. It’s now more important than ever to stay atop the regulatory environment, as federal agencies provide the guideposts to an emerging new health economy. But that’s just the starting point. As consumers shoulder more of the costs for care, prepare to see dynamic changes as the industry shifts to compete for the newly insured.

Learn more about the healthcare regulatory environment through the following resources:



Week of 08/03/2015

  • FDA approves new drug using special voucher
  • Increased competition puts downward pressure on exchange premiums
  • Most hospitals in line for a slight Medicare pay increase
  • FDA issues cybersecurity warning
  • New HRI Spotlight: CMS proposes ‘two-midnight’ hospital payment compromise

Week of 07/27/2015

  • CMS doubles the number of it highest quality rating for hospitals
  • CMS experiments with combining hospice and curative care
  • Court clears path for introduction of first biosimilar in US
  • For-profit hospitals generate highest medical charges
  • 2016 insurance exchange premium rates vary widely by state

Week of 07/20/2015

  • HHS sees mixed results in efforts to fight healthcare fraud
  • FDA finalizes drug shortage reporting rule
  • Slavitt nomination leads a year of change for agencies, associations
  • Ohio and California pass PBM reimbursement transparency laws
  • BCBS takes proactive approach to cyberattacks
  • Tax Research: Changes to high-deductible health plans, out-of-pocket maximums, on the horizon

Week of 07/13/2015

  • In the wake of King v. Burwell ruling, states reconsider exchange operations
  • CMS proposes bundled payment model for knee, hip replacements
  • White House releases draft guidance on protecting patient data
  • Medicaid expansion marches forward
  • New HRI Spotlight: CMS final rule establishes flexibility for Medicare ACOs

February 25, 2014

Final rules on ACA's employer mandate include new transition relief

The IRS issued final regulations providing guidance on the Affordable Care Act's employer shared responsibility provisions, sometimes called the 'employer mandate' or the 'pay or play' rules. The regulations apply for periods after December 31, 2014 to applicable large employers who fail to offer coverage to their full-time employees. The regulations extend earlier transition rules and provide new ones to help employers comply with the requirements.

Highlights of the final regulations include:

  • an extended transition period for employers with between 50 and 99 full-time equivalent employees, so they won't be subject to penalties until 2016
  • a temporary rule for employers with 100 or more full-time employees, so the largest penalty will not apply for 2015 if the employer offers coverage to at least 70% of its full-time employees (rather than 95% as will be required after 2015)
  • final rules for determining full-time employee status reflect the proposed regulations, including the optional look-back measurement period and stability period, with numerous clarifications and new definitions
  • additional guidance for the monthly method of determining full-time status
  • rules for determining full-time status for special categories of employment, including a new definition of seasonal employees
  • an additional year for employers who do not now offer coverage to their employees' dependents to comply, as long as coverage is offered to the children of employees by the 2016 plan year
  • safe harbors for determining if employer-provided coverage is affordable for employees for purposes of the employer penalties
  • The Treasury Department and the IRS plan to issue final regulations soon intended to simplify and streamline the associated employer reporting requirements.

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