Legislative/Judicial/Regulatory Updates
 A federal judge for the U.S. District Court for the Northern District of Texas issued a decision in Texas v. Azar on Dec. 14 declaring the individual mandate for health insurance coverage to be unconstitutional and further cannot be severed from the rest of the ACA, thus making the entire law invalid. Read the Academy alert.
CMS on Dec. 7 released a final rule on the methodology for the risk-adjustment program operated by HHS for the 2018 benefit year. Read the Academy alert.
CMS’ Office of the Actuary released data on U.S. national health expenditures for 2017 on Dec. 6. Read the Academy alert.
The Maine Business and Consumer Court issued an order on Dec. 6 in response to a motion from Gov. Paul LePage requesting a stay on a Nov. 21 ruling that the state’s Department of Health and Human Services begin implementing a voter-approved expansion of the state’s Medicaid program by Dec. 5. The court’s order extended the deadline for implementation of the Medicaid expansion to Feb. 1, but noted that the central determinations made in its Nov. 21 ruling have not changed. LePage’s term expires on Jan. 2. The court stated the extension will give the new state legislature an opportunity to review the expansion.
Sens. Ron Wyden and Chuck Grassley introduced a bill on Dec. 4 that would allow HHS to fine drug companies participating in the Medicaid program that knowingly misclassify products and recover rebate payments that are due. The bill gives HHS the ability to correct such misclassifications.
CMS sent a letter to the Minnesota Department of Commerce on Nov. 30 announcing that it would provide the state an estimated $84.7 million in federal pass-through funding for its state-based reinsurance program in 2019, down from an estimated $130.7 million in federal pass-through funding for 2018.
HHS’ Dec. 10 final rule on risk adjustment cited the HPC’s issue paper on the ACA risk adjustment program.
A Section 1115 Medicaid waiver request from New Hampshire was approved by CMS on Nov. 30. Under the waiver, Medicaid enrollees will be required to perform 100 hours of work or community engagement activities each month as a condition of Medicaid eligibility.
A proposed rule released by CMS would make several changes to the Medicare Advantage and Part D programs with the intention of lowering drug costs. The proposed changes include providing Part D plans with greater flexibility to negotiate discounts for drugs in “protected” therapeutic classes; requiring Part D plans to provide enrollees with a patient’s out-of-pocket cost obligations when a prescription is written; allowing “step therapy” for Part B drugs; and implementing a statutory requirement, recently signed by President Trump, prohibiting pharmacy “gag” clauses in Part D. Comments on the proposed rule are due Jan. 25.
CMS reapproved a Section 1115 Medicaid waiver request from Kentucky on Nov. 20. The waiver, which was originally approved by CMS in January, was vacated by the U.S. District Court for the District of Columbia in June in response to a lawsuit filed by a group of Kentucky Medicaid enrollees. Following the court’s ruling, CMS exposed the waiver’s provisions for a new public comment period. The reapproved waiver includes requirements for work or community activities as a condition of Medicaid eligibility.
Sen. Bernie Sanders and Rep. Ro Khanna announced on Nov. 20 that they would introduce companion bills in Congress aimed at reducing prescription drug prices. The legislation would require the HHS secretary to make sure Americans don’t pay more for prescription drugs than the median price in Canada, the United Kingdom, France, Germany, and Japan. The bill allows for the federal government to approve cheaper generic versions of drugs that fail to meet that threshold, regardless of any patents or market exclusivities in place on other drugs.
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