EMPLOYEE BENEFITS BLOG

CMS Releases CY 2025 Advance Notice for Medicare Advantage and Part D

by Emily Curran and Kristen O'Brien | Mar 21, 2024 | Employee Benefits, Health and Welfare Plans

On January 31, 2024, the US Centers for Medicare & Medicaid Services (CMS) released the Advance Notice of Methodological Changes for Calendar Year (CY) 2025 for Medicare Advantage (MA) Capitation Rates and Part C and D Payment Policies. CMS also released a press release and fact sheet. The advance notice is released on an annual basis and includes proposed updates to the capitation and risk adjustment methodologies used to calculate payments to MA plans, as well as other payment policies that impact Part D. The final CY 2025 rate announcement will be published no later than April 1, 2024.

The advance notice discusses several updates the Inflation Reduction Act of 2022 (IRA) made for 2025, including:

Newly defined Part D benefit design composed of three phases: annual deductible, initial coverage and catastrophic coverage
Lower out-of-pocket threshold of $2,000
Sunset of the Coverage Gap Discount Program and establishment of the Manufacturer Discount Program, and
Changes to the liability of enrollees, sponsors, manufacturers and CMS (Draft Part D Redesign Program Instructions, Draft Part D Redesign Program Instructions Fact Sheet)

As a result of the IRA, CMS proposes updates to the Part D risk adjustment model to reflect the Part D benefit design.

CMS is annually required to update the parameters for the defined standard Part D drug benefit. This is meant to ensure that the actuarial value of the drug benefit tracks changes in Part D expenses. For non-low-income subsidy beneficiaries, the advance notice outlines the benefit parameters for defined standard benefits in 2025 as follows:

California Employee Civil Rights Defenses Following Estrada Case

by Saniya Ahmed, Pankit Doshi, Yesenia M. Gallegos and Maria C. Rodriguez | Mar 19, 2024 | Employment

On January 18, 2024, in a highly anticipated and unanimous decision, the Supreme Court of California barred striking a claim under the Private Attorneys General Act (PAGA) on trial manageability grounds alone, instead authorizing due process defenses to PAGA claims (Estrada v. Royalty Carpet Mills, Inc.). The decision also commented approvingly on representative testimonies, surveys and statistical analyses. As a result of the decision, employers now face a new challenge of marshalling such evidence to their defenses and challenging the misuse of such evidence on due process grounds in future PAGA litigation.

Read more here.

Pending Oregon Law Undermines Traditional Physician Practice Structure

by Dale C. Van Demark, Patrick Zanayed and Joel Rush | Mar 14, 2024 | Employee Benefits, Health and Welfare Plans

In an apparent attempt to shield physician practices from perceived abuses of close association with physician practice management (PPM) companies, a pending Oregon law could undermine a broad range of structures and transactions between physicians and laypersons, including loans, real estate leases, practice sales, national virtual care platforms, investor sponsored practice roll-ups and payor-provider joint ventures.

Oregon House Bill 4130 prohibits several relationships and control structures which would materially constrain the typical PPM structure utilized by hospitals, private equity sponsors, virtual care providers, managed care companies and others to create a more integrated approach to care delivery, to take advantage of efficiencies and, in many instances, simply to operate.

Read more here.

How Pending Fishing Boat Cases at the Supreme Court Could Rock the Benefits Plan Boat

by Alden Bianchi, Wilber H. Boies, PC, Scott Kenkel and J. Christian Nemeth | Mar 12, 2024 | Employee Benefits

If the US Supreme Court strikes down the established doctrine of significant judicial deference to certain government agency interpretations in two upcoming fishing boat cases, this decision could have ripple effects on employee benefit plan sponsors and fiduciaries. Such a decision would rock the boat and create more uncertainty in administering employee benefits.

Read more here.

CMS Approves New York 1115 Medicaid Redesign Waiver

by Katie Waldo and Kayla Holgash | Mar 7, 2024 | Employee Benefits, Health and Welfare Plans

On January 9, 2024, the Centers for Medicare and Medicaid Services (CMS) approved the New York State (NY) 1115 Medicaid waiver “Medicaid Redesign Team” (MRT). The MRT is a long-standing waiver in NY that has continuously evolved to improve the administration, structure and financing of the NY Medicaid program; enhance Medicaid beneficiaries’ access to services; and improve health outcomes across the state. The recently approved waiver represents the next step in Medicaid redesign in NY and builds on the previous Delivery System Reform Incentive Payment (DSRIP) program.

This article reviews the major initiatives included in the MRT, components of the MRT that were excluded from the approval, implications for stakeholders and more.

Read more here.