PPACA Final Rule on "Sunshine Act"

On Friday afternoon, February 1, the Centers for Medicare & Medicaid Services (CMS) released the final rule implementing the “Sunshine Act” which was included in the PPACA (section 6002) and facilitates reporting payments or other transfers of value manufacturers make to physicians and teaching hospitals. The timeline outlined in the final rule provides that data collection begin on August 1, 2013; data for August through December of 2013 will be reported to CMS by March 31, 2014; and information will be available on a public website by September 30, 2014. CMS will provide a single review period of 45 days to review data before it’s available on a public website, as well as an additional 15 days for resolving and correcting disputes. Physicians will be able to register with CMS to receive information and have immediate access to information at the beginning of the review and correction period.

PPACA Regulations on Coverage/Exchanges

The Internal Revenue Service (IRS) and Centers for Medicare and Medicaid Services (CMS) issued proposed regulations under the PPACA which provides for exemptions from the “individual shared responsibility” requirement in hardship cases; in which a tax return does not have to be filed due to low income; in which coverage is unaffordable (more than 9.5% of household income); in which individuals qualify because of religious beliefs; and in which the lapse in coverage does not extend beyond 3 months. States who chose to operate their own health insurance exchanges would be able to use a “federally managed service” to determine an applicant’s eligibility for an exemption. Individuals who do not obtain “minimum essential coverage” beginning in 2014 and go through the process to obtain a “certificate of exemption” would not have to pay the IRS penalty for non-coverage. Comments are due by March 18, 2013. The IRS also issued a final regulation regarding individuals, related to employees who are enrolled in employer-sponsored health plans, who are ineligible for health insurance premium tax credits under health insurance exchanges. The rules state that for taxable years beginning before Jan. 1, 2015, an eligible employer-sponsored plan is “affordable” for related individuals if the portion of the annual premium the employee must pay for self-only coverage (the so-called required contribution percentage) does not exceed 9.5% of the taxpayer’s household income. When the employer plan is affordable for self-only coverage (even if family coverage is not affordable), such related individuals are ineligible for premium subsidies under PPACA health insurance exchanges.

Senate Hearings on Mental Health/Gun Rights and Need for Primary Care Docs

At a Senate Judiciary hearing last week, former Arizona Rep. Gabrielle Giffords testified that Congress needs to act “now” to stem gun violence. On the other hand, the CEO of the National Rifle Association said the nation’s mental health system is broken and called for a study into the “the full range of mental health issues, from early detection and treatment, to civil commitment laws, to privacy laws that needlessly prevent mental health records from being included in the National Instant Criminal Background Check System.” Senator John Cornyn (R-TX) said that background-check legislation should be “updated to screen out the growing number of people who are subjected to court-ordered outpatient mental-health treatment.” Apparently a bipartisan group of senators are drafting legislation that would include mental health records in background checks. Also, at a Senate HELP Subcommittee on Primary Health and Aging, Senator Bernard Sanders (I-VT) warned that the nation faces “a major crisis in primary health care access” with as many as 30 million Americans being added to the health insurance rolls as a result of the PPACA. He said the nation needs 16,000 more primary care physicians by 2025 and a major hurdle in meeting this goal is that only 7% of medical school graduates choose primary care practice.

CMS on DMEPOS Competitive Bidding Expansion

CMS announced that, as a result of the Round Two expansion of the existing Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) competitive bidding program beginning July 1st, it is expected that Medicare beneficiaries will pay substantially lower prices on certain types of durable medical equipment, such as walkers and oxygen equipment.

CMS Meaningful Use Payments

CMS reported that almost $10.7 billion in meaningful use incentive payments have been made pursuant to the economic stimulus legislation to more than 190,000 hospitals and eligible professionals through the end of December 2012. Also, CMS said that 350,844 physicians and other eligible professionals are registered under either Medicare or Medicaid, an increase of 4.5% from the 335,879 who were registered in November 2012.

Health Legislation Recently Introduced

H.R. 418 (MEDICARE), to reduce Medicare waste, fraud, and abuse by providing for enhanced penalties to combat Medicare and Medicaid fraud, for a Medicare data-mining system, for a study on applying biometric technology, and for other purposes; ROS-LEHTINEN; jointly, to the committees on Energy and Commerce and Ways and Means, Jan. 25.

S. 177 (REFORM), to repeal the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 entirely; CRUZ; read the first time, Jan. 29.

S. 183 (MEDICARE), to amend Title XVIII of the Social Security Act to provide for fairness in hospital payments under Medicare; MCCASKILL; to the Committee on Finance, Jan. 30.

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