In what feels like a final drive to exercise authority prior to the election, and a potential shift in control of the presidency and administration, over the last month the federal government has taken several steps to enhance oversight and regulation in the healthcare sector.
These actions reflect what the current administration hopes will be viewed as efforts to make good on commitments to protect consumers and ensure fair practices in the rapidly evolving landscape of healthcare services, in areas ranging from the Affordable Care Act (ACA) exchanges to healthcare company mergers and acquisitions to mental health parity.
For example, it seemed notable last week when the Centers for Medicare & Medicaid Services (CMS) released a proposed rule to empower the agency to review and suspend health insurance agents and brokers for violating rules on enrolling beneficiaries in ACA plans. These brokers, also known as marketers, operate within the ACA marketplace to assist consumers in selecting health insurance plans from the federal exchanges.
According to some experts, CMS wants to be seen taking a firmer stance against health insurance marketers that fraudulently switch exchange enrollees’ plans without their consent. CMS notes that many of these brokers operate with minimal oversight, which can lead to misinformation and a lack of transparency in choices presented to consumers.
This comes as CMS announced last month that it would continue monitoring agents for marketplace fraud after receiving over 200,000 complaints in the first half of the year.
The proposed rule also contains provisions requiring ACA insurers to review networks for certain providers, offer multiple standardized plans, and pay increased user fees.
On the antitrust front, a final rule recently approved by the Federal Trade Commission (FTC) aims to prevent anti-competitive practices that can arise from industry consolidation. Healthcare companies pursuing mergers and acquisitions will be required to submit additional information about their proposals when the rule goes into effect, likely next year.
These companies, when involved in such proposals, will have to list other acquisitions that occurred within the last five years, disclose private equity stakeholders with decision-making authority, and report supplier relationships shared by the merging parties to the FTC. According to the FTC Chair, the rule “will provide antitrust agencies with probative intelligence as to whether a proposed deal risks violating antitrust laws.”
However, it will likely take time to see how the guidelines laid out in the rule, which are not legally binding, will be adhered to by companies and interpreted by the courts.
Meanwhile, last month, the U.S. Department of Health and Human Services (HHS), in conjunction with the Labor and Treasury Departments, issued new mental health parity standards to address what HHS has suggested is a pattern by health plans of imposing stricter limits on mental health coverage. As such, the regulation finalized requirements for health plans to cover mental health and substance use disorder services to the same degree they cover medical benefits, and to develop comparative analyses to inform coverage improvements.
It also eliminates “discriminatory practices such as higher co-pays, restrictive treatment limits, and lower reimbursement rates” for mental health providers, which means that in order to comply, health plans may need to add more mental health providers to their networks, markedly raise reimbursements, or curtail prior authorization constraints.
In sum, recent crackdowns by the feds signal the intent to enhance healthcare regulation and consumer protection priorities before time expires on the Biden Administration. We’re seeing this play out via stricter rules, tighter scrutiny, and more complex, onerous requirements in areas of healthcare that have been recognized for their importance to the larger industry.
As these regulations take shape, they are likely to have lasting impacts on the quality and accessibility of healthcare, fostering what the government hopes will be a more informed and empowered consumer base before a new administration comes in.
With the April 1 update, the Centers for Medicare and Medicaid Services (CMS) implemented 80 new PCS codes. To break it down, there are 24
In the FY 2027 Inpatient Prospective Payment System (IPPS) Proposed Rule, the Centers for Medicare and Medicaid Services (CMS) has introduced a notable and potentially
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