In this issue:

• Implementing the federal “surprise medical billing” legislation
• Extending the Medicare sequestration moratorium
• Renewing the Public Health Emergency (PHE) and more…

As the COVID-19 PHE continues, PAI’s advocacy efforts have focused on securing adequate financial supports and regulatory flexibilities that allow physicians to safely care for their patients and remain financially viable. Please visit PAI’s Resources page and Healthsperien’s Resource Updates page for up-to-date information on COVID-19. For additional information on key health policy issues and identifying potential reforms under the Biden Administration, the 117th Congress, and in the states, please visit Healthsperien’s resource page here. 

Senators Cassidy and Hassan Outline Implementation Details of No Surprises Act

At the end of 2020, Congress passed the No Surprises Act as part of the Consolidated Appropriations Act of 2021. In late April, Senators Bill Cassidy (R-LA) and Maggie Hassan (D-NH) sent a letter to Department of Health & Human Services (HHS) Secretary Xavier Becerra discussing Congressional intent to help information HHS’ implementation of the law. The law generally includes patient protections from surprise billing by including transparency requirements of covered benefits and physician rates and establishes an arbitration process for health care providers and insurers to settle disputed out of network bills. Notably, this letter outlines the specific factors that should be considered equally during the arbitration process: 



While the final regulations have yet to be released, the first set of implementation regulations need to be published by July 1, 2021. The adopted regulatory language is critically important, and PAI will continue efforts to ensure that the regulations support fair and transparent negotiations between insurers and health care providers over the appropriate payment rates for out-of-network services. The first rule will establish the methodology health plans and issuers will use to determine the in-network cost sharing amounts for surprise bills, and the information that plans and issuers must share with non-participating physicians and facilities. HHS will also publish regulations on a process for consumers to submit complaints related to surprise billing.

PAI will continue to advocate for policies to ensure more rigorous network adequacy oversight, use of independent data to drive payment and the IDR process, transparent and accurate plan information for patients, especially regarding in-network and out-of-network payment and cost-sharing policies, and accurate physician directories.  PAI will track insurers’ unfair practices that would undermine fair payment and contracting for in-network and out-of-network physicians.  

President Biden Extends Medicare Sequestration Moratorium Through December 2021

On April 13, the House passed H.R.1868 to extend the Medicare sequester moratorium through the end of the year. The Senate-approved bill passed by a 384-38 vote in the lower chamber and has been signed into law by President Biden. The Centers for Medicare & Medicaid Services (CMS) has been holding all claims with dates of service on or after April 1 until the House reconvened for the vote. Unlike the original House version, the latest iteration of the bill does not include waiving Pay-As-You-Go (PAYGO) cuts triggered by the American Rescue Plan. PAYGO is a budget enforcement mechanism requiring that any new legislation that adds to the deficit must be fully offset by other spending or revenue changes for the net effect of legislative changes to be deficit neutral. The COVID relief bill is expected to increase cuts to Medicare by $36 billion beginning in 2022 under the PAYGO scorecard. If Congress does not pass legislation to offset the deficit increase or mitigate the PAYGO requirements, the Office of Management and Budget will be required to issue up to a 4% cut to Medicare reimbursement rates beginning in September of this year.
 
PAI supports the extension signed into law by President Biden. PAI previously advocated to Congressional leaders on extending the sequestration moratorium through 2021 as the pandemic has created an unstable and threatening environment for physicians who are already struggling.

HHS Renews COVID-19 Public Health Emergency Declaration

On April 15, HHS Secretary Becerra issued a 90-day renewal of the existing COVID-19 PHE. The renewal will take effect on April 21 and was largely procedural, given that the Biden Administration had previously indicated they anticipate the PHE will continue through the end of 2021. The PHE was first declared on January 27, 2020 and has been subsequently renewed five times since that date, providing HHS and CMS with the ability to waive a host of existing regulations on physicians given the extraordinary circumstances. It remains to be seen which of these flexibilities the Administration will choose to maintain, modify, or eliminate upon the conclusion of the PHE. Many of these decisions, such as those related to flexibilities provided for telehealth services, will require Congressional action to be made permanent. PAI is continuing to closely monitor the situation as well as advocate for additional support for physicians through the PHE and beyond.

CMMI Director Liz Fowler Comments on Future Direction of CMMI

On April 20, the Centers for Medicare and Medicaid Innovation (CMMI) Director Elizabeth Fowler spoke at the National Association of ACOs (NAACOS) 2021 Spring Conference. In her speech, Fowler discussed future objectives for CMMI and the direction the country should take in continuing the transition from fee-for-service to value-based care. Notably, Fowler intends to refresh CMMI’s strategy for achieving the value-based care vision with a closer eye on multi-payer alignment and health equity. Fowler stated that health disparities will be something the agency will ask about when stakeholders meet with them.
 
CMMI is already taking its first steps with its new strategy for value-based care. It is currently reviewing all models and recently paused the Geographic Direct Contracting Model, Primary Care First’s Seriously Ill Population Model, and the Kidney Care Choices Model. The agency also ended the application cycle early for the Global and Professional Direct Contracting Models and has decided to delay the ACO track for the Community Health Access and Rural Transformation (CHART) model. Other notable insights from Fowler’s speech include: 

• Fowler expects to expand CMMI’s portfolio of models to reach Medicaid and engage with other payors.
• It will look at payment models that deliver health system transformation rather than focusing on whether models achieve formal evaluation measures. Fowler noted, “is cost savings the most important measure of success or does quality improvement count just as much?”
  
  PAI is building an alternative payment model (APM) resource guide for members who are considering joining an APM. This guide will include relevant details such as evaluating risk and understanding attribution as well as feature videos from member physicians on their experiences participating in APMs. 

Congress Reintroduces Public Option Legislation 

On April 15th, Democratic Senators Chris Murphy (D-CT), Jeff Merkley (D-OR), and Dianne Feinstein (D-CA), along with nine other Senate Democrats, introduced the Choose Medicare Act which would offer every individual and employer the opportunity to purchase a “Medicare Part E plan” through the existing state and federal Exchanges. Key details of the legislation are highlighted below:
 

The typical coverage would look similar to plans currently on the state and federal exchanges, in that they would require coverage of the ACA’s ten essential health benefits and reproductive services. The plan follows a long and growing list of Democratic health care expansion proposals but faces an uphill battle in the Senate where it would require 60 votes, including ten Republican votes, for passage.

PAI plans to work with Congressional leaders to gain greater insight into the impact of different versions of a public plan option and how that impact may vary by geographic location, practice site, and medical specialty. PAI will also communicate concerns about the unintended adverse implications of government rate setting in the private health care marketplace.