Section 1983’s Private Right of Action Might Live to See Another Day: An Overview of Oral Arguments in HHC v. Talevski

On the morning of November 8, while many Americans were still casting their votes and getting ready for Election Night parties, the Supreme Court heard oral arguments for Health & Hospital Corporation of Marion County v. Talevski. At issue in Talevski is whether a Medicaid beneficiary can file a “Section 1983” civil rights suit in federal court to seek relief for violation of the 1987 Federal Nursing Home Reform Act (FNHRA).… More

HHS Ordered to Correct Medicare Payments to 340B Hospitals for Remainder of 2022

We have noted before the link between the Medicaid prescription drug rebate program and the 340B program.  As we wrote in an earlier Client Alert, in June 2022, the U.S. Supreme Court struck down HHS’s Medicare payment cuts to 340B hospitals for separately payable outpatient drugs.  The Court then remanded to the district court to determine the appropriate remedy. The 340B-specific Medicare payments started in 2018,… More

CMS Approves Two New Medicaid Waivers to Expand Coverage, Provide Flexibilities

On September 28, 2022, the Centers for Medicare & Medicaid Services (CMS) issued approval letters for Section 1115 Medicaid demonstration applications previously submitted by Oregon and Massachusetts.  Section 1115 waivers allow the Secretary of Health and Human Services to waive certain provisions of the Medicaid law to provide states with additional flexibilities to design and improve their Medicaid programs through experimental, pilot, or demonstration projects. These projects must be budget neutral and are approved for a five-year period,… More

CMS Releases Long-Awaited Proposed Rule to Ease Medicaid Enrollment Burdens

Before delving into CMS’ long-awaited proposed rule to ease Medicaid enrollment burdens, Medicaid and the Law would like to formally introduce its readers to Kian Azimpoor, a Law Clerk in the Washington, DC office who will serve as a regular contributor to the blog. Using his experiences from Capitol Hill and the MD Anderson Cancer Center, Kian looks forward to exploring the far-reaching impact of Medicaid and Medicare law.

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On September 7,… More

Medicaid’s Right of Recovery Against Legal Settlements

The United States Supreme Court recently answered an important question in Medicaid law:  can a state Medicaid plan recover funds from a legal settlement involving a Medicaid beneficiary to pay for that beneficiary’s future medical expenses?  This question required the Court to first unlock several interlocking provisions of federal Medicaid law.  And, in answering this question in the affirmative, the Supreme Court also likely affected the future structure of settlement arrangements negotiated by personal injury lawyers on behalf of Medicaid beneficiaries.… More

Enforcing Medicaid’s Requirements in the Federal Courts

The Supreme Court has announced that it will consider a case next term that has the potential to upend several decades of jurisprudence involving the Medicaid program.  It involves a complicated area of the law, and in writing about this topic in the past, we have described the developments in this area of the law as a “saga.”  In granting review in the case of Health and Hospital Corporation of Marion County v.… More

Averting a Medicaid Coverage Cliff: CMS’s Continuous Enrollment Unwinding Guidance

Bracing for the inevitable end of the COVID-19 Public Health Emergency (PHE), CMS has begun issuing voluminous guidance to states on unwinding Medicaid’s continuous enrollment requirement without precipitating a calamitous drop in coverage. We’ve previously discussed the continuous enrollment requirement here, here and here.

By way of background, section 6008 of the Families First Coronavirus Response Act (FFCRA),… More

Summary and Considerations on CMS’ RFI on ‘Access to Coverage and Care in Medicaid & CHIP’

The Medicare and Medicaid programs themselves are not old enough to qualify for Medicare coverage (quick history lesson: President Lyndon Johnson signed the Social Security Amendments into law on July 30, 1965, and the Medicaid program launched on January 1, 1966; note that CMS traces the origin of its programs back to President Theodore Roosevelt’s advocacy for social insurance).  Over the past half-century (and then some),… More

Enforcing Medicaid’s Guarantee of Access to Prescription Drugs

Over the years, we’ve written about the difficulties in challenging the entitlement to Medicaid in the federal courts. In light of a series of Supreme Court decisions dating back to 1990, the pathway for an aggrieved Medicaid beneficiary or provider of services to a Medicaid beneficiary to challenge a state Medicaid plan’s alleged violation of a requirement of the Medicaid program has become increasingly narrow.… More

Oregon’s New Waiver Request to Exclude Accelerated Approval Drugs from Medicaid Coverage

Hello readers! Today’s post focuses on a topic we’ve touched on a few times in the past – Medicaid drug formularies.

Back in December 2021, the state of Oregon released a draft Medicaid waiver proposal that caught the attention of many stakeholders. In the draft proposal, Oregon stated that it was considering asking CMS for approval to a) adopt a commercial-style closed drug formulary and b) exclude from Medicaid coverage certain drugs approved via the accelerated approval pathway “with limited or inadequate evidence of clinical efficacy.” Oregon proposed to “use its own rigorous review process to determine coverage of new drugs and to prioritize patient access to clinically proven,… More