Proponents of the new health overhaul law are frustrated with the administration for not publicly weighing in on whether states may opt out of Medicaid and shift that population into the insurance exchanges in 2014. Residents below the poverty line would not be eligible for subsidies, health reform boosters say, but others say an amendment in the reconciliation bill made subsidies available to those below the poverty line.

The national coverage analysis that CMS opened on Provenge, whether intended or not, fits into the parallel review initiative between CMS and FDA, sources say, because companies may be more inclined to meet with CMS earlier during FDA reviews to avoid having CMS question their product immediately after approval. A Medicare advisory panel last week reviewed the clinical evidence on the prostate-cancer drug, and they talked about ways to gather more information, which included discussing whether CMS should collect data from the registry that FDA is requiring as a condition of approval.

As part of its stepped-up enforcement posture, CMS has sanctioned three health plans the agency says have violated Medicare rules that include marketing malfeasance that in a few cases may have put patients health and safety at risk, the agency announced Friday (Nov. 19) afternoon. The sanctions could amount to fines on the plans, but could also result in CMS terminating their contracts with Medicare.

CMS intends to allow the Medicare Advantage plans that received the five-star rating for quality to market to Medicare beneficiaries year-round and to enroll them at any time, a top CMS official tells Inside Health Policy. Normally plans are only allowed to market their MA plans from Oct. 1 through the open enrollment period (Nov. 15 - Dec. 31) and sign up new patients during this time so the agency's move provides those plans with 5 stars a clear competitive advantage.

CMS Administrator Don Berwick finally faced Senate Finance Committee on Wednesday during a hearing that featured a few tough questions from the GOP side, but with few policy revelations. The hearing lasted only a hour and a half due to scheduled votes, and nearly every GOP member expressed frustration at the truncated schedule which limited questioning to five minutes. Sen. Jim Bunning (R), the retiring junior senator from Kentucky, warned Berwick that he will be appearing before lots of House committees next Congress.

Senate Majority Leader Harry Reid (D-NV) gained Senate passage late Thursday (Nov. 18) for a 31-day payment "patch" to the Medicare sustainable growth rate formula that would freeze current rates and temporarily avert a 23 percent cut to physicians slated for Dec. 1 after Finance Committee leaders announced a two-part deal late in the day.

HHS provided a one-year accounting mechanism to give so-called "mini-med" plans a break from the new medical loss ratio rule announced Monday, rather than the straightforward exemption favored by many stakeholders concerned that the rule could drive the limited benefit plans out of business. But department officials said no one covered by a limited-benefit policy will lose coverage next year as a result of the MLR, and a leading supporter of special treatment for mini-meds expressed support for the approach that HHS ultimately adopted.

The Premier health care alliance is touting a quality demonstration program that resulted in $2 billion in savings over two years for the 157 hospitals involved as a "test bed" for hospitals as they gear up for future value-based purchasing initiatives under the health reform law.

Community pharmacies are concerned that some states may reduce or do away with product and dispensing fees now that the federal government has established a federal upper limit (FUL) on reimbursement which, if states meet the ceiling, would allow pharmacies to break even on most of the generic drugs they dispense, according to the National Community Pharmacists Association (NCPA). Oregon and Alabama are the only states to propose adjusting product and dispensing fees, but community pharmacists expect other states to announce plans soon as state governments release budgets and state legislative sessions begin.

CMS has decided to limit the health reform law's "short-cycle" dispensing requirements to brand-name drugs and allow for longer dispensing cycles for many pharmacies during the first year, responding to long-term care and community pharmacies' concerns that broadly imposing the requirements would unduly burden small pharmacies.

A draft technical assessment finding "moderate" evidence that Provenge helps patients might lead CMS to limit coverage of the expensive, newly approved prostate cancer vaccine to on-label use, analysts predict. The assessment is somewhat of a relief, at least temporarily, to industry observers who have worried that CMS would set a precedent by denying coverage for the therapy over efficacy concerns.

Rep. Joe Barton (R-TX) was confident going into the House Republican Conference meetings earlier this month that he was the "front runner" to take over as chair of the powerful House Energy and Commerce Committee, and said if he regains the gavel he will invite HHS and CMS political appointees to "share their insights" about the law.

MLR Rule Closely Tracks NAIC Proposal

As CMS puts the finishing touches on its accountable care organization proposed rule, a bipartisan group of 17 House lawmakers is asking the agency to let specialists form ACOs, if those specialists also provide primary care.

CMS is taking steps to expand hospital reporting of adverse events in response to an HHS Inspector General finding that such events happen to one in seven Medicare patients during hospital stays, costing Medicare $4.4 billion annually. The agency plans to broaden its definition of adverse events, a move that will require hospitals to report more types of events that are factored into what they are paid under the Hospital Value-Based Purchasing Program created by health reform and the Healthcare-Acquired Conditions (HAC) payment policy expanded by the reform law, the agency told the HHS IG's office.