Compliance Stuff

I was sitting with a model of care (MOC) recently — not skimming it, actually reading it — and it brought back a conversation I had with a colleague that I have not been able to shake. We were talking about our years leading case management teams inside Special Needs Plans (SNPs). Both of us held senior roles. Both of us supervised the people responsible for coordinating some of the most medically complex, socially fragile members in managed care. When we asked each other the same question, we got the same answer: We did not remember ever having the MOC in our line of sight. Not pinned to the wall. Not referenced in team huddles. Not pulled out when a new case manager was onboarded or when a difficult member situation required a reset. The policies and procedures? Yes. The workflows? Certainly. But the MOC — the document that defines why all those policies exist, whom they were designed to serve, and how the health plan envisioned care being coordinated for its most vulnerable enrolle...

Providers that rely on telehealth for Medicare patients can continue to do so as a result of an extension of the Medicare telehealth rules that were originally implemented during the COVID-19 Public Health Emergency (“COVID”). On February 3, 2026, the Consolidated Appropriations Act, 2026, H.R. 7148 was signed into law and, among other features, extends key components of the emergency telehealth requirements and will continue to allow for increased provider eligibility, remote care from home and relaxed site-of-service, all rules upon which providers have extensively relied since COVID . CMS extended these rules in order to provide greater flexibility and remote health care access. Providers should be aware that this extension only will last through December 31, 2027, unless Congress puts a permanent solution in place. [ View source .] Source(s): Medicare Telehealth Expansion Continues Under New Federal Extension | JD Supra . (2026). JD Supra. https://www.jdsupra.com/legalnews/medicare...

Consistent with the President’s  Executive Order 14221 , “Making America Healthy Again by Empowering Patients with Clear, Accurate, and Actionable Healthcare Pricing Information,” on Dec. 19, 2025, the Centers for Medicare & Medicaid Services, in partnership with the Department of Labor and the Department of the Treasury (collectively, the Departments) jointly proposed changes to the payer price transparency regulations to improve the accessibility of pricing disclosures to participants, beneficiaries, and enrollees, and the standardization and reliability of the public pricing disclosures from non-grandfathered group health plans and health insurance issuers offering non-grandfathered group and individual health insurance coverage.  These proposed changes build on the historic disclosure requirements the Departments issued in the Transparency in Coverage final rules on November 12, 2020 (the 2020 final rules) in line with  the President’s June 24, 2019, Executiv...

The Centers for Medicare and Medicaid Services (“CMS”) “60-Day” overpayment rule (“60-Day Rule”) was established as part of the Affordable Care Act (“ACA”) in 2010. [i]   I n a nutshell, Section 1128J(d) [ii]  of the ACA provides  that a person who has received an overpayment shall report and return the overpayment to CMS [iii]  in writing, stating the reason for the overpayment, within 60 days after the overpayment was identified (or the date the corresponding cost report is due). To encourage and enforce reporting of overpayments, Section 1128J(d) is clear that any improperly retained overpayments become a potential false claim under the False Claims Act (“FCA”). [iv] The obligation to return overpayments in a timely manner seems deceptively simple, but the mechanics of the process has been the subject of debate since it was enacted in 2010, and CMS again set forth regulatory direction for the 60-Day Rule on December 9, 2024. [v]   This article sets forth the ...

  On October 3, the Department of Health and Human Services (HHS) Office of Inspector General (OIG) published a   strategic plan   for improving oversight of public grants and contracts “to strengthen compliance with HHS award requirements; promote award practices that achieve program outcomes; and mitigate fraud, waste, abuse, and mismanagement.” This comes as grant fraud related to awards by HHS and other agencies routinely makes the news. For example, in July Janet Mello was   sentenced   to 15 years in prison for stealing over $100 million from a U.S. Department of Agriculture (USDA)/Department of Defense (DoD) grant program aimed at helping military families. Similarly, fraud stemming from the Paycheck Protection Act has been dubbed the “biggest fraud in a generation.” In Fiscal Year (FY) 2023, excluding the Centers for Medicare and Medicaid Services (CMS), HHS awarded about 142,000 grants totaling more than $77 billion and over 50,000 contracts amounting t...

  As employers look toward open enrollment for their group health plans, now is a good time to review action items needed for those plans by year-end, as well as upcoming deadlines in the near future. While fully-insured health plans generally have their compliance obligations satisfied by the insurer, self-insured health plans usually rely on the employer or the plan's third-party administrator (TPA) to meet the compliance requirements. Below is a brief summary of items that employers should be aware of for their health plans and, as appropriate, we have delineated when such compliance is limited only to self-insured health plans. Capitol Bridge Health Plan: Effective 03/01 - 02/28 TDB Communication, Inc. Health Plan: Effective 07/01 - 06/30 Capitol Bridge Health Services Health Plan: Effective 07/01 - 06/30 Capitol Bridge Puerto Rico: Effective (TO BE DETERMINED) 1. HIPAA Privacy Extends Special Protections to Reproductive Health Care: Employer Action Required by 12/23/24 Earlier...