The Affordable Care Act (ACA) expands eligibility to the
Medicaid program by requiring participating states, by 2014, to
cover nearly all people under age 65 with household incomes at or
below 133% below the federal poverty level. Medicaid is jointly
funded by federal and state funds and the ACA requires the federal
government to cover 100% of this expansion from 2014 through 2016,
with gradual reductions beginning in 2017 until it reaches 90%
funding in 2020 and continuing thereafter. Because federal funds
are necessary for states to provide Medicaid, the states are
arguing this expansion is "coercion" meaning they are
being forced to provide Medicare coverage even though technically
Medicaid is a voluntary program to the states.
If the Medicaid expansion is struck down, millions of low income
patients who would be qualified under the expanded eligibility
provisions will lose access to health coverage. Kaiser Family
Foundation estimates that as a result of the ACA changes Medicaid
enrollment is projected to increase by 15.9 million by 2019. These
individuals likely would not be able to afford to purchase health
insurance coverage in the Exchanges (were the Court to uphold those
provisions of the law) or on the individual market.
If these individuals lack health insurance coverage they are
less likely to see a health care provider until their condition
worsen to the point where they need emergency care. This could
result in not only an increase in overall health care costs, but
would mean providers likely would not be compensated for the care
they provide; a situation exacerbated by the payment reductions to
hospitals and other providers called for under the ACA. Moreover,
the ACA increased Medicaid reimbursement rates (which are
historically low in most areas of the country) to Medicare
reimbursement levels in order to encourage more providers to treat
Medicaid patients to the benefit of both existing and newly
eligible beneficiaries. Were the Court to strike these provisions,
many of the individuals currently in the Medicaid program will
likely continue to face challenges in finding providers who will
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While some may consider improper multiple dependent claims as failing to comply with a mere formality, this case serves as a reminder that a court may consider any statutory requirement when assessing patent validity.
Mintz, Levin, Cohn, Ferris, Glovsky and Popeo, P.C.
While at first pass the case focuses on a small set of insurance policies, this decision could have broader implications on the individual market and further threaten the sustainability of the risk pools.
The Centers for Medicare & Medicaid Services and the Office of Inspector General have reviewed the use of Modifier 25 to unbundle payments for evaluation and management services when a procedure is performed.
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