Browse Advisory Opinions

Concerning an arrangement under which a managed care company will disburse pay-for-performance financial incentives on behalf of a State's Medicaid program.

Concerning a pharmaceutical manufacturer's proposal to establish a patient assistance program to provide the company's drugs to financially-needy Medicare Part D enrollees outside of the Part D benefit.

Concerning a free clinic's practice of dispensing drugs on behalf of patient assistance programs ("PAPs") sponsored by pharmaceutical manufacturers that provide free drugs to financially-needy patients, including some patients enrolled in the Medicare Part D outpatient prescription drug benefit.

Concerning a pharmaceutical company patient assistance program that provides free outpatient prescription drugs to financially-needy Medicare Part D enrollees entirely outside of the Part D benefit.

Concerning a geriatric group practice's proposal to employ certain primary care physicians to serve as consultants in connection with the group's nursing home patients.

Concerning the waiver of Part B cost-sharing obligations for equipment and supplies used by Medicare beneficiaries to monitor blood glucose levels in a clinical trial sponsored by the National Institutes of Health.

Concerning an ambulance company's proposed arrangement to collect a fixed annual subscription fee in lieu of Medicare Part B cost-sharing amounts from its members.

Concerning a proposed arrangement by which a Medigap plan would indirectly contract with hospitals for discounts on the otherwise applicable Medicare inpatient deductibles for its policyholders and would also, at the time of the next policy renewal, reduce the premium for policyholders utilizing a network hospital for an inpatient stay.

Concerning a proposed arrangement that would involve a company developing and managing distinct part inpatient rehabilitation units located within general acute care hospitals in exchange for a management fee calculated on a per patient per day basis.

Concerning a proposed program by a provider of home health care services to provide free medical-alert pagers and pager monitoring service to homebound patients during the period such patients are receiving the company's home health services.

Concerning a proposed modification to a drug company's patient assistance program to pay Medicare Part B cost-sharing amounts for financially needy beneficiaries following surgery.

Concerning the waiver of Part B cost-sharing obligations for equipment and supplies used by Medicare beneficiaries to monitor blood glucose levels in a clinical trial sponsored by the National Institutes of Health.

Concerning a proposed arrangement involving an internet-based chronic disease management business that would (1) contract with managed care organizations and employer-based health plans to enroll their members in an on-line clinical compliance program that includes awarding points redeemable for goods and services to members and their physicians for undertaking compliance activities, and (2) sell advertising on its web site to advertisers, including pharmacies and pharmaceutical companies.

Concerning whether the offering of discounts to customers, based on their purchases of dialysis equipment and supplies - some of which 05/be reimbursed under different Medicare part B methodologies - would violate the administrative authorities related to the anti-kickback statute.

Concerning the proposed waiver of coinsurance for portable x-ray services provided to nursing facility residents who are eligible for Medicare and Medicaid, but who do not meet the eligibility requirements for Qualified Medicare beneficiaries.

Concerning a payment arrangement between a Medicare-certified hospice and certain nursing facilities for services provided to residents of such facilities who are eligible both for Medicaid and Medicare hospice benefits ("Dually Eligibles"). Specifically, for Dually Eligibles, the hospice pays the nursing facilities the full Medicaid nursing facility per diem rate for non-hospice patients, which covers pharmacy services, plus a separate payment for drugs used by Dually Eligibles in connection with their terminal illness. You have asked whether such an arrangement would constitute grounds for the imposition of sanctions under the exclusion authority at section 1128(b)(7) of the Social Security Act (the "Act") or the civil monetary penalty provision at section 1128A(a)(7) of the Act, as those sections relate to the commission of acts described in section 1128B(b) of the Act.

Concerning a managed care organization's employment of an excluded individual and potential sanctions under section 1320a-7a(a)(6) of the SSA.

Concerning a managed care organization's proposal to subsidize the Medicare+Choice premiums andcopayments of its members eligible for both Medicare and certain limited Medicaid benefits.

Regarding the "coordination of benefits" provisions of a provider agreement between a nursing home and a health care plan.

Concerning an exclusive contract between a city and an ambulance company for the provision of emergency medical services for city residents that includes a requirement that the contracting ambulance company waive out-of pocket Medicare copayments for city residents.