Legal Analysis

State leaders face a complex legal and political environment for reforming health care under the Affordable Care Act, and private health care organizations are challenged with integrating these new rules. Well-designed reforms must carefully consider the legal ramifications of proposed changes in care delivery and payment models.

We have an in-depth knowledge of the vast array of laws and regulations that govern health care in both the public and private sectors, including the ACA, Medicaid, the Children’s Health Insurance Program, the Americans with Disabilities Act (ADA), and the Employee Retirement Income Security Act (ERISA). Our team understands the legal framework that governs public program administration, and possesses extensive experience advising states on compliance with these rules.

Our team was extensively involved with the development, drafting, and implementation of Massachusetts’ 2006 and 2012 landmark health care reforms, which embody many of the system delivery and payment reform principles included in the ACA. We also have private sector experience representing hospitals, physicians, academic medical centers, payers, professional associations, and other health care organizations. By partnering with state policymakers, we help develop solutions for complex state health care reform initiatives, including Accountable Care Organizations and programs for those “dually eligible” for both Medicare and Medicaid. 

Our areas of expertise include:

  • Comprehensive legal solutions to policy problems, including statutory or regulatory changes
  • Options for nagivating legal barriers to reform
  • Potential implications of proposed and/or implementated legal reforms for providers, payers and consumers, as well as interactions between proposed legal reforms and current law
  • Legal reforms adopted by states and trends in state and federal health care reform
  • Obtaining Medicaid waivers, state plan amendments, or contracts with Medicaid providers 
  • Medicare ACO program requirements (Medicare Shared Savings Program and Pioneer ACO Program) 
  • Legal, financial and policy implications of individual financing options, including the state's financial obligations and providers' risks and incentives
  • Federal compliance requirements that may be associated with a financing option, including Upper Payment Limits (UPLs) for Medicaid
  • Alternative payment system implications for safety net providers and the uninsured
  • State and federal requirements for data protection, required data release specifications, and data privacy procedures
  • Devising State Plan amendments, requests for Medicaid 1115 Research and Demonstration waivers, Medicaid 1915(c) Home and Community Based Services waivers, and other public and private mechanisms to implement improvements
  • Impact of new or proposed Medicaid and CHIP rules on public programs or policies