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Payers, Plans, and Managed Care

 
Back to Practice Groups

Welcome to the Payers, Plans, and Managed Care Practice Group (PPMC PG). We keep you up to date on all legal issues concerning health plans, insurers, third-party administrators, pharmacy benefit managers, and other hybrid organizations.

 

Here are the top four things you can do to make the most of your membership in the PPMC PG:

  1.  Register for a webinar or listen to an archived webinar: Web-based seminars deliver invaluable knowledge, insight and networking.  Click here to access a list of upcoming and past webinars sponsored by the PPMC PG.
  2. Join the Payers, Plans, and Managed Care Community: Discussion includes issues related to the operation and regulation of health maintenance organizations, managed care payers, and employee health benefit plans, including related liability, health insurance, and payment issues. To join the Community, visit your "myAHLA" profile at www.healthlawyers.org/myahla, enter your login information, click the blue button to customize your "Email and List Preferences," and click "Save." 
  3. Sign up for an Affinity Group: Available at no additional fee, Affinity Groups facilitate networking and provide educational opportunities for members who share similar professional interests. If you did not select an Affinity Group when you joined AHLA, you can still do so. Simply complete and return this enrollment form or call AHLA's Member Service Center at (202) 833-1100, prompt #2. PPMC PG members can enroll in the following Affinity Groups:
    •  Health Plan Affinity Group: Provides, obtains, and facilitates information exchange and best practices among lawyers who represent health plans or who work at health plans, and focuses on the unique issues these lawyers face.
    • Managed Care Contracting Affinity Group: The group addresses areas of particular concern to any entity that enters into managed care contracts, including all types of managed care organizations, payors, and providers. These areas of concern include preparation of model contract language, identification of potential contractual liability, "hot" issues relevant to managed care contracts, such as HIPAA, COB, indemnification, compliance and insolvency.
    • Medicare Advantage and Part D Affinity Group: Focuses on issues related to the two major programs providing private health plan options to Medicare beneficiaries.
  4. Check out the PPMC PG Topical Library: This is where you can access the most relevant and recent AHLA publications and resources related to your practice area. It's the hub for AHLA content on AMCTH.

 

In addition, here are other benefits available to you through the PPMC PG:

  • Email Alerts, Executive Summaries, and Member Briefings: Timely alerts are delivered directly to your inbox—when a new law, regulation, or decision is published, we do the initial legwork and summarize it for you.
  •  Great Opportunities for Involvement: The PPMC PG leadership welcomes and encourages members to become active participants by writing, speaking, tweeting, serving as a mentor, and taking on other leadership roles. Visit www.healthlawyers.org/volunteer to view available volunteer opportunities.
  • Task Forces: For those health law topics that cross over several Practice Groups, AHLA has established Task Forces that produce collaborative, substantive resources for the benefit of the sponsoring Practice Groups' members. PPMC PG members are automatically enrolled in

 

PPMC PG will provide you with industry-focused programming and attention to all facets of managed care.  We hope that your active participation in the PPMC PG will help you in serving your clients' needs.

 
Summaries of the Office of Inspector General (OIG) Advisory Opinions are provided by the Advisory Opinions Task Force of the Fraud and Abuse Practice Group. The Task Force aids Practice Group members in keeping abreast of new Advisory Opinions. For each new opinion issued by the OIG, a summary is released via an email alert and posted on several Practice Groups'websites.

​OIG Advisory Opinions

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You may access this content by joining AHLA and enrolling in Payers, Plans, and Managed Care Practice Group.


Already a member? Sign in

You may access this content by enrolling in Payers, Plans, and Managed Care Practice Group.

You may access this content by Renewing your membership for Payers, Plans, and Managed Care

You may access this content by joining AHLA and enrolling in Payers, Plans, and Managed Care Practice Group.


Already a member? Sign in

You may access this content by enrolling in Payers, Plans, and Managed Care Practice Group.

You may access this content by Renewing your membership for Payers, Plans, and Managed Care

You may access this content by joining AHLA and enrolling in Payers, Plans, and Managed Care Practice Group.


Already a member? Sign in

You may access this content by enrolling in Payers, Plans, and Managed Care Practice Group.

You may access this content by Renewing your membership for Payers, Plans, and Managed Care


You may access this content by joining AHLA and enrolling in Payers, Plans, and Managed Care Practice Group.


Already a member? Sign in

You may access this content by enrolling in Payers, Plans, and Managed Care Practice Group.

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  • Practical Considerations for Analyzing Telemedicine and Telehealth Legal Issues
    - Published on September 21, 2017
    This Toolkit covers all of the basics and need-to-know legal issues affecting telemedicine and telehealth today, including:

    •    The Overarching Principles of Telemedicine
    •    What is Telemedicine?
    •    How is Telemedicine and Telehealth Used Today?
    •    State Regulatory Framework: Legal Issues and Key Questions to Ask
    •    Federal Regulatory Framework and Legal Issues

  • Pharmacy Maximum Allowable Cost (MAC) Laws: A 50 State Survey
    - Published on August 8, 2017
    This 50 state survey on pharmacy maximum allowable cost (MAC) laws summarizes the laws of each state regarding how they govern the way payers—including pharmacy benefit managers (PBMs)—can reimburse pharmacies for products dispensed to patients.

  • Managed Care Contracting Toolkit
    - Published on June 22, 2009; Updated on December 7, 2016
    Originally created in June 2009 and updated in December 2016, the updated Managed Care Contracting Toolkit (Toolkit) follows the previous form but provides updated information in light of changes in law, including the implementation of the Affordable Care Act. The Toolkit is organized in the order of a typical managed care contract and outlines general principles that should be considered when negotiating contract provisions as a Provider or Managed Care Organization (MCO). Where applicable and unambiguous, sample contract language has been marked as either MCO- or provider-friendly, or neutral. Important principles have been listed at the beginning of each section to provide a roadmap and some general thoughts for contracting parties.
  • Emergency Preparedness Toolkit
    - Published on May 4, 2010
    When an emergency hits a hospital, administrators often turn to their lawyers as issues arise in providing care during an emergency. This Emergency Preparedness Toolkit (Toolkit) is designed as a complement to AHLA’s Emergency Preparedness Response & Recovery Checklist: Beyond the Emergency Management Plan by providing a one-stop resource of emergency preparedness form policies, procedures, links, articles, sample contract language, and legal summary memoranda to assist healthcare attorneys, administrators, and providers in preparing for and responding to the issues that arise during an emergency.​
  • Medicare Advantage and Part D Preemption 
    - Published on February 25, 2010
    As part of the Medicare Modernization Act of 2003, Congress significantly expanded the scope of the federal preemption clause for Medicare Part C (which is incorporated by reference into Medicare Part D). Courts are beginning to rule on cases involving these preemption issues, which will affect Medicare Advantage Organizations, Part D Plan Sponsors, their network providers, and Medicare beneficiaries. In an effort to assist its members in staying abreast of developments in this area, the Payers, Plans, and Managed Care Practice Group has posted key documents to this toolkit.

You may access this content by joining AHLA and enrolling in Payers, Plans, and Managed Care Practice Group.


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You may access this content by enrolling in Payers, Plans, and Managed Care Practice Group.

You may access this content by Renewing your membership for Payers, Plans, and Managed Care

Health Plan Management System Memoranda Archive
This is an archive of memoranda distributed by the Centers for Medicare & Medicaid Services' Health Plan Management System (HPMS) from October 2008 - December 2016. For more information about the HPMS, please access the HPMS website. To receive the HPMS memoranda, please email HPMS@cms.hhs.gov.

You may access this content by joining AHLA and enrolling in Payers, Plans, and Managed Care Practice Group.


Already a member? Sign in

You may access this content by enrolling in Payers, Plans, and Managed Care Practice Group.

You may access this content by Renewing your membership for Payers, Plans, and Managed Care

Upcoming:

January 8, 2019 2:00 PM-3:30 PM Eastern

Past:

Upcoming:

Past:

WEDNESDAY, JANUARY 14, 2015

Upcoming:

Past:

February 9, 2016 12:00 PM-1:15 PM Eastern

Upcoming:

Past:

October 24, 2018 12:00 PM-1:00 PM Eastern
November 2, 2017 12:00 PM-1:00 PM Eastern
June 6, 2017 1:00 PM-1:30 PM Eastern
May 30, 2017 1:00 PM-1:30 PM Eastern
April 18, 2017 1:00 PM-1:30 PM Eastern

​Affinity Groups

Affinity Groups are created to facilitate networking and educational opportunities with other Practice Group members who share similar professional interests.
Please note: You must be a member of Payers, Plans, and Managed Care Practice Group or a government, academician, student, or PG 15 member (all-Practice Groups access) to enroll in these Affinity Groups.

Task Forces

Task Forces are established for those health law topics that cross over several Practice Groups, and they provide collaborative, substantive resources for the benefit of the sponsoring Practice Groups' members.
Please note: You must be a member of the Payers, Plans, and Managed Care Practice Group or one of the other sponsoring Practice Groups to receive benefits produced by these Task Forces.
  • Accountable Care Organization Task Force
    The mission of the ACO Task Force is to provide members with a wide array of information relating to accountable care organizations, integrated care models, and other initiatives designed to improve quality and lower costs, for better population health. The ACO Task Force analyzes the impact and trajectory of ACO and other integrated care developments nationwide, including commercial ACOs, Medicaid ACOs, and the Medicare ACO programs.

    The mission of the ACO Task Force includes informing members of any new or updated regulations, waivers, and guidance relating to the main federal ACO programs, including the Medicare Shared Savings Program and the Pioneer ACO program, as well as to provide information on a broader array of issues integral to ACOs, integrated care systems, population health, and payment models.

    The ACO Task Force provides webinars, written material, and sponsored in-person programming pertaining to the relationship between ACOs and population health, as well as other topics germane to ACO formation and development. Since the ACO Task Force mission is so broad, it often partners with other AHLA Practice Groups to provide deeper insight into the unique legal and policy considerations for ACOs.
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  • Behavioral Health Task Force
    The Behavioral Health (BH) Task Force is committed to advancing the understanding of laws impacting behavioral health, including the delivery of services to those living with mental illness, certain neurological conditions, substance use disorders or developmental disabilities, and reimbursement for such services. A complex framework of federal and state laws concerning privacy, information sharing and exchange, reimbursement, involuntary commitment, and other subjects provides unique challenges to health care providers and payers of behavioral health services. Scientific, legislative, and other developments, including health care reform, have presented new issues and opportunities in this area, including primary and behavioral health care integration initiatives, insurance coverage parity mandates, changes to Medicaid, and evolving public policy, to name a few. The BH Task Force monitors and evaluates these laws and developments through written materials, webinars, and in-person educational activities so that AHLA members are better equipped to advise clients on behavioral health topics. In addition, the work of the BH Task Force serves to raise awareness about how behavioral health laws influence health improvement efforts, and will include collaborative efforts with AHLA's Public Interest activities.
  •  
  • Health Care Reform Educational Task Force
    The Health Care Reform Educational Task Force serves as a single key point-of-contact for the Association membership for institutional resources regarding comprehensive health care reform initiatives at the state and federal levels. The Task Force works to educate AHLA members on proposed health care reform initiatives as well as report on ongoing experiences with recently enacted reform initiatives.

  • Webinars

    January 8, 2019 2:00 PM-3:30 PM Eastern

    Roundtable Discussions


    Image of LeahStewart
    Leah B. Stewart Chair Dell Medical School at UT Austin Austin, TX (512) 495-5146 Email
    Image of XavierBaker
    Xavier Baker Vice Chair - Research & Website Crowell & Moring LLP Washington, DC (202) 624-2842 Email
    Image of ArdithBronson
    Ardith M. Bronson Vice Chair - Publications DLA Piper LLP (US) Miami, FL 305.423.8562 Email
    Image of KarenPalmersheim
    Karen R. Palmersheim Vice Chair - Membership Cigna Glendale, CA (818) 500-6497 Email
    Image of MelissaWong
    Melissa Wong Vice Chair - Educational Programs Holland & Knight LLP Boston, MA (617) 305-2156 Email
    Image of JaniceZiegler
    Janice H. Ziegler Vice Chair - Strategic Planning and Special Projects Dentons US LLP Washington, DC (202) 408-9158 Email
    Image of KateMcDonald
    Kate McDonald Social Media Coordinator McDermott Will & Emery LLP Washington, DC (202) 756-8803 Email

     

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