United States: Weekly Washington Healthcare Update - June 30, 2014

Last Updated: July 9 2014
Article by Stephanie A. Kennan and Brian J. Looser

This Week: Bipartisan, bicameral post-acute care reform legislation introduced... CMS releases fraud prevention system report... HHS proposed rule on annual eligibility determinations

1. Congress

House

Energy and Commerce Continues "21st Century Cures" Sessions

On June 24, the Energy and Commerce Committee continued its bipartisan 21st Century Cures initiative, this time turning attention to how new technologies can advance digital health care and the discovery, development and delivery cycle of new cures and treatments. By fostering innovation in health information technology, genomics, data analytics, sensors, telemedicine, mobile apps, cloud technology and other technologies and platforms, the committee hopes it can make the U.S. health care system more personalized and proactive and thus better for patients. Participants in the discussion included Dr. Jeff Shuren, Director of the Center for Devices and Radiological Health (CDRH) at the Food and Drug Administration (FDA); Dr. Joseph M. Smith, Chief Medical and Science Officer at West Health; Dr. Brian Druker, Director of the Knight Cancer Center at the Oregon Health and Science University; Gina Gavlak, RN, BSN, Chair, National Advocacy Committee for the American Diabetes Association; Sean Hogan, Vice President for Health Care at IBM; Martin Harris, Chief Information Officer of The Cleveland Clinic; Anne Wojcicki, CEO & Co-Founder of 23andMe; Dr. Mark Blatt, Worldwide Medical Director of Intel Corporation; Jonathon Bush, CEO & President of Athenahealth, Inc.; and Paul Magelli, CEO of Pervasive Health.

Oversight Subcommittee Hearing Examines Medicare Fraud

On June 25, the Energy and Commerce Subcommittee on Oversight and Investigations held a hearing entitled "Medicare Program Integrity: Screening Out Errors, Fraud, and Abuse." The Subcommittee is following up on recent laws and reports that either authorize or recommend further actions that could be taken to protect Medicare from errors, fraud and abuse. The U.S. Department of Health and Human Services (HHS), Centers for Medicare and Medicaid Services (CMS) has also intensified efforts to address Medicare fraud, waste and abuse. The purpose of the hearing is to review key recommendations, assess ongoing efforts and identify additional actions that could be taken or expedited.

Witnesses:

Shantanu Agrawal, M.D.
Deputy Administrator and Director
Center for Program Integrity, Centers for Medicare and Medicaid Services

Gary Cantrell
Deputy Inspector General for Investigations
Office of Inspector General, Department of Health and Human Services

Accompanied by Gloria L. Jarmon
Deputy Inspector General for Audit Services
Office of Inspector General, Department of Health and Human Services

Kathleen M. King
Director
Health Care, U.S. Government Accountability Office

For more information, or to view the hearing, please visit energycommerce.house.gov.

Veterans Affairs Committee Hearing on Veterans Health Administration

On June 23, 2014, the House Veterans' Affairs Committee held a hearing entitled "Evaluating the Capacity of the VA to Care for Veteran Patients." The hearing comes as lawmakers work to address public concern over recent discoveries that veterans have been subject to significant wait times in Veterans Health Administration (VHA) facilities. Of particular note, the hearing occurred on the same day a letter from the Office of Special Counsel was issued to the White House updating the President on whistleblower disclosures from employees at the Veterans Affairs Medical Center in Jackson, Mississippi. The letter states, "The Jackson VAMC cases are part of a troubling pattern of responses by the Department of Veterans Affairs (VA) to similar disclosures from whistleblowers at VA medical centers across the country. The recent revelations from Phoenix are the latest and most serious in the years-long pattern of disclosures from VA whistleblowers and their struggle to overcome a culture of non-responsiveness. Too frequently, the VA has failed to use information from whistleblowers to identify and address systemic concerns that impact patient care."

Witnesses:

Thomas Lynch, M.D.
Assistant Deputy Under Secretary for Health for Clinical Operations
Veterans Health Administration
U.S. Department of Veterans Affairs

Accompanied by:
Carolyn M. Clancy, M.D.
Assistant Deputy Under Secretary for Quality, Safety, and Value
Veterans Health Administration
U.S. Department of Veterans Affairs

For more information, or to view the hearing, please visit veterans.house.gov.

Senate

Bicameral, Bipartisan Post-Acute Bundling Legislation Introduced

Senate Finance Committee Chairman Ron Wyden, D-Ore.; Ranking Member Orrin Hatch, R-Utah; House Ways and Means Chairman Dave Camp, R-Mich.; and Ranking Member Sandy Levin, D-Mich., introduced the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act). According to a joint press release, the bill would require data standardization to allow Medicare to compare quality across different post-acute care settings and improve hospital and post-acute care discharge planning. The legislation follows the release of a discussion draft in March that was largely based on input the lawmakers received from the post-acute care community. Last year, the lawmakers invited interested stakeholders to submit ideas on how to strengthen post-acute care, a variety of health care services that support a patient's continued recovery from a serious illness.

2. Administration

IRS Small Business Tax Credit Final Rule

The IRS has released final regulations on the tax credit available to certain small employers that offer health insurance coverage to their employees. The credit is provided under Section 45R of the Internal Revenue Code (Code), enacted by the Patient Protection and Affordable Care Act. These regulations affect small employers, both taxable and tax-exempt, that are or might be eligible for the tax credit.

Specifically, the tax credit is available to employers that offer health coverage and have no more than 25 full-time employees with annual average wages up to $50,000. Under the rules, employers also must have a qualifying arrangement in effect that requires them to pay at least 50 percent of the premium cost of a qualified health plan offered to their employees through a Small Business Health Options Program (SHOP) exchange. Federal, state, local or Indian tribal government entities aren't eligible for the tax credit under Section 45R, unless they are organizations described in Section 501(a) and otherwise meet the eligible small-employer requirements. The final rule goes into effect June 30, 2014.

CMS Releases Fraud Prevention System Second-Year Implementation Report

Last week, CMS released its "Report to Congress Fraud Prevention System Second Implementation Year," in which the agency found double the number of improper Medicare payments were identified or prevented as in the program's first year. Specifically, the Fraud Prevention System (FPS) has run predictive algorithms and other sophisticated analytics nationwide against all Medicare fee-for-service (FFS) claims prior to payment. In addition, CMS is applying advanced analytics against Medicare FFS claims on a streaming, nationwide basis as part of its comprehensive program integrity strategy, which has resulted in CMS' taking action against 938 providers and stakeholders. The identified savings, certified by the OIG, associated with these prevention and detection actions due to FPS was $210.7 million, which resulted in more than a $5 to $1 return on investment, an increase from last year's $3 to $1 return.

This year's Report to Congress introduces the new concept of adjusted savings. The adjusted savings number is an attempt to estimate the dollars that CMS has already returned or, from a financial auditing perspective, is likely to return to the Treasury in the future from the larger category of identified savings based on historical experience with the Medicare program.

3. State Activities

Oregon Hospital Sees Uninsured Patient Population Dwindle

According to local reports, the Oregon Health and Science University hospital saw its uninsured population fall from 5 percent to 2 percent in the first three months of this year. Moreover, Lawrence Furnstahl, the university's chief financial officer, told his board that in the last two months the ratio has dropped to less than 1 percent. The decline, which was somewhat unexpected, has been attributed to the large number of Oregonians who signed up for the state's low-income Medicaid program -- more than 340,000 of them -- starting in January.

DC Insurance Department Releases 2015 Health Rates

The DC Department of Insurance, Securities and Banking received proposed health insurance plan rates to sell on the District of Columbia's health insurance marketplace, DC Health Link, for plan year 2015. According to a press release issued by the department, four major insurance companies -- Aetna, CareFirst BlueCross BlueShield, Kaiser Permanente and UnitedHealthcare -- have proposed rates for individuals, families and small businesses. UnitedHealthcare proposed rate decreases of 8 percent for all of their 2015 plans; Aetna and Kaiser Permanente proposed a mix of rate increases and decreases resulting in a slight overall net decrease for Aetna and a slight overall net increase for Kaiser; and CareFirst proposed rate increases for all plans. Most of the individual plans and all small business or "SHOP" plans reflect increases greater than 10 percent. Based on the 2014 market experience, some insurers modified or discontinued plan offerings. Forty-two new plans are proposed for 2015, all in the SHOP market with the exception of one individual plan. UnitedHealthcare and Aetna also eliminated some plans that had little or no enrollment in 2014, resulting in a total of 227 proposed plans.

4. Regulations Open for Comment

HHS Proposed Rule: Annual Eligibility Redeterminations for Exchange Participation and Insurance Affordability Programs

HHS has issued a proposed rule that would specify additional options for annual eligibility redeterminations and renewal and re-enrollment notice requirements for qualified health plans offered through the Exchange, beginning with annual redeterminations for coverage for plan year 2015. Specifically, in the notice of proposed rulemaking entitled "Patient Protection and Affordable Care Act; Annual Eligibility Redeterminations for Exchange Participation and Insurance Affordability Programs; Health Insurance Issuer Standards Under the Affordable Care Act, Including Standards Related to Exchanges," HHS proposes that a Marketplace must conduct annual redeterminations using either the procedures described in 45 CFR §155.335(b) through (m), alternative procedures specified by the Secretary for the applicable plan year, or alternative procedures approved by the Secretary based on a showing by the Exchange that such procedures meet specified criteria. This guidance specifies alternative procedures for plan year 2015 that, if a final rule is promulgated permitting a Marketplace to elect such process, will constitute the alternative procedures designated in proposed 45 CFR §155.335(a)(2)(ii). If permitted under such a final rule, the federally facilitated Marketplace (FFM) will adopt the alternative procedures specified in this guidance for plan year 2015, consistent with proposed 45 CFR §155.335(a)(2)(ii)2.

These alternative procedures are intended to preserve a feature of the annual redetermination process specified in 45 CFR §155.335(g), namely, that an enrollee may take no action and still have his or her coverage renewed for 2015, which is important in promoting continuity of coverage while limiting administrative burden for enrollees, issuers and Marketplaces.

Draft Guidance for Industry on Drug Supply Chain Security Act Implementation: Identification of Suspect Product and Notification; Availability

On June 11, 2014, FDA announced the availability of a draft guidance for industry entitled "Drug Supply Chain Security Act Implementation: Identification of Suspect Product and Notification." The draft guidance addresses new provisions in the Federal Food, Drug, and Cosmetic Act (the FD&C Act), as amended by the Drug Supply Chain Security Act (DSCSA). The draft guidance is intended to aid certain trading partners (manufacturers, repackagers, wholesale distributors and dispensers) in identifying a suspect product and terminating notifications regarding illegitimate product. This draft guidance identifies specific scenarios that could significantly increase the risk of a suspect product entering the pharmaceutical distribution supply chain; provides recommendations on how trading partners can identify the product and determine whether the product is a suspect product as soon as practicable; and for product that has been determined to be illegitimate, or (for manufacturers) has a high risk of illegitimacy, sets forth the process by which trading partners should notify FDA of illegitimate product and how they must terminate the notifications, in consultation with FDA. Public comments on the draft guidance will be accepted through Aug. 11, 2014.

CMS Proposed Rule: Medicare, Medicaid EHR Incentive Program

On May 23, 2014, CMS issued a proposed rule that would change the meaningful use stage timeline and the definition of certified electronic health record technology (CEHRT). It would also change the requirements for the reporting of clinical quality measures for 2014. Certified EHR technology is defined for the Medicare and Medicaid HER Incentive Programs at 42 CFR 495.4, which references the Office of the National Coordinator for Health Information Technology's (ONC) definition of CEHRT under 45 CFR 170.102. For Stages 1 and 2 of meaningful use, CMS and ONC worked closely to ensure that the definition of meaningful use of CEHRT and the standards and certification criteria for CEHRT were coordinated. The definition of CEHRT under 45 CFR 170.102 requires, beginning with federal fiscal year (FY) and calendar year (CY) 2014, EHR technology certified to the 2014 Edition EHR certification criteria. Therefore, all EPs, eligible hospitals and CAHs must use 2014 Edition CEHRT to meet meaningful use under the Medicare and Medicaid EHR Incentive Programs, beginning with FY 2014 and CY 2014. Beginning in 2015, all eligible hospitals and professionals would still be required to report using the 2014 Edition CEHRT. The proposed rule also includes a provision that would formalize CMS' and ONC's previously stated intention to extend Stage 2 through 2016 and begin Stage 3 in 2017.

To view the CMS press release on the proposed rule, visit cms.gov.

Medicare Program; Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Items

On May 23, 2014, CMS issued a proposed rule that would establish a prior authorization process for certain durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) items that are frequently subject to unnecessary utilization and would add a contractor's decision regarding prior authorization of coverage of DMEPOS items to the list of actions that are not initial determinations and therefore not appealable.

The proposed rule is intended to replicate the Medicare Prior Authorization of Power Mobility Device Demonstration. Launched in 2012, the demonstration established a prior authorization process for certain power mobility devices. Based on September 2013 claims data, monthly expenditures for certain power mobility devices decreased from $12 million in September 2012 to $4 million in August 2013 across the seven demonstration states (California, Florida, Illinois, Michigan, New York, North Carolina and Texas) with no reduction in beneficiary access to medically necessary items. CMS seeks to leverage this success by extending the demonstration to an additional 12 states. These states include Arizona, Georgia, Indiana, Kentucky, Louisiana, Maryland, Missouri, New Jersey, Ohio, Pennsylvania, Tennessee and Washington. This will bring the total number of states participating in the demonstration to 19.

CMS also proposes to establish a prior authorization process for certain durable medical equipment, prosthetics, orthotics and supplies items that are frequently subject to unnecessary utilization. Through a proposed rule, CMS will solicit public comments on this prior authorization process, as well as criteria for establishing a list of durable medical items that are frequently subject to unnecessary utilization that may be subject to the new prior authorization process. CMS will launch two payment model demonstrations to test prior authorization for certain non-emergent services under Medicare. These services include hyperbaric oxygen therapy and repetitive scheduled non-emergent ambulance transport. Information from these models will inform future policy decisions on the use of prior authorization.

The deadline to submit comments is July 28, 2014.

OIG Proposed Rule to Promote Civil Monetary Penalties for Health Fraud

On May 12, the Department of Health and Human Services Office of Inspector General published a rule in the Federal Register that would expand the use of civil monetary penalties (CMPs). Under the rule, CMPs could be applied to entities for failing to provide OIG with quick access to documents, ordering or prescribing medication or services while excluded from participation in federal health care programs, making false statements on enrollment applications, failing to report or return overpayments, and making a false statement that is part of a fraudulent claim. In addition, the proposed rule would also allow CMPs to be imposed on Medicare Advantage and Medicare Part D organizations. Comments on the rule are due July 11.

CMS Proposed Rule FY 2015 Hospice Payment Rate Update

On May 2, 2014, CMS issued a proposed rule [CMS-1609-P] that would update fiscal year (FY) 2015 Medicare payment rates and the wage index for hospices serving Medicare beneficiaries. As proposed, hospices would see an estimated 1.3 percent ($230 million) increase in their payments for FY 2015. The hospice payment increase would be the net result of a proposed hospice payment update to the hospice per diem rates of 2 percent (a "hospital market basket" increase of 2.7 percent minus 0.7 percent for reductions mandated by law), and a 0.7 percent decrease in payments to hospices due to updated wage data and the sixth year of CMS' seven-year phase-out of its wage index budget neutrality adjustment factor (BNAF). This rule also provides an update on hospice payment reform analyses and solicits comments on "terminal illness" and "related conditions" definitions, and on a process and appeals for Part D payment for drugs, while beneficiaries are under a hospice election. In addition, the rule proposes timeframes for filing the notice of election and the notice of termination/revocation; adding the attending physician to the hospice election form; a requirement that hospices complete their hospice inpatient and aggregate cap determinations within five months after the cap year ends, and remit any overpayments; and updates for the hospice quality reporting program.

Public comments on the proposal will be accepted until July 1, 2014.

CMS Final Rule -- Federally Qualified Health Center Prospective Payment System

On May 2, 2014, CMS issued a final rule with comment period to implement methodology and payment rates for a prospective payment system (PPS) for federally qualified health center (FQHC) services under Medicare Part B beginning on Oct. 1, 2014, in compliance with the statutory requirement of the Affordable Care Act. In addition, it establishes a policy that allows rural health clinics (RHCs) to contract with nonphysician practitioners when statutory requirements for employment of nurse practitioners and physician assistants are met, and makes other technical and conforming changes to the RHC and FQHC regulations. Finally, this final rule with comment period implements changes to the Clinical Laboratory Improvement Amendments (CLIA) regulations regarding enforcement actions for proficiency testing (PT) referrals. Comments will be accepted through July 1, 2014.

CMS Issues Proposed Hospital Inpatient Payment Regulation

CMS issued a proposed rule that would update fiscal year (FY) 2015 Medicare payment policies and rates for inpatient stays at general acute care and long-term care hospitals (LTCHs). This rule builds on the Obama administration's efforts through the Affordable Care Act to promote improvements in hospital care that will lead to better patient outcomes while slowing the long-term health care cost growth. CMS projects that the payment rate update to general acute care hospitals will be 1.3 percent in FY 2015. The rate update for long-term care hospitals will be 0.8 percent. The difference in the update is accounted for by different statutory and regulatory provisions that apply to each system.

The rule's most significant changes are payment provisions intended to improve the quality of hospital care, which reduce payment for readmissions and hospital acquired conditions (HACs). The rule also includes proposed changes to the Hospital Inpatient Quality Reporting (IQR) Program. The rule also describes how hospitals can comply with the Affordable Care Act's requirements to disclose charges for their services online or in response to a request, supporting price transparency for patients and the public.

CMS will accept comments on the proposed rule until June 30, 2014, and will respond to comments in a final rule to be issued by Aug. 1, 2014.

Fiscal Year 2015 Inpatient Psychiatric Facilities Prospective Payment System

On May 1, 2014, CMS issued a proposed rule that would update the prospective payment rates for Medicare inpatient hospital services provided by inpatient psychiatric facilities (IPFs). These changes would be applicable to IPF discharges occurring during the fiscal year (FY) beginning Oct. 1, 2014, through Sept. 30, 2015. This proposed rule would also address implementation of ICD-10-CM and ICD-10-PCS codes; propose a new methodology for updating the cost of living adjustment (COLA); and propose new quality measures and reporting requirements under the IPF quality-reporting program. The proposed rule will appear in the May 6, 2014, Federal Register and will be open to public comment for 60 days.

Proposed Fiscal Year 2015 Payment and Policy Changes for Medicare Inpatient Rehabilitation Facilities

On May 1, 2014, CMS issued a proposed rule that would update the prospective payment rates for inpatient rehabilitation facilities (IRFs) for federal fiscal year (FY) 2015 (for discharges occurring on or after Oct. 1, 2014, and on or before Sept. 30, 2015) as required by the statute. The rule also proposes to collect data on the amount and mode (that is, Individual, Group and Co-Treatment) of therapy provided in the IRF setting according to therapy discipline, revise the list of impairment group codes that presumptively meet the "60 percent rule" compliance criteria, provide for a new item on the Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRF-PAI) form to indicate whether the prior treatment and severity requirements have been met for arthritis cases to presumptively meet the "60 percent rule" compliance criteria, and revise and update quality measures and reporting requirements under the IRF quality reporting program (QRP). The proposal also addresses the implementation of the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), for the IRF prospective payment system (PPS), effective when ICD-10-CM becomes the required medical data code set for use on Medicare claims and IRF-PAI submissions. The proposed rule will appear in the May 7 Federal Register and will be open to public comments for until June 30, 2014.

FDA Proposed Rule on Deeming Tobacco Products To Be Subject to the Federal Food, Drug, and Cosmetic Act

FDA has issued a proposed rule that would deem products meeting the statutory definition of "tobacco product," except accessories of a proposed deemed tobacco product, to be subject to the Federal Food, Drug, and Cosmetic Act (the FD&C Act), as amended by the Family Smoking Prevention and Tobacco Control Act (Tobacco Control Act). The Tobacco Control Act provides FDA authority to regulate cigarettes, cigarette tobacco, roll-your-own tobacco, smokeless tobacco and any other tobacco products that the Agency by regulation deems to be subject to the law. Option 1 of the proposed rule would extend the Agency's "tobacco product" authorities in the FD&C Act to all other categories of products, except accessories of a proposed deemed tobacco product, that meet the statutory definition of "tobacco product" in the FD&C Act. Option 2 of the proposed rule would extend the Agency's "tobacco product" authorities to all other categories of products, except premium cigars and the accessories of a proposed deemed tobacco product, that meet the statutory definition of "tobacco product" in the FD&C Act. FDA also is proposing to prohibit the sale of "covered tobacco products" to individuals under the age of 18 and to require the display of health warnings on cigarette tobacco, roll-your own tobacco and covered tobacco product packages and in advertisements. FDA is taking this action to address the public health concerns associated with the use of tobacco products. Comments are due July 9, 2014.

5. Reports

Private Health Insurance: The Range of Average Annual Premiums in the Small Group Market by State in Early 2013

On June 24, GAO reported the range of average premiums for health insurance products sold to small employers in the small group market of each of the 50 states and the District of Columbia during the first quarter of 2013. The average premiums reflected information from data submitted by insurers to the Center for Consumer Information and Insurance Oversight (CCIIO) within the Department of Health and Human Services' (HHS) Centers for Medicare & Medicaid Services (CMS). They represented an annual average of the premiums paid per covered life by all small employers that purchased a particular product. Actual average premiums per covered life for each employer may have been higher or lower than our calculated average premiums per covered life, because each employer's premiums would have been determined based on the health status of its employees and other factors.

White House Council of Economic Advisors: Third Estimate of GDP for the First Quarter of 2014

On June 25, the White House Council of Economic Advisors announced that first-quarter GDP was revised down, largely reflecting updated estimates of consumer spending on health care, which was substantially lower than originally reported, as well as exports, which were below the initial estimates. Specifically, the contribution of spending on health care services was revised down 1.2 percentage points, while the net export contribution was revised down 0.6 percentage point. Also of note, the new figures show Q1 health care prices rising "exceptionally slowly" at an annual rate of 0.5 percent. Utilization fell at a 1.4 percent annual rate in the quarter. Year over year, health care prices have increased by 0.9 percent, and utilization has increased by 2.6 percent.

Affordable Care Act: Despite Initial Challenges, the Internal Revenue Service Successfully Implemented the Branded Prescription Drug Fee

According to a recent report released by the Treasury Inspector General for Tax Administration (TIGTA), the IRS successfully implemented the branded prescription drug fee through collaborative efforts with the various third parties and an alternative approach to calculate and assess the fee. The alternative approach was needed after the IRS learned that the purchasing government agencies' branded prescription drug sales data would not be available until after the legislative deadline for calculating the annual fee. In order to implement the fee, the IRS developed a new reporting form (Form 8947, Report of Branded Prescription Drug Information) and instructions. It also developed procedures and a database to process covered entities' sales data and to accurately calculate the annual fees. TIGTA reviewed a judgmental sample of 15 Forms 8947 (representing more than 80 percent of the sales volume used to calculate the fee) for calendar years 2011 and 2012 and independently calculated the fee assessments. TIGTA determined that the IRS's calculation, assessment and collection of the fees were accurate for our sampled cases. TIGTA did identify one area requiring attention, however. From TIGTA's sample of 15 cases, TIGTA determined that some covered entities incorrectly interpreted the temporary regulations. Changes to Form 8947 and its instructions should help clarify these issues and reduce the burden on taxpayers. TIGTA recommends that the Commissioner, Large Business and International Division, revise sections of Form 8947 and its instructions to clarify certain issues. Covered entities should also be notified of these revisions. IRS management agreed with TIGTA's recommendation and plans to revise sections of Form 8947 and its instructions to clarify taxpayer understanding and reduce taxpayer burden.

Medicaid: Financial Characteristics of Approved Applicants and Methods Used to Reduce Assets to Qualify for Nursing Home Coverage

According to a recent report, GAO's review of 294 approved Medicaid nursing home applications in three states showed that 41 percent of applicants had total resources -- both countable and not countable as part of financial eligibility determination -- of $2,500 or less and 14 percent had over $100,000 in total resources. Moreover, nearly 75 percent of applicants owned some noncountable resources, such as burial contracts; the median amount of noncountable resources was $12,530. To qualify for Medicaid coverage for long-term care, including nursing home care, individuals must be within certain eligibility categories -- such as those who are aged or disabled -- and meet functional and financial eligibility criteria. The financial eligibility standards differ based on whether an individual is married or single. Federal law also limits Medicaid payments for long-term care for individuals who have transferred assets for less than FMV during a specified time period. States are responsible for assessing applicants' financial eligibility for Medicaid.

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

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The Content is general information only. It is not intended to constitute legal advice or seek to be the complete and comprehensive statement of the law, nor is it intended to address your specific requirements or provide advice on which reliance should be placed. Mondaq and/or its Contributors and other suppliers make no representations about the suitability of the information contained in the Content for any purpose. All Content provided "as is" without warranty of any kind. Mondaq and/or its Contributors and other suppliers hereby exclude and disclaim all representations, warranties or guarantees with regard to the Content, including all implied warranties and conditions of merchantability, fitness for a particular purpose, title and non-infringement. To the maximum extent permitted by law, Mondaq expressly excludes all representations, warranties, obligations, and liabilities arising out of or in connection with all Content. In no event shall Mondaq and/or its respective suppliers be liable for any special, indirect or consequential damages or any damages whatsoever resulting from loss of use, data or profits, whether in an action of contract, negligence or other tortious action, arising out of or in connection with the use of the Content or performance of Mondaq’s Services.

General

Mondaq may alter or amend these Terms by amending them on the Website. By continuing to Use the Services and/or the Website after such amendment, you will be deemed to have accepted any amendment to these Terms.

These Terms shall be governed by and construed in accordance with the laws of England and Wales and you irrevocably submit to the exclusive jurisdiction of the courts of England and Wales to settle any dispute which may arise out of or in connection with these Terms. If you live outside the United Kingdom, English law shall apply only to the extent that English law shall not deprive you of any legal protection accorded in accordance with the law of the place where you are habitually resident ("Local Law"). In the event English law deprives you of any legal protection which is accorded to you under Local Law, then these terms shall be governed by Local Law and any dispute or claim arising out of or in connection with these Terms shall be subject to the non-exclusive jurisdiction of the courts where you are habitually resident.

You may print and keep a copy of these Terms, which form the entire agreement between you and Mondaq and supersede any other communications or advertising in respect of the Service and/or the Website.

No delay in exercising or non-exercise by you and/or Mondaq of any of its rights under or in connection with these Terms shall operate as a waiver or release of each of your or Mondaq’s right. Rather, any such waiver or release must be specifically granted in writing signed by the party granting it.

If any part of these Terms is held unenforceable, that part shall be enforced to the maximum extent permissible so as to give effect to the intent of the parties, and the Terms shall continue in full force and effect.

Mondaq shall not incur any liability to you on account of any loss or damage resulting from any delay or failure to perform all or any part of these Terms if such delay or failure is caused, in whole or in part, by events, occurrences, or causes beyond the control of Mondaq. Such events, occurrences or causes will include, without limitation, acts of God, strikes, lockouts, server and network failure, riots, acts of war, earthquakes, fire and explosions.

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