CMS Proposes Sweeping Changes for Nursing Home Oversight

On July 16, 2015, the Center for Medicare and Medicaid Services (“CMS”) published a Proposed Rule with new standards that will have a sweeping effect on the long-term care industry. This new Rule is the first comprehensive review and update to Medicare and Medicaid nursing home standards since 1991. Since the last update, the number of Medicare beneficiaries, excluding Medicare Advantage beneficiaries, residing in nursing homes has tripled to 1.8 million residents and the Medicaid Program has become the primary payer of long term care (64% of residents are on Medicaid).[1]

The 403 page Proposed Rule sets high standards for quality of care and patient safety in nursing homes and long term care facilities that participate in Medicare and Medicaid.[2] The U.S. Department of Health and Human Services (“DHHS”) summarizes the proposed changes as follows:

  • Making sure that nursing home staff is properly trained on caring for residents with dementia and in preventing elder abuse.
  • Ensuring that nursing homes to take into consideration the health of residents when making decisions on the kinds and levels of staffing a facility needs to properly take care of its residents.
  • Ensuring that staff members have the right skill sets and competencies to provide person-centered care to residents. The care plan developed will take the resident’s goals of care and preferences into consideration.
  • Improving care planning, including discharge planning for all residents with involvement of the facility’s interdisciplinary team and consideration of the caregiver’s capacity, giving residents information they need for follow-up, and ensuring that instructions are transmitted to any receiving facilities or services.
  • Allowing dietitians and therapy providers the authority to write orders in their areas of expertise when a physician delegates the responsibility and state licensing laws allow.
  • Requiring nursing homes to provide greater food choice for residents while also giving flexibility for nursing homes.
  • Updating the nursing home’s infection prevention and control program, including requiring an infection prevention and control officer, and an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.
  • Strengthening rights of nursing home residents, including placing limits on when and how binding arbitration agreements may be used.[3]

To improve quality of care, the Proposed Rule requires nursing facilities to meet the Quality Assurance and Performance Improvement (QAPI) requirements and requires compliance and ethics programs. The Proposed Rule also focuses upon enhancing a resident’s quality of life and protecting residents’ rights.

Attentive doctor and nurse caring for an elderly hospital patienThe Proposed Rule significantly expands and strengthens governmental oversight of nursing facilities in an attempt to curb perceived fraud and abuse in the nursing homes.[4] The Proposed Rule increases the focus upon abuse, sexual abuse, and neglect in nursing homes. The Rule prohibits nursing homes from employing professionals that have received some form of professional discipline for abuse, mistreatment or even theft and requires that nursing homes craft, which means that facilities will have to conduct extensive professional disciplinary background checks before hiring professionals. The Proposed Rule also requires developing and enforcing policies to prevent abuse, mistreatment, and theft.

The proposed regulation also requires increased supervision and review of the use of medications. Under the Proposed Rule, a pharmacist will have to review a resident’s medical chart every six months and under certain circumstances at admission and then report any drug irregularities, including unnecessary drugs. Additionally, the regulations would limit the use of psychotropic drugs to residents by restricting these drugs to medically necessary uses and tapering long term users off of them with dose reductions and behavioral health services.

As indicated above, the federal and state payers, especially Medicaid, pay the bulk of the cost of long term care. As a result, the Proposed Rule is going to have an enormous impact on long term care facilities. Moreover, CMS estimates that the Proposed Rule would cost the nursing home industry $729 million in the first year and $638 million in the second year, serious figures for an industry with 15,000 long-term care facilities.[5]

CMS will accept Public Comments on the proposed rule for 60 days. For assistance with Public Comments on the Proposed Rule or for more information on how the Proposed Rule will affect long term care facilities, contact the attorneys at McBrayer.

Emily HordEmily M. Hord is an Associate of McBrayer, McGinnis, Leslie & Kirkland, PLLC.  Ms. Hord concentrates her practice in healthcare law and is located in the firm’s Lexington office. She can be reached at ehord@mmlk.com or at (859) 231-8780. 

This article is intended as a summary of federal and state law and does not constitute legal advice.

[1] Dickson, Virgil, Modern Healthcare, “Obama administration moves to strengthen nursing home oversight” (July 13, 2015), http://www.modernhealthcare.com/article/20150713/NEWS/150719975

[2] “Reform of Requirements for Long-Term Care Facilities (CMS-3260-P),” https://www.federalregister.gov/regulations/0938-AR61/reform-of-requirements-for-long-term-care-facilities-cms-3260-p-

[3] DHHS, Press Release, “HHS proposes to improve care and safety for nursing homes residents” (July 13, 2015) http://www.hhs.gov/news/press/2015pres/07/20150713d.html

[4] DHHS, Press Release, “HHS proposes to improve care and safety for nursing homes residents” (July 13, 2015) http://www.hhs.gov/news/press/2015pres/07/20150713d.html

[5] Dickson, Virgil, Modern Healthcare, “Obama administration moves to strengthen nursing home oversight” (July 13, 2015), http://www.modernhealthcare.com/article/20150713/NEWS/150719975

Changes and Challenges for Mental and Behavioral Health Providers

As Kentucky’s Senate Bill 192 highlights, coverage and treatment of substance abuse problems is dramatically changing as the current penal model is slowly being replaced with a treatment model. Even terminology for what has been called “drug addiction” is now referred to as a “substance disorder” problem. Behavioral health has become the new catchall name for both mental health and substance disorders. As substance disorders become medical problems rather than drug abuse problems, the Federal Mental Health Parity Act and the Affordable Care Act now mandate that substance disorders and mental health problems, which often go hand in hand, must be covered by health insurance just as medical problems are covered. As of January 1, 2015, these illnesses must also covered by Medicare and Medicaid. Paving the road for coverage, however, has not been easy as a wealth of new federal and state government regulations are creating a complicated framework with a host of changes for behavioral health providers. While Kentucky struggles to provide and pay for services for the 150,000+ new Medicaid beneficiaries, these new laws and regulations significantly affect not just behavioral health providers, but also employers as the struggle to treat individuals who suffer from these maladies is addressed.

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To bolster behavioral health services, Kentucky recently created a multitude of new behavioral health provider types that are eligible for reimbursement under the state’s Medicaid plans, but which will also be reimbursed by health insurance. The most significant are the Behavioral Health Services Organization (“BHSO”) and the Behavioral Health Multi-Specialty Group (“MSG”). Licensed under 902 KAR 20:430, BHSOs may provide a comprehensive variety of services from mental health and substance disorder providers that may include physicians, psychologists, therapists, social workers, nurse practitioners and physician assistants. Under this license, BHSOs may provide these services in both outpatient and residential settings. As opposed to BHSOs, MSGs are provider groups that can include only therapists and do not require licensure, but must meet credentialing requirements to be paid by Medicaid.

Kentucky’s behavioral health providers are a key part of the state’s plan to combat a growing substance use problem that threatens to spiral out of control. Senate Bill 192, Kentucky’s “heroin bill,” became law on March 25, 2015. A key provision of the new law exempts several behavioral health providers from the requirement of a Certificate of Need. SB 192 also requires Kentucky’s Department for Medicaid Services (“DMS”) and Medicaid managed care organizations (“MCOs”) to approve or credential, respectively, behavioral health providers within forty-five days of application, expediting the process. The law requires MCOs to adjudicate all clean claims in a timely fashion as provided by statute or face a civil penalty of $100 per day. This provision addresses failures of MCOs to handle and pay claims in a timely fashion.

As health insurance, Medicaid, and Medicare begin to cover important behavioral health services that allow patients to participate in activities of daily living including work, employers will confront complicated and thorny issues about how individual employees should be treated when undergoing treatment for these problems. Issues like use of medicated assisted therapies by employees in the work place are difficult and can have significant legal implications that range from employees’ rights to privacy of protected health information to rights to continued employment under the Americans with Disabilities Act.

Paradoxically, as the new legal and regulatory framework is developed with the intent of broadening access to important behavioral health services, the base of providers available to serve these patients is shrinking because of the cost of compliance with regulatory requirements and extremely low reimbursement. For instance, the regulatory landscape and the need for more providers to treat these substance disorder problems became even more complicated when the Kentucky Board of Medical Licensure (“KBML”) issued regulations establishing prescribing standards for buprenorphine, also known as Suboxone, which is a narcotic prescribed by physicians to treat opioid addiction disorders. Buprenorphine is one of several medication-assisted therapies now eligible for Medicaid coverage in Kentucky for the treatment of the substance use disorders. The new regulations are the KBML’s attempt to curb the abuse of these therapies and prevent doctor shopping. Law enforcement’s efforts to combat Kentucky’s serious drug problem by focusing on medical professionals and regularly reviewing KASPER and other reports may motivate behavioral health providers to choose less regulated areas for practice. Medicaid’s low reimbursement rates drive providers to close their practices to Medicaid patients as the cost of compliance does not justify the rate of reimbursement.

The federal government’s Centers for Medicare and Medicaid has just announced its intent to allow MCOs to pay all inclusive rates for behavioral health treatment, which, if enacted, may create financial incentives for providers to treat Medicaid patients if rates area reasonable. All inclusive payments for behavioral health services are being incorporated into the private health insurance market as well. Payment to providers to keep a substance disorder patient in compliance rather than on a fee for service basis may be in the future.

Interesting times are ahead for Kentucky’s health care providers as the framework for treatment and payment for behavioral health services is developed and becomes recognized as a basic component of primary care and overall health. Keeping mental health and substance disorder patients healthy and productive members of the workforce will require new treatment models and most certainly will provide a host of new issues for employers. Both changes and challenges lie ahead for providers, insurance companies, regulators, and employers as the new framework is developed, but the reward will be that individuals with these issues will become productive members of our workforce.

Lisa HinkleLisa English Hinkle is a Member of McBrayer, McGinnis, Leslie & Kirkland, PLLC.  Ms. Hinkle concentrates her practice area in health care law and is located in the firm’s Lexington office.  She can be reached at lhinkle@mmlk.com or at (859) 231-8780. 

This article is intended as a summary of federal and state law and does not constitute legal advice.

Think Twice about DEA Voluntary Surrender

It can be an intimidating experience to be sure… A DEA agent or Diversion Investigator, on an unscheduled visit to your office, confronts you with a KASPER, a KBML complaint or some other state regulatory action and alleges violations of the Controlled Substances Act. The DEA Agent then asks you to sign DEA Form 104. This form, which is titled “Voluntary Surrender of Controlled Substances Privileges,” is placed in front of you while the agent explains why you should sign it immediately, rather than face potential action to revoke your DEA and other adverse consequences. The DEA Agent tells you that you are already in deep, deep trouble (of a vague and unspecified nature), and that the simple act of signing this form can make your troubles go away and prevent federal action. Also, he tells you that all you have to do to get the number back is to reapply! Hold on…this is not the full story! This scenario is becoming a harsh reality and common situation for physicians, pharmacists, nurse practitioners, and PAs.

The truth is that signing any voluntary surrender will create multiple problems for providers including the loss of Medicare and Medicaid participation among other things that have the potential to destroy medical practices and livelihoods. Providers should know, for instance, that the DEA’s final rules, codified at 21 C.F.R. §§ 1301.52(a) and 1301.62(a), state that signing this form and handing it to a DEA employee will result in immediate loss of prescribing privileges for controlled substances in schedules II through V. When a voluntary surrender is executed, the DEA does not have to investigate further or bring any sort of charges – the signed form is akin to agreeing to a criminal sentence by bypassing an arrest, arraignment and trial, with the consequences being immediate forfeiture of a provider’s ability to prescribe any controlled substances. Make no mistake – the form may say “voluntary,” but it is in the best interest of the DEA to make the form as much the opposite as possible.

Prescription Drugs With A SyringeWhen a provider signs the form, there are three important things that happen – the provider’s surrender becomes officially “voluntary,” no matter how much that provider was pressured into signing; the provider’s signature officially resolves any governmental concerns that led to the provider being asked to sign, essentially proving the government’s case for them; and the signature creates a waiver of any right to an administrative hearing that could prevent the loss of the provider’s DEA registration. In other words, signing the form essentially is an irrevocable action.

There are other consequences beyond the immediate loss of the registration number. Once a DEA registration number is lost, it becomes excruciatingly difficult to regain. The proceedings will likely take between 18 months and two years, with the DEA opposing the provider at every step. All the while, the provider has no DEA registration and can’t prescribe controlled substances, rendering practice potentially impossible.

Also, when the form is signed, the DEA reports it to Medicare and Medicaid, which mot likely results in termination of participation. Understandably, Medicare and Medicaid do not want to pay for a provider’s services when he or she can not provide the full spectrum of care that includes prescribing controlled substances. Additionally, signing the form may trigger administrative and disciplinary action like civil monetary penalties or loss of medical staff privileges. Essentially, one signature has the potential to destroy a provider’s entire livelihood.

The DEA agent, of course, will do his or her level best to convince you that this is your best possible legal action. The DEA Agent’s intent is far from giving the provider the full story. The only advice that a provider should be accepting is legal advice from her or his attorney. When a provider confronts a DEA Agent, particularly in an unscheduled visit, the first thing a provider should do is contact an attorney before making any decisions as to how to proceed, whether the DEA is requesting consent to a search or a surrender of controlled substance prescribing privilege. Above all, do not sign anything without the advice your attorney. Tell the DEA Agent that you will have to consult with your attorney before signing any voluntary surrender or making any statements. The DEA Voluntary Surrender Form 104 is not a simple matter, whatsoever!

For information about DEA voluntary surrender, or if you need advice in an investigation, contact McBrayer’s health care team!

Lisa HinkleLisa English Hinkle is a Member of McBrayer, McGinnis, Leslie & Kirkland, PLLC.  Ms. Hinkle concentrates her practice area in health care law and is located in the firm’s Lexington office.  She can be reached at lhinkle@mmlk.com or at (859) 231-8780. 

This article is intended as a summary of federal and state law and does not constitute legal advice.

The Compounding Regulations Surrounding Drug Compounding

Drug compounding as a practice has, until recently, been met with far looser regulation than the manufacture of drugs. This practice serves to meet the needs of individuals who require certain formulations not available in manufactured form, such as discontinued medications or forms of manufactured drugs that do not contain ingredients to which a patient might be sensitive. Compounding may also change the form of the drug for patients who cannot take manufactured drugs in the manner in which they exist commercially. As industrial-level compounding grows to provide larger amounts of compounded drugs, regulators are scrambling to ensure the quality and safety of these drugs.

The biggest difference between a manufacturer of drugs and a drug compounding facility is that drug manufacturers must receive FDA approval before selling drugs to the public. Drugs from compounding facilities are not tested in the same manner for safety, efficacy or quality. After an outbreak of Aspergillus Meningitis between 2012 and 2013 due to tainted steroid injections from a compounding facility, Congress passed the Drug Quality and Security Act of 2013 (“DQSA”) in 2013, and a particular title called The Compounding Quality Act (“CQA”) to regulate the compounding industry. The DQSA/CQA set up a new regulatory regime that applies to all compounding pharmacies, and those pharmacies, large or small, should take notice as the FDA will soon release final rules implementing the provisions of the acts.

The CQA creates two different classes of compounders – traditional compounders and outsourcing facilities. Traditional compounders, such as small pharmacies that compound drugs based on prescriptions or in limited quantities, meet certain requirements that make them exempt from many of the strictures of the CQA, leaving them regulated largely by the states. Deviations from these exemptions will open these pharmacies up to federal inspection and potential enforcement actions.

PrescriptionThe second class created by the CQA is for a new kinds of pharmacies known as outsourcing facilities. These facilities must adhere to a set of stringent standards created in the CQA: the compounding must be done at a state or federally licensed pharmacy and by a licensed pharmacist; the compounding must be done pursuant to a prescription order; each facility must be registered with the FDA and create a procedure for reporting “adverse events”; bulk drug ingredients must be approved by the FDA, appear in the U.S. Pharmacopeia or have a monograph in the National Formulary, and other ingredients must also appear in the U.S. Pharmacopeia or National Formulary; a compounded drug cannot contain a drug found to be ineffective or unsafe or essentially be a copy of another drug; the compounded drugs must not be considered by the FDA to be difficult to compound (and therefore result in safety or efficacy problems); the drugs cannot be wholesaled by the compounder; the facility must be up-to-date with all fees; the compounding must occur in a state that has a memorandum of understanding on file with the FDA regarding the compounding program and limitations on outsourcing facilities; and all drugs must be labeled with specific information to identify the facility so that the FDA, a patient or health care provider can contact the facility if some adverse event takes place.

Outsourcing facilities will now also be subject to Current Good Manufacturing Practices requirements, standards that have applied in the past to drug manufacturers. The FDA released several sets of guidance documents in July of 2014 that explain how the agency will view implementation of these standards.

Final rules implementing the DQSA/CQA have yet to be adopted and enforced, but traditional compounders and potential outsourcing facilities alike should begin to take steps toward compliance in anticipation of the new regulatory regime. The attorneys of McBrayer can help bring you into compliance ahead of time.

Molly Lewis Molly Nicol Lewis is an Associate of McBrayer, McGinnis, Leslie & Kirkland, PLLC.  Ms. Lewis concentrates her practice in healthcare law and is located in the firm’s Lexington office. She can be reached at mlewis@mmlk.com or at (859) 231-8780. 

This article is intended as a summary of federal and state law and does not constitute legal advice.

Plan for the Worst, Hope for the Best: Why You Must Have a HIPAA Risk Assessment

“The single biggest and most common compliance weakness is the lack of a timely and thorough risk analysis.”

-Leon Rodriguez, former head of the U.S. Health and Human Services Office for Civil Rights

When the Office for Civil Rights (“OCR”) auditor drops by your health facility to ensure that you are complying with HIPAA, one thing is for certain: he will be asking to see your Risk Assessment. Do you have one? Is it completed? Has it been used to develop and implement appropriate policies and procedures?

Audit Risks Are Real

The OCR is cracking down on covered entities’ and business associates’ compliance with HIPAA. Audits are becoming commonplace and resulting in more and more providers being hit with fines and sanctions. You may think that even if you are subject to an audit, then penalty will be a slap on the wrist. Think again. The maximum penalty for a HIPAA violation is now $1.5 million. Maybe you are too small of a provider to be the target of an audit? Think again, again. In January of 2013, Hospice of North Idaho agreed to pay the Department of Health and Human Services (“HHS”) $50,000 to settle potential HIPAA violations stemming from a 2010 incident involving a stolen, unencrypted laptop. It was the first HIPAA breach settlement involving less than 500 people. The hospice did not have a risk assessment in place.

Risk Assessments Are Not Optional

A HIPAA risk assessment is a thorough investigation and analysis of areas where there is potential risk of violating HIPAA laws. A risk assessment is not optional and it is not just a checklist. Covered entities, and now business associates, are required to have an assessment done. Specifically, entities must:

Conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information held by the covered entity.

These assessments are critical to compliance with the HIPAA Security Rule. An assessment should include questions addressing administrative, physical, and technical safeguards, and the Breach Notification Rule. Many assessments are created in the form of a table and not only analyze the level of the risk, but also whether there is a policy in place and who should be responsible for ensuring each provision is implemented.

Risk Assessments Are Just the First Step

Once your facility’s risk assessment is complete, then it and any relevant accompanying documents should be kept in your HIPAA security files. Assessing risks is only a first step. You must use the results of your risk assessment to develop and implement appropriate policies and procedures. The use of a privacy officer is highly recommended. Consider offering training to employees where a sign-in sheet is required and certifications are provided once training is complete. This kind of documentation will be very beneficial when the OCR auditor is at your door.

If you are a provider and would like help creating and implementing a HIPAA risk assessment, contact the health care attorneys at McBrayer, McGinnis, Leslie & Kirkland, PLLC. We are available to provide privacy and security training, along with a risk assessment tool which can be catered to individual providers. It is not a question of if there is a breach at your facility, but rather when. Let us help you be prepared.

Molly LewisMolly Nicol Lewis is an Associate of McBrayer, McGinnis, Leslie & Kirkland, PLLC.  Ms. Lewis concentrates her practice in healthcare law and is located in the firm’s Lexington office. She can be reached at mlewis@mmlk.com or at (859) 231-8780. 

This article is intended as a summary of state law and does not constitute legal advice.

Structuring Healthcare Provider Agreements for Compliance

On June 23rd, the Healthcare Law Blog discussed the Fraud Alert recently issued by the Office of Inspector General of the United States Department of Health and Human Services regarding physician compensation arrangements which telegraphed the Office of Inspector General’s intention to increase scrutiny of financial arrangements between physicians and providers to whom physicians make referrals. In today’s post, we examine the steps physicians and other healthcare providers should take to ensure that any financial relationships are in compliance with federal statutes and regulations.

The first fundamental task to determine if an arrangement is compliant with applicable laws is to review the written agreement between the parties to determine if its terms are in keeping with regulatory requirements. The following questions should be asked:

  1. What are the services to be performed under the agreement?
  1. Are the services to be performed needed and is the arrangement commercially reasonable?
  1. Is the compensation for the services consistent with fair market value and how was fair market value determined?
  1. Does the compensation take into account, in any manner, the volume or value of referrals made by the physician?
  1. Is the physician carefully documenting the services that are being performed by keeping time sheets or similar documentation and submitting that documentation to the healthcare entity in a timely manner to justify the compensation being paid?

While the Anti-Kickback Statute prohibits many types of arrangements that result in prohibited referrals, Congress created statutory exceptions to the Anti-Kickback Statute prohibition. The statute does not apply to certain payment practices as specified by the Secretary of the United States Department of Health and Human Services. Pursuant to this Congressional authorization, the Secretary of Health and Human Services issued Safe Harbor Regulations to set forth certain legitimate arrangements which are categorically protected from prosecution or the imposition of sanctions under the Anti-Kickback Statute if all the elements of a Safe Harbor are satisfied.

Business - meeting in an office; lawyers or attorneys (only handThe Safe Harbor that is best suited to medical directorship arrangements between a physician and another healthcare provider is the Safe Harbor for personal services and management contracts. This Safe Harbor exempts from the definition of “remuneration” under the Anti-Kickback Statute any payment made as compensation between a principal and an agent for the services of the agent if all the elements of the Safe Harbor are met. The Safe Harbor for personal services and management contracts is set forth by regulation at 42 C.F.R. § 1001.952(d). Physicians and other healthcare providers should examine any medical directorship or similar arrangements in light of this particular Safe Harbor regulation to determine if its requirements are satisfied.

The Stark Statute prohibits referrals to and the filing of claims for “designated health services” where Medicare is the payment source if the referring physician has a direct or indirect financial relationship with the entity providing the designated health service. However, the Stark Statute and implementing regulations set forth exceptions to the general prohibition against referrals where a financial relationship exists between the parties.

The Stark exception that is best suited to medical directorship arrangements between a physician and another healthcare provider is the regulatory exception for personal services arrangements between a physician and an entity in which the physician is to provide specified services to the entity. The regulatory exception for personal services arrangements is set forth by regulation at 42 C.F.R. § 411.357(d). Physicians and other healthcare providers should examine any medical directorship or similar arrangements in light of this regulation and ensure that all of the required elements of the exception are satisfied and properly documented.

With the Office of Inspector General intending to focus its enforcement scrutiny on physician compensation arrangements, physicians and other healthcare providers would be well-advised to conduct their own self-examination of any and all existing arrangements through their compliance program or through their counsel in order to be prepared for any investigation by the Office of Inspector General and to demonstrate the legality of the arrangements.

Chris ShaughnessyChristopher J. Shaughnessy is an attorney at McBrayer, McGinnis, Leslie & Kirkland, PLLC.  Mr. Shaughnessy concentrates his practice area in health care law and is located in the firm’s Lexington office.  He can be reached at cshaughnessy@mmlk.com or at (859) 231-8780. 

This article is intended as a summary of federal and state law activities and does not constitute legal advice.

ALERT – Supreme Court Upholds Affordable Care Act Insurance Subsidies

In a 6-3 decision on Thursday, June 25th, the United States Supreme Court upheld the legality of the government healthcare insurance subsidies provided under the Patient Protection and Affordable Care Act (“ACA”) in the case of King v. Burwell. At issue was language in the ACA that granted subsidies to taxpayers enrolled in an insurance plan through “an Exchange established by the State.” 26 U.S.C. §§36B(b)(2)(A).

The opinion, written by Chief Justice John Roberts, interpreted the ACA’s language to include the Federal Exchange as an equivalent to a state-run exchange. The opinion suggested that the language required the context of the surrounding provisions to make sense in the law, and that the ACA provides many other examples of what the court referred to as “inartful drafting.”

Justice Scalia penned a blistering dissent, joined by Justice Thomas and Justice Alito, suggesting that the majority imbued meaning not present into the phrase to achieve the result in the opinion.

The decision preserves subsidies for lower-income individuals required, under the ACA, to purchase health insurance, regardless of whether that insurance is purchased through a state or federal exchange. This case was the second major challenge to the ACA with a potential to force significant changes to the law; the Supreme Court upheld the major tenets of the law in both cases.

The provisions of the ACA are now likely to remain in place, and healthcare providers will likely continue to experience the effects of the law. The attorneys of McBrayer can assist healthcare providers complying with the regulatory features of the ACA and other healthcare laws as well as counsel them on how to best capitalize on the incentives and programs offered through the law.