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<br />American Rescue Plan Act of 2021. Effective March 11, 2021, the American Rescue Plan Act of 2021
<br />became law and provides $1.9 trillion in economic stimulus measures, including extended leave, additional
<br />unemployment benefits, and additional funding for vaccines and other public health programs. However, the impact
<br />of this legislation on the operations and revenues of the Corporation remains unknown.
<br />Continued Medicare Sequestration Moratorium. As of March 25, 2021, both the House and Senate have
<br />passed versions of a bill that would extend the moratorium on Medicare sequestration cuts through 2021 in order to
<br />help providers struggling financially during the COVID-19 pandemic. The bill is scheduled to be finalized in April,
<br />and CMS plans to hold Medicare claims until the bill is signed into law as CMS has done in the past. The bill calls for
<br />an increase in 2030 sequester cuts in order to pay for the current moratorium.
<br />Regulatory Waivers and other Regulatory Changes. COVID-19 has led to legislative and regulatory changes
<br />specifically impacting the healthcare industry. In March and April of 2020, CMS published final rules related to
<br />“blanket” Section 1135 waivers for long-term care facilities and skilled nursing facilities. The waivers include waiver
<br />of the 3-day prior hospitalization requirement, the timeframe requirements for minimum data set assessments and
<br />transmission, requirements for submitting staffing data through the payroll based journal system, and the pre-
<br />admission screening and annual resident review, among others. Further, in September of 2020, CMS issued an
<br />additional interim final rule adding new reporting requirements for healthcare facilities, along with expanded CMS
<br />enforcement authority, to ensure compliance with such reporting requirements, in order to assist public health officials
<br />in detecting and tracking COVID-19 outbreaks. The rule also modified various aspects of Medicare reimbursement
<br />methodologies for health plans, physicians, and other providers. In November of 2020, CMS issued a final rule relating
<br />to COVID-19 vaccine administration, state innovation waivers during the public health emergency, enhanced
<br />payments for COVID-19 treatments, and price transparency for COVID-19 diagnostic tests. When the public health
<br />emergency is over and the waivers are no longer in effect, the Corporation will need to unwind any arrangements and
<br />operations that it has undertaken in reliance on these waivers. This may result in significant compliance costs and
<br />increased liability risks for the Corporation. It is too soon to tell how these and other waivers and rule changes in
<br />response to the pandemic will affect the operations and revenues of the Corporation, and it is impossible to predict
<br />their short term and long term effects on the Corporation.
<br />Healthcare Reform
<br />The Patient Protection and Affordable Care Act, as was subsequently amended by the Health Care and
<br />Education Reconciliation Act of 2010 (collectively referred to as the “ACA”) was enacted in March 2010. The ACA
<br />addresses almost all aspects of healthcare provider operations and health care delivery, and has changed and is
<br />changing how health care services are covered, delivered and reimbursed. As a result of the ACA, substantial changes
<br />have occurred and are anticipated to continue to occur in the United States health care system. The ACA has and is
<br />impacting the delivery of health care services, the financing of health care costs, reimbursement of health care
<br />providers and the legal obligations of health insurers, providers, employers and consumers. The enactment of the ACA
<br />represents a significant reform of federal health care legislation. Additionally, Congress continues to consider the
<br />adoption of additional laws to modify several aspects of such legislation.
<br />The future of the ACA is uncertain. Former President Trump and certain Congressional leaders, prior to the
<br />election of President Biden and Democratic control of the Senate, previously included a repeal of all or a portion of
<br />the ACA in their respective legislative agendas. While no full repeal bills passed both chambers of Congress, the Tax
<br />Cuts and Jobs Act eliminated the tax penalty associated with a key provision of the ACA known as the “individual
<br />mandate” in 2019. It is not possible to predict the effect of the elimination of the individual mandate penalty. It is also
<br />not possible to predict whether the ACA will be further modified in any significant respect or wholly repealed. Any
<br />legal, legislative or executive action that reduces federal health care program spending, increases the number of
<br />individuals without health insurance, reduces the number of people seeking health care, or otherwise significantly
<br />alters the health care delivery system or insurance markets could have a material adverse effect on the results and
<br />operations of the Project.
<br />Following the elimination of the individual mandate tax penalty in the Tax Cuts and Jobs Act, twenty states
<br />had filed a lawsuit against the U.S. government claiming that, under the U.S. Supreme Court’s decision upholding the
<br />ACA, that law is now unconstitutional without the individual mandate tax penalty. On December 14, 2018, the District
<br />Court for the Northern District of Texas issued a declaratory judgment holding the ACA to be unconstitutional without
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