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CMS has released a proposed rule that updates its Medicaid managed care organization (MCO) regulations. The last time CMS updated MCO rules was in 2002.
In the rule, CMS calls for health plans to dedicate a minimum portion of the rates they receive toward medical services – a threshold known as a medical loss ration (MLR). Plans doing business with Medicaid and the Children’s Insurance Program are the only health plans that aren’t subjected to the MLR. The Obama administration is now proposing an 85% threshold for Medicaid managed-care plans.
Experts say the MLR that CMS has proposed for Medicaid plans is a suggestion and not an enforceable mandate. However, many plans will still be affected if states follow through on the agency’s suggestion. Over the past four years, Medicaid managed-care enrollment has increased by 48% to 46 million beneficiaries.
The rule would impose new standards to ensure beneficiaries have adequate provider networks. The new rule would require plans extend time and distance standards for specialists, such as OB/GYNs, behavorial health specialist and dentists. The rule also includes a provision that would require greater transparency in how states determine whether the rates they pay are sufficient to cover the services required under the contract.
Furthermore, the rule includes a section on managed Medicaid long-term care. In the rule, CMS would allow participants enrolled in Medicaid Long-Term Services and Supports (MLTSS), to switch plans or disenroll and switch to fee-for-service if their provider is not in-network for the managed care plan.
Click here to see the proposed rule.
Click here to the CMS press release.
Click here to read more.
According to a new report by the United Health Foundation on the state of seniors’ health, preventable hospitalizations have dropped. The third edition of its annual America’s Health Rankings Senior Report show “encouraging news for senior health nationally,” but also indicates the setbacks seniors have faced compared to previous years.
Among the major gains is a 6.8 percent reduction in preventable hospitalizations, a measure that’s also dropped 11 percent since 2013. Reasons for the reduced hospital admissions and readmissions include the push for better population health management and the shift from fee-for-service model to value-based payments.
The report also found a 9.3 percent increase in the number of home health workers year over year, and a 38 percent increase in seniors who choose hospice care at the end of their lives. These findings are supported by a recent report that indicated nursing homes may replace hospitals as the major providers of senior care – a trend that is fueled by the increased interest in palliative care.
Click here to see the report.
Click here to read more.
CMS is hosting a Special Open Door Forum (SODF) call on Tuesday, June 2, 2015 from 1:30 p.m. to 2:30 p.m. EST to provide home health agencies (HHAs) and other interested parties with additional information on the new “Pay-for-Reporting Performance Requirement” described in the CY 2015 Home Health Final Rule. The first 12-month reporting period for the new Quality Assessments (QAO) measure begins on July 1, 2015. HHA compliance will potentially affect the Annual Payment Update (APU) for CY 2017.
The session follows up on information presented during the Open Door Forum on November 12, 2014 and will include a review of the content and format of the new QAO Historical Performance Reports that will distributed to HHAs for information purposes only by the end of June.
Click here for a link to materials for this SODF, including a slide deck, a summary of the QAO methodology, and a sample QAO Historical Report.
A transcript and audio recording of this SODF will be posted here.
Click here to read more from CMS.
CMS held its third Special Open Door Forum call for the voluntary electronic clinical template for the home health face-to-face (F2F) encounter on May 20. CMS officials presented the latest version of the electronic and paper templates. The paper version is two pages and consists mostly of questions requiring a narrative response; the electronic version is a combination of questions that require a narrative response and checkboxes. Included in these revised versions is a “Progress Note Guidance” page that describes the purpose of the template and the criteria for the home health certification, including the F2F encounter.
During the forum, presenters reminded participants that the templates are not mandatory but can serve as a physician progress note and/or guide for documenting the F2F encounter for patients who are referred to home health care. CMS also informed participants that the Office of Management and Budget must approve the templates before they can be released. CMS estimates that it will take approximately six months.
The majority of the call was dedicated to a question and answer period related to process issues when a physician’s co-signature would be required on the F2F encounter document. CMS did not provide a definitive answer to these questions because it is currently reviewing its policies on co-signatures on the F2F encounter document. However, CMS was clear the progress note must be completed by the physician or the allowed non-physician practitioner.
Click here to view the revised electronic and paper F2F encounter templates.
Click here to read more.
The Hospice Quality Reporting Program National Provider Call scheduled by CMS is on June 17, 2015, from 1:30 p.m. to 3:00 p.m. EST.
During this call, CMS will discuss the new Hospice Item Set (HIS) Manual (V1.02), with a focus on updates that were made to the HIS Manual from V1.01 to V1.02 and provide clarifications of HIS definitions and expectations for use. Providers should review V1.02, which will be available on the HIS website prior to the call.
Click here to register.
Event: Hospice Quality and Hospice Item Set Manual V1.02
Topic: Hospice Quality Reporting Program
When: Wednesday, June 17, 2015
Time: 1:30 PM – 3:00 PM Eastern Time
Click here for more info.