Anthem, Hartford HealthCare Fail To Reach Agreement

As the midnight deadline passed, Anthem Blue Cross and Blue Shield and Hartford HealthCare failed to reach an agreement on contract terms. Starting today, Anthem and Hartford will face higher, out-of-network rates for services at Hartford HealthCare hospitals, and will be forced to seek medical attention elsewhere. Anthem spokespeople have said the main sticking point was payment increases in the first year of the new contract, saying Hartford wants a 100 percent guaranteed increase. Anthem, on the other hand, wants a combination of guaranteed increases and dollars paid based on the network’s performance. If negotiations fail for another month, more facilities, including Natchaug Hospital, Rushford Center mental health and addiction services, VNA Healthcare, Southington Care Center rehabilitation clinic and Jerome Home will all be out of network. Hartford HealthCare has already sent letters to 104,500 people who have Anthem coverage and have been patients in the past 12 months, warning them they would be out of network if no agreement is reached. Some hospital procedures, such as emergency care, will still be charged at in-network rates.

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Breaking News: Appeals Court Strikes Down ACA Insurance Subsidies For Federal Exchange

A federal appeals court has ruled that the Obama administration cannot subsidize insurance premiums for 7 million Americans. Today, two judges with the D.C. Circuit Court of Appeals ruled that the text of the reform law “forbids income-tax subsidies to go to low-and middle-income Americans who use one of the 34 federally run insurance exchanges.” Officials from the D.C. Court of Appeals argue that the actual text of the law says that the sliding-scale tax credits are only available for coverage purchased “through an exchange established by the state” which only 16 states have done.

“Because we conclude that the ACA unambiguously restricts the section 36B subsidy to insurance purchased on Exchanges’ established by the State, we reverse the district court and vacate the IRS’s regulation,” the judges added.

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CMS Backs Down On Hospice Drug Restrictions

CMS issued a new memorandum moderating their regulation on “Part D Payment for Drugs for Beneficiaries Enrolled in Hospice.” The new directive limits prior authorization by hospices to four classes of drugs: analgesics, anti-nauseants, laxatives and anti-anxiety drugs. In March, CMS announced that it would require prior approval for all hospice drugs under Medicare Part D prescription drug benefit. The recent change was made after a June meeting between officials and stakeholders including hospice providers, insurers and pharmacies and patient advocates “who described the operational challenges of requiring all hospice drugs to be approved before they could be dispensed.”

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Medicare Contractor’s OASIS Audit On Hold Until Further Notice

In correspondence with the National Association for Home Care and Hospice, CMS has indicated that it has directed its contractor, Strategic Health Solutions (SHS), to stop its audit of timely submission of valid OASIS documentation. SHS will begin issuing cancellations of its ADR requests. For more information, click here.

Supreme Court Says Employers Can Deny Contraceptive Coverage

The Supreme Court issued a major ruling this morning. In a 5-4 decision, the justices ruled that the government cannot force private companies to provide the broad insurance coverage for contraceptives called for by the ACA. The ruling favors companies like Hobby Lobby, which have religious objections to covering birth control methods like the morning-after pill and intrauterine devices.

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Breaking News: NAHC Gains Reversal of MA F2F Encounter Policy

Today, CMS informed the National Association for Home Care & Hospice (NAHC) that it’s reversing its position requiring MA plans to apply Medicare Fee-for-Service face-to-face certification requirements to home health services. Previously, CMS, in its final call letter for 2015 rates for Medicare Advantage (MA) plans, determined that the MA plans would apply the same certification requirements as fee-for-service (FFS) Medicare to plan members who receive home health services. This rule would also require that the plans apply the face-to-face requirement-NAHC had some serious concerns with this directive and spoke to CMS officials about them. NAHC questioned the reasoning behind the requirement, since MA plans have a preauthorization process already in place that would negate the need to follow Medicare FFS certification requirements. In addition, NAHC expressed its interpretation of the regulation to require that the MA plans offer the same scope of benefits to their members as Medicare but need not apply the same certification criteria as Medicare. To see a recent NAHC report article on MA plans, click here.

CMS has shared the following memorandum that it issued to the MA plans on June 11, 2014:

This memorandum is to correct the Final Call Letter of April 7, 2014 regarding Medicare Advantage organization’s (MAO’s) certification of enrollees for home health services. We are clarifying that an MAO’s authorization for home health services may substitute for the Original Medicare face-to-face certification requirement for the authorization of home health care services.

In certain circumstances, MAOs are not required to follow Original Medicare documentation requirements for the provision of Medicare covered services, but may substitute methods they deem appropriate for ensuring that the services provided are medically necessary, so long as they are not more restrictive than the coverage standards that apply in Original Medicare.

Proposed Rule Provides EHR Certification Flexibility

CMS and the Office of the National Coordinator for Health Information Technology are issuing a proposed rule that would allow providers to use the 2011 edition of certification criteria in 2014. The new rule, released on May 20, will be published in the Federal Register on May 23 and will allow providers to use the 2011 edition of certified electronic health record technology for Stage 1 or Stage 2 in 2014. Additionally, providers will have the option to attest to the 2013 definition of Meaningful Use core and menu items and use the 2013 definition of clinical quality measures.

Providers will need to use the 2014 edition of certification criteria in 2015. The proposed rule “formalizes the agencies’ intention to extend Stage 2 to 2016 and to begin Stage 3 in 2017.”

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