CMS Releases Proposed Rule Intended To Modernize Medicaid Managed Care

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.

CMS Holding Special Open Door Forum For New “Pay-for-Reporting Performance Requirement”

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 Holds Third Special Open Door Forum On F2F Encounter Templates

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.

Attention Hospices: Registration For National Provider Call Now Open

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.

Additional information:

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.

MedPAC Calls For Cancellation Of Medicare Pay Raise For Nursing Homes

In a proposed rule published in the April 20 Federal Register, CMS said it is seeking a 1.4% net hike in the nursing home Medicare payment rate. The rate increase would reflect a market basket increase of 2.6% and two deductions, including a 0.6% cut for productivity adjustment and a 0.6% cut as a forecast error adjustment. However, in a letter to CMS, MedPAC has said that it believes no update is warranted because “Medicare’s current level of payments appears more than adequate to accommodate cost growth, even before any update.”

MedPAC argues that the aggregate Medicare margin for freestanding nursing homes in 2013 was 13.1%, the 14th consecutive year it exceeded 10%. However, the American Health Care Association is now shooting back at MedPAC’s decision, claiming MedPAC’s own research shows that nursing homes operate at an overall margin of only 1.9%.

MedPAC is now calling for CMS to move toward value-based purchasing and quality reporting programs. Additionally, MedPAC has recommended that Congress eliminate the market basket update, revise the prospective payment system, and rebase payments beginning with a 4% reduction to the base rate. Comments to CMS’ proposed rule are due on June 19.

Click here to read more.

CMS Reissues Hospice CR 9114

CMS has rescinded Change Request 9114 (originally issued April 3) and has posted a replacement CR 9114. Additionally, a related Medlearn Matters article has also been posted.

CMS’ action is in response to concerns that the original issuance on April 3 was inconsistent with statements issued as part of the final hospice payment rule for FY 2015 relating to requirements surrounding designation of the attending physician. The final rule that was published in August 2014 suggested that in clearly identifying the attending physician the election statement should include the physician’s name, address or NPI. The April 3 CR indicated that the physician’s name and NPI must be included on the election statement.

In the reissued CR 9114, CMS “has revereted to the language included in the final rule. Because the new attending physician requirements were effective October 1, 2014 and the new language is reflective of what was included in the final payment rule, the effective date of changes in the revised CR9114 is October 1, 2014.”

NAHC has included two excerpts from the new CR 9114 on the attending physician designation to represent language that will be incorporated in Chapter 9 of the Medicare Benefit Policy Manual.

Click here to read more from NAHC.

New Legislation Introduced To Refine Hospice F2F Requirements

New legislation (HR 2208, The Hospice Commitment to Accurate and Relevant Encounters ACT – Hospice CARE) has been introduced to address “key issues related to the requirement that hospice providers conduct a face-to-face encounter with patients entering their third or subsequent benefit period to gather information that helps support documentation for continuing eligibility for hospice care.” The legislation would make the following changes into law:

  • It would allow any of the following practitioners to conduct the hospice face-to-face encounter: hospice physician, nurse practitioner, clinical nurse specialist, or physician assistance, or other health professional as designated by HHS.
  • In cases of a new readmission to hospice care where exceptional circumstances exist, it would allow the face-to-face encounter occur no later than seven calendar days after the individual’s election of services.

Click here to read more.