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.

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DOL Proposes Changes To Overtime Exemption For Salaried Workers

On May 5, 2015, the U.S. Department of Labor submitted a proposed rule for review by the Office of Management and Budget (OMB) to modify the standards of the application of overtime exemptions for professional and executive personnel who are paid on a salary basis. Although the details of the rule are not yet available, it is expected that the rule change will raise the minimum salary level required for an application of the exemptions and tighten the standards for determining whether an employee is a “professional” or an “executive.”

Currently, the minimum salary necessary to qualify for exemptions is $455 per week. In March of last year, President Obama stated that he wanted the standards to be updated an ordered the Department of Labor to begin revising the rules.

Although there are many speculations on the content of the proposed rule, many observers expect the minimum salary level for qualification for the exemptions will likely double. The proposed rule is expected to be released by OMB in a matter of weeks.

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OSHA Revises Guidelines For Preventing Workplace Violence

The Department of Labor, Occupation Safety and Health Administration (OSHA) has issued a revised version of their Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers. It has been updated from OSHA’s 1996 and 2004 voluntary guidelines.

The new guidelines state that healthcare and social service workers face a significant risk of job-related violence. The Bureau of Labor Statistics (BLS) show that 27 out of 100 fatalities in healthcare and social service settings that occurred in 2013 were due to assaults and violent acts. Between 2011 and 2013, workplace assaults ranged from 23,540 and 25,630 annually, with 70 to 74% occurring in healthcare and social service settings.

The new guidelines are based on industry best practices and feedback from stakeholders, and provide recommendations for developing policies and procedures to eliminate or reduce workplace violence in a range of settings.

Click here to see OSHA’s revised guidelines.

Click here for more info on preventing workplace violence.

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NAHC Develops “IN FOCUS” Series To Provide In-Depth Coverage Of FY 2016 Hospice Payment Rule

The National Association for Home Care & Hospice (NAHC) published an initial overview of the proposed FY 2016 Hospice Payment Rule in NAHC Report on May 1, 2015. However, in order to provide more in-depth coverage, NAHC is developing a series of “IN FOCUS” articles that will be published over the next few weeks. Part 1 of the series has been published. Click here to see it. Part 1 focuses on hospice diagnosis reporting and CMS’ expectations of hospice responsibilities in this regard.

GAO: Small Percentage Of Medicaid Enrollees Cost The Most

According to newly released findings from the Government Accountability Office (GAO), only 5% of Medicaid-only eligible enrollees accounted for nearly 50% of the billions of government dollars paid in Medicaid-only eligible claims between 2009 and 2011. Unlike the high-cost 5% group, the least expensive 50% of Medicaid-only enrollees accounted for less than 8% of the expenditures for those enrollees. For fiscal year 2013, Medicaid expenditures totaled about $460 billion, covering 72 million enrollees -some of whom were eligible for Medicare, too. The GAO suggests CMS improve efforts to manage expenditures and facilitate improvements to care by identifying additional information about Medicaid-only eligible enrollees responsible for a high proportion of expenditures.

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CMS Posts Hospice HIS Updates & Announces Training For June 17

CMS has scheduled training on the Hospice Item Set (HIS) for Wednesday, June 17 from 1:30pm to 3:00 p.m. EST,

The training will cover updates that were made to the HIS Manual from V1.01 to V.02. Updates to the HIS Manual, and the related HIS training, will provide clarifications of HIS item definitions and expectations for use.

Providers cannot register for the MLN Connects National Provider Call yet. However, instructions for registration will be posted on the MLN National Provider Calls and Events webpage, and on the CMS HQRP HIS website.

Additionally,  CMS posted the HIS Q + A document for the first quarter of 2015. Click here for additional information.

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Tiptastic Tuesday: 4 Essential Steps For Healthcare Compliance

According to new guidance from the U.S. Department of Health and Human Services’ Office of Inspector General (OIG), healthcare providers must focus on four major principles in order to create effective compliance programs.

The increase in fraud crackdowns means compliance is more important than ever. OIG collaborated with industry leaders to develop the four following guidelines:

  1. Define your audit, compliance and legal departments’ jobs and relationships with one another. Make sure each department understands its role in the compliance process.
  2. Assess your organization’s protocols for gathering information and reporting issues. Make sure each compliance-related sector reports on its compliance and risk-management efforts and measures its implementation of compliance programs.
  3. Identify and audit potential risk areas. Make sure to establish clear processes for risk identification.
  4. Encourage compliance throughout the enterprise. The OIG recommends regular performance assessments to help facilitate this process.

Click here to see the guidance.

Click here to read more.