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 Delays Repayment Final Rule

CMS is officially postponing implementation of a new rule on collecting hundreds of millions of dollars in overpayments until February 16, 2016. The proposed rule would require Medicare providers and suppliers of services under Part A and B of title XVIII to return overpayments within 60 days – a move CMS says is required by the ACA. In Tuesday’s Federal Register notice, CMS stated the one year delay was due to “exceptional circumstances” regarding the “complexity of the rule and scope of comments.” The new rule will give CMS a 10-year “look-back period” on claims not identified by a provider or supplier. The new feature has led to harsh industry criticism that the agency is overstepping its statutory authority because it conflicts with the shorter look-back period for Part C and D overpayments.

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Attention Hospices: CMS Releases Proposed Rule

CMS has issues a proposed rule (CMS-3302-P) to revise Conditions of Participation (CoPs) for providers, Conditions for Coverage (CfCs) for suppliers, and requirements for long term care facilities. The proposed rule is to ensure that certain requirements are consistent with the Supreme Court decision in United States v. Windsor, 570 U.S. 12, 133 S. Ct. 2675 (2013), and U.S. Health and Human Services policy. This Supreme Court decision is related to the Defense of Marriage Act.

The new rule addresses certain regulations governing Medicare and Medicaid participating providers and suppliers “where current regulations look to state law in a matter that implicates – or may implicate – a marital relationship.” CMS hopes to “provide equal treatment to spouses, regardless of sex, whenever the marriage was valid in the jurisdiction in which it was entered into, without regard to whether the marriage is also recognized in the state of residence or the jurisdiction in which the health care provider or supplier is located, and where the Medicare program explicitly or impliedly provides for specific treatment of spouses.”

CMS is accepting comments on the proposal until February 10, 2015.

Click here to see the proposed rule.

Click here to see the Fact Sheet.

Click here to read more from NAHC.

Basic Health Program Funding Methodology Proposed Notice

CMS has issued a proposed notice establishing the methodology for determining federal funding for the Basic Health Program in program year 2016. The Basic Health Program gives states the option to establish a health benefits coverage program for lower-income individuals as an alternative to Health Insurance Marketplace coverage under the ACA. This voluntary program enables states to create health benefits program for residents with incomes that are too high to qualify for Medicaid through Medicaid expansion in the ACA.

CMS proposes to use the same payment methodology for program year 2016 as it established for 2015, with updated values for several factors. The proposed notice will be posted in the Federal Register tomorrow.

Click here to see the proposed notice.


CMS Proposes Policy And Payment Changes For 2014

The Centers for Medicare & Medicaid Services (CMS) proposed rule [CMS-1601-P] would update Medicare payment policies and rates for hospital outpatient department and ASC services.  The rule would also update and streamline programs that encourage high-quality care in outpatient settings consistent with policies included in the Affordable Care Act.  Some of the guidelines of the rule are:

  • CMS proposes to update the OPPS market basket by 1.8 percent for CY 2014.
  • For 2014, CMS proposes to package seven new categories of supporting items and services. For many of these services, the OPPS will continue to make a separate payment if they are reported alone on a claim.
  • CMS proposes to update the two payment rates for community mental health centers and the two payment rates for hospital-based PHPs.
  • CMS is proposing five new measures for the OQR program, affecting payment in CY 2016, with data collection beginning in CY 2014 while also proposing to remove two measures: (OP-19)/(OP-24)

The proposed payment system would reduce unnecessary procedures and remove opportunities for up-coding.

Click here to read more

CMS Proposes 2% Increase For Rehab Facilities

A rule proposed by the Centers for Medicare & Medicaid Services (CMS) could increase the Medicare inpatient rehabilitation facility payment rates by up to 2% in FY 2014. The proposed increase is based on a marketbasket update and requirements of the Patient Protection and Affordable Care Act (PPACA).

Click here to read more.

Insurers Will Pay To Participate In Health Exchanges

State health insurance exchanges are expected to cost millions of dollars to operate.  As a result, the U.S. Department of Health & Human Services (HHS) has decided to pass a portion of those administrative costs onto insurers.

Any insurer interested in selling in the federally-run exchange program will be charged a monthly “user fee” according to a new proposed rule by HHS. Under the plan, insurers would pay 3.5% of the total premiums received through plans they sell on the federal exchange starting in 2014.

Click here to read more.