CMS outlines steps toward VBP for nursing facilities

On April 25, 2016, the Centers for Medicare and Medicaid Services (CMS) published proposed rules in the Federal Register on Medicare reimbursement for skilled nursing facilities. The proposed rules address inflation and productivity adjustments for these facilities under the current Medicare prospective payment system (PPS), quality of care reporting requirements, and a step-by-step transition to a new, value-based purchasing (VBP) system offering incentives to improve quality of care. For the fiscal year beginning October 1, 2016, aggregate Medicare payments to these facilities will increase $800 million as compared to the prior year, about 2.1 percent overall, based mainly on 2.6 percent inflation adjustments partially offset by -0.5 percent productivity adjustments. Nursing facilities that don’t meet CMS quality of care reporting requirements will subsequently face -2.0 percent offsets in annual PPS updates per the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT). [More]

CMS announces extension of SHOP direct enrollment transition

On April 18, 2016, CMS released guidance entitled “Extension of state-based SHOP Direct Enrollment Transition,” which extends the option of direct enrollment until the end of 2018 giving state based SHOPs more time to make online enrollment available. In order to allow facilitation of enrollment without SHOP portal functionality, CMS has allowed states to direct enroll employers and their employees, while also extending the small business tax credits to those eligible small employers offering coverage on a state-based SHOP utilizing direct enrollment. This most recent guidance includes three options for states regarding enrolling SHOP eligible employers in 2019. States should begin planning now, because significant time is needed to not only give CMS notice but also to implement the option of choice. [More]

Final Medicaid Managed Care Rules

CMS released a proposed overhaul of the regulations governing Medicaid and CHIP Managed Care last May and accepted comments through July. In addition to their sweeping impact, these rules are particularly meaningful as they are the first major changes to the rules governing Medicaid Managed Care since 2002. As states agencies and others review the final regulations, we are sharing a summary of the proposed regulations that we first released last summer. The proposed regulations seek to modernize the rules in light of the expanded use and scope of managed care in Medicaid programs across the country. [More]

U.S. Supreme Court hears oral argument on conduct giving rise to liability under the FCA

On April 19, 2016, the U.S. Supreme Court heard oral argument in an action that will test whether a theory that is described as “implied certification” is a valid one for determining liability under the False Claims Act (FCA). The “implied certification” theory refers to the extent to which violation of a regulation or contract provision is “material” for purposes of triggering liability under the FCA. [More]

HHS issues report on ACA premium increases

On April 12, 2016, the U.S. Department of Health and Human Services (HHS), Assistant Secretary for Planning and Evaluation (ASPE), issued a report entitled, “Marketplace Premiums after Shopping, Switching, and Premium Tax Credits, 2015-2016.” Data in the report show how price competition among health plans on Exchanges controls premiums for consumers who shop for coverage there, and how tax credits for low income consumers keep premiums affordable for them. [More]

CMS announces CPC+ primary care model

On April 11, 2016, the Centers for Medicare and Medicaid Services (CMS) announced the Comprehensive Primary Care Plus (CPC+) model. The CPC+ model, which builds on the CPC model launched in October 2012, is designed to align Medicare, state Medicaid agencies, and commercial insurance payers to achieve comprehensive, coordinated primary care, especially for patients with complex medical and behavioral health needs. [More]

NEJM examines Medicare physician reimbursement system

On April 7, 2016, the New England Journal of Medicine (NEJM) published an article entitled, “Finding Value in Unexpected Places – Fixing the Medicare Physician Fee Schedule.” The NEJM article notes that the Medicare physician fee schedule (MPFS) may: affect how physicians spend time with patients, drive unneeded tests and procedures, influence physicians’ specialty choices, and worsen shortages of much-needed primary care physicians and geriatricians. [More]

NAS issues report on improving health outcomes for at-risk populations

On April 7, 2016, the National Academies of Sciences, Engineering, and Medicine (NAS) issued a report entitled, “Systems Practices for the Care of Socially At-Risk Populations.” The report cites research and case studies showing that collaboration between health care delivery systems and community-based social service organizations can achieve improvements in health care outcomes for at-risk, low income populations afflicted by social isolation and limited health literacy. [More]

ESSA regulations are underway

According to a March 31, 2016, POLITICO Pro posting, the U. S. Department of Education (USDE) plans to introduce regulations very soon on accountability under the Every Student Succeeds Act (ESSA). The regulations will apply to state accountability and reporting systems. Up to seven states will be allowed to participate in a pilot program to experiment with innovative tests. [More]

CMS finalizes mental health parity rules

On March 30, 2016, the Centers for Medicare and Medicaid Services (CMS) published final rules on mental health/substance use disorder parity requirements applicable to Medicaid managed care organizations (MCOs), Medicaid alternative benefit plans (ABPs), and the Children’s Health Insurance Program (CHIP). The final Medicaid/CHIP rules are based on the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), which generally prohibits more restrictive cost-sharing (e.g., co-payments and deductibles), quantitative limitations (e.g., visit limits), and non-quantitative limitations in mental health/substance use disorder benefits under a health plan than in medical/surgical coverage under the same plan. [More]