April 2016

April 2016

Final Rule: Medicaid and Mental Health Parity

On March 30, 2016, the Centers for Medicare and Medicaid Services (CMSpublished a final rule applying the Mental Health Parity and Addiction Equity Act (MHPAEA) to Medicaid and the Children’s Health Insurance Program (CHIP), strengthening access to mental health (MH) and substance use disorder (SUD) services for Medicaid and CHIP beneficiaries. In an effort to align with regulations for the commercial market, under this final rule, CMS applies certain MH/SUD parity provisions of MHPAEA to the coverage provided to the enrollees of Medicaid managed care organizations (MCOs), Medicaid alternative benefit plans (ABPs) and CHIP to ensure that financial requirements (such as copays and coinsurance) and treatment limitations (such as visit limits) on mental health and substance use disorder benefits generally are no more restrictive than the requirements and limitations that apply to medical and surgical benefits in these programs. Health plans must disclose information on MH/SUD benefits upon request, including the criteria for determinations of medical necessity.  

This final regulation requires the state to determine whether the overall delivery system complies with the provisions of this final rule, including when some MH/SUD services are not included in the MCO benefit package. States have up to 18 months after the date of the publication of the final rule to comply with the finalized provisions. Additional information can be found at https://www.medicaid.gov/medicaid-chip-program-information/by-topics/benefits/mental-health-services.html. 

Publication of State Operations Manual changes to CAH checklist
On March 25, 2016, CMS published revisions to the Critical Access Hospital Recertification Checklist as Transmittal 153. The checklist is one of the exhibits in the State Operations Manual used for re-evaluating the compliance of currently certified critical access hospitals (CAHs) with the status and location requirements at 42 CFR 485.610. This transmittal implements the changes that were announced in the February 12 memorandum to State Survey Agencies. Publication of Transmittal 153 makes no new changes to the CAH survey polices; it merely adds the February 12 changes to the Manual.

Announcement of Calendar Year (CY) 2017 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter
On April 4, 2016, CMS released final updates to the Medicare Advantage and Part D programs through the 2017 Rate Announcement and Call Letter. This final letter presents the annual Medicare Advantage (MA) capitation rate for each MA payment area for CY 2017, the factors used in adjusting those rates, and the final Part D benefit parameters. The final estimate of the National Per Capita MA Growth Percentage for combined aged and disabled beneficiaries is 3.08 percent, and the final estimate of the FFS Growth Percentage is 3.12 percent. County-specific monthly MA capitation rates are posted on the CMS website.  

Key updates to the MA rates include incorporating encounter data in calculating risk scores, calculating risk scores based on dual-eligibility status, and enhancing the methodology and measures used for Star Ratings. For Part D, updates include expecting Part D sponsors to implement formulary-level cumulative opioid point-of-sale edits to prevent opioid overutilization, monitoring opioid and acetaminophen overuse through a new Patient Safety measure and clarifying that MA plans have the same obligation to cover substance use disorder treatment as is available under Original Medicare and that Part D plans must ensure access to medication-assisted treatments that are covered under Medicare Part D.

Request for Information (RFI) on Concepts for Regional Multi-Payer Prospective Budgets
On April 14, 2106, the CMS Innovation Center published a new Request for Information (RFI) seeking input on the concept of developing regional multi-payer payment models. This RFI provides an opportunity to think more creatively about how to focus on population health in a way that provides meaningful participation by rural providers. Rural hospital and clinic experts are encouraged to offer their perspectives on how a global budgeting approach could be developed that would offer a pathway for key rural safety net providers like CAHs and low-volume rural hospitals to focus on improving health in their communities through more creative and flexible financing.  

In this RFI, CMS is explicitly asking for input from rural providers and experts on how one might build a global budgeting system that takes into account the historical financial protections for CAHs and other special designations for rural hospitals like Sole Community Hospitals or Medicare Dependent Hospitals and special billing provisions for Swing Beds and Method II billing for CAH physicians. It will also be important to hear ideas from Rural Health Clinics and rural Community Health Centers as well as post-acute care providers.  

This is an opportunity to think beyond cost-based reimbursement or the traditional fee-for-service arrangements that have offered some protections to ensure access in rural areas, but which also create significant challenges in allowing rural providers to truly shape their delivery system to meet local need and improve the health of their service area. 

In additional, rural providers should offer their thoughts to CMS on what sort of incentives could be created to encourage regional partnerships of providers and public and private payers that would ensure meaningful rural participation.  

Comments on the RFI should be submitted electronically to regionalbudgetconcept@cms.hhs.gov by Friday, May 13, 2016. Additional details on the regional budget payment concept will be posted at https://innovation.cms.gov/initiatives/regional-budget-payment/ as they become available. For more information, please contact regionalbudgetconcept@cms.hhs.gov