May 2016

May 2016

Medicaid and Children’s Health Insurance Program (CHIP) Programs; Medicaid Managed Care, CHIP Delivered in Managed Care, and Revisions Related to Third Party Liability  

This final rule is the first major overhaul of Medicaid managed care in past 10 years, and it modernizes the Medicaid managed care regulations to reflect changes in the usage of managed care delivery systems.  This far-reaching rule encourages and provides guidance for stakeholder engagement as states develop and implement these provisions.  Some major provisions that rural stakeholders, state offices of rural health and other advocates will want to monitor within their state include:

Interim Final Rule with Comment Period:  Patient Protection and Affordable Care Act; Amendments to Special Enrollment Periods and the Consumer Operated and Oriented Plan Program

On May 11, 2016, the Centers for Medicare & Medicaid Services (CMS) published this interim rule with comment period that waives the typical proposed rule/comment period because CMS feels that delaying these rules could cause harm. The first provision of the rule would allow state insurance regulators to permit certain issuers in the State facing financial hardship to extend the timeline for paying risk adjustment charges to make payments over 4 years instead of one lump sum payment. CMS has become aware that certain issuers with lower capital levels may have difficulty paying full risk adjustment charges immediately. The second provision amends the definitions of eligible board members for CO-OPs to allow inclusion of external, knowledgeable individuals while maintaining protections against conflicts of interest. It also clarifies that CMS will take into account all facts and circumstances when determining whether a CO-OP made a good effort to ensure that two-thirds of their business was with the individual and small group market. By considering good-faith effort instead of a strict adherences to ‘two-thirds’ of business, CO-OPs will have more flexibility to enter into potentially beneficial new lines of business, such as Medicare or Medicaid products or ancillary lines such as dental or vision. CMS will consider comments received by July 5, 2016.

Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models

On May 9, 2016, CMS published this proposed this rule that makes historic changes to how clinicians will be paid. At the heart of the proposed rule is the Quality Payment Program which, beginning in 2019, would offer new systems for paying doctors and other clinicians who serve Medicare beneficiaries. One, the Merit-Based Incentive Payment System (MIPS), would evaluate the quality of care delivered based on four performance categories: cost, quality, exchange of information (use of electronic health records) and clinical practice improvement. The second system, advanced Alternative Payment Models (APMs), offers higher financial incentive to clinicians who improve quality by coordinating care across providers and settings. Initiatives for coordinated care include CMS’s Accountable Care Organization (ACO) Model and Comprehensive Primary Care.

FY 2017 Medicare Hospital Inpatient Prospective Payment Systems (IPPS)

On April 27, 2016, CMS published a proposed rule updating policy and payment rates for acute care hospitals and other inpatient services for FY 2017. In addition, the rule proposes and revises requirements for quality reporting programs, including hospital pay-for-performance programs. Finally, this rule implements statutory provisions to notify beneficiaries of their observation status, per the NOTICE Act, and implements the Frontier Community Health Integration Project (FCHIP) demonstration. Comments are due by June 17, 2016. For more information, see the CMS fact sheet on this year’s rule.

FY 2017 Medicare Long-Term Care Hospital Prospective Payment System (LTCH PPS)

On April 27, 2016, CMS published a proposed rule updating policy and payment rates for LTCHs for FY 2017. In addition to the annual payment revisions, CMS updates administrative policy and quality reporting requirements. Comments are due by June 17, 2016. For more information, see the CMS fact sheet on this year’s rule.

Temporary Exception for Certain Severe Wound Discharges From Certain LTCHs and Modification of Limitations on Redesignation by the MGCRB

On April 21, 2016, CMS published an interim final rule with comment period implementing section 231 of the Consolidated Appropriations Act of 2016 (CAA) and decisions in the Geisinger v. HHS and Lawrence v. Burwell court cases. Comments are due by June 17, 2016.

FY 2017 Skilled Nursing Facility Prospective Payment System (SNF PPS)

On April 25, 2016, CMS published a proposed rule updating policy and payment rates for SNFs for FY 2017. In addition to annual payment revisions, CMS updates the quality measures and administrative procedures under both the SNF value-based purchasing (VBP) program and SNF quality reporting program (QRP). Finally, CMS details the current phase of research to replace the SNF PPS, which currently bases payment on therapy provided. Comments are due by June 20, 2016. For more information, see the CMS fact sheet on this year’s rule.

FY 2017 Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS)

On April 25, 2016, CMS published a proposed rule updating policy and payment rates for IRFs for FY 2017. In addition to annual payment revisions, CMS updates the quality measures and reporting requirements under the IRF quality reporting program (QRP). Comments are due by June 20, 2016. For more information, see the CMS fact sheet on this year’s proposed rule.

FY 2017 Hospice Payment Rate Update

On April 21, 2016, CMS displayed its proposed rule updating policy and payment rates for hospice providers FY 2017. In addition to standard annual payment revisions, the rule contains changes to the quality measures and reporting requirements under the hospice quality reporting program (HQRP), and details regarding the Medicare Care Choices Model demonstration program which combines hospice and curative care. Finally, CMS plans comprehensive, provider-level monitoring to track general hospice trends and assess the impact of recent hospice payment reforms to help inform future policy efforts and program integrity measures. Comments are due by June 20, 2016. For more information, see the CMS fact sheet on this year’s proposed rule.