February 2016

February 2016

Revised Survey & Certification Guidance for Critical Access Hospital (CAH) Recertification

On February 12, 2016, the Centers for Medicare & Medicaid Services (CMS) issued guidance to State Survey Agencies about the process for re-evaluating the compliance of currently certified CAHs with the status and location requirements at 42 CFR 485.610. Of note for CAHs and State Offices of Rural Health this guidance includes a revised list of documentation that can be used to verify CAH Necessary Provider status, including an edition of the State’s Rural Health Plan, published in 2005 or earlier. 

CMS Quality Measure Development Plan

Updated instructions for submitting comments

On December 18, 2015, CMS released a draft Quality Measure Development Plan to serve as a strategic framework for the future of clinician quality measure development for the transition to new Merit-Based Incentive Payment System (MIPS) and alternative payment models (APMs). Beginning 2019, CMS will apply payment adjustments to eligible professional (e.g. physicians, nurse practitioners, physician assistants) based on measures across four categories: quality, resource use, clinical practice improvement activities, and meaningful use of certified electronic health record technology. This plan is an opportunity for rural providers and stakeholders to give CMS input on the beginning stages of the measure development process. Comments for the draft plan are due March 1, 2016 and can be sent 1) online [https://www.surveymonkey.com/r/26NYQRB]; 2) via the MDP dedicated email address [MACRA-MDP@hsag.com]; or 3) by U.S. mail [Attn: Eric Gilbertson, CMS MACRA Team; Health Services Advisory Group, Inc.; 3133 East Camelback Road, Suite 240; Phoenix, AZ 85016-4545].

Proposed Rule: Confidentiality of Substance Use Disorder Patient Records

New rule updates patient confidentiality measures for substance use disorder patients 

On February 8, 2016, SAMHSA published the proposed rule Confidentiality of Substance Use Disorder Patient Records. This proposed rule provides updates and changes to 42 CFR Part 2, which was published in 1987, with the objective of promoting a foundation of information sharing that supports care coordination, electronic management and exchange of patient information, and development of effective performance measurement tools for patients with substance use disorder. These updates include changes and consolidations of existing key terms and definitions to more accurately describe current delivery systems. For example, the term “program” has been expanded to accommodate care settings in both general medical facilities as well as general medical practices. The rule establishes a foundation for electronic data management through enabling additional security provisions for electronic records, electronic signatures for consent forms and enhanced capacity to disclose program data, though patient consent will still be required before disclosure or exchange of medical records that identify patients diagnosed or treated with substance use disorder. The rule facilitates scientific research in this area through providing qualified personnel the ability to use patient data as well as providing data linkages to other federal data repositories. Comments for the proposed rule are due April 11, 2016.  

Proposed Rule: Medicare Shared Savings Program and Accountable Care Organizations Benchmark Methodology

On January 28, 2016, CMS issued a proposed rule to update the methodology used to calculate the benchmarks of Accountable Care Organizations (ACOs) that continue their participation in the Medicare Shared Savings Program (MSSP) after an initial three-year agreement period. The proposed changes are focused on incorporating regional fee-for-service (FFS) expenditures into the methodology for establishing, adjusting, and updating an ACO’s historical benchmark for its second or subsequent agreement period. CMS has also proposed modifications to streamline the methodology used for adjusting the ACO’s benchmark for composition changes, encourage ACOs to transition to performance-based risk arrangements, and to provide greater administrative finality around the program’s financial calculations.  

The proposed changes to the methodology for determining the ACO’s rebased historical benchmark may be of interest to rural providers and stakeholders because CMS is seeking to reflect an ACO’s performance against providers in the same market, rather than just evaluating the ACO against its own past performance. CMS believes this proposal will improve MSSP incentives for ACOs by recognizing an ACO’s efficiency relative to its region and limiting the link between an ACO’s performance and its future benchmarks. CMS encourages all interested members of the public, including ACOs, providers, suppliers, and Medicare beneficiaries to submit comments as they develop the final rule. Comments are due March 28, 2016.

In response to requests for data to model proposed changes to the rebasing methodology, CMS has made new data files available through the MSSP guidance website. These data can be used in combination with publicly available ACO financial performance data available through Data.CMS.gov for Performance Year One and Performance Year 2014 of the MSSP.

Final Rule: Face-to-Face Requirements for Home Health Services under Medicaid 

On January 27, 2016, CMS issued a final rule first proposed July 12, 2011 (76 FR 41032) to implement portions of the Affordable Care Act. Now including revisions required by the Medicare Access and CHIP Reauthorization Act of 2015, the final rule implements a face-to-face requirement for Medicaid home health services which requires that practitioners describe and document how beneficiaries’ health status at the time of the encounter relates to the primary reason they need home health services or medical equipment. The final rule aligns the provisions of the face-to-face requirement between Medicare and Medicaid. According to CMS, this alignment will help reduce disparities in care and coverage for dual-eligible individuals, ensure all beneficiaries receive necessary medical care and equipment, and provide clearer and more consistent guidance to states and providers. As finalized, the rule applies only to Medicaid fee-for-service and features the following provisions:

  • Requires that physicians or certain non-physician practitioners (i.e., nurse practitioners, certified nurse specialists, certified nurse-midwives, and physician assistants) document the occurrence of a face-to-face encounter (including via telehealth) with Medicaid beneficiaries for the initial ordering of home health services or certain medical equipment within a reasonable timeframe
  • Certified nurse-midwives are not included in the list of authorized NPPs for the order of medical equipment 
  • The same timeframes for the face-to-face requirement in Medicare and Medicaid—for home health: no more than 90 days before or 30 days after the start of services, and for medical equipment: no more than six months before the start of services
  • Revises the Medicaid definition of “medical supplies, equipment, and appliances,” including the addition of the term “disability” and clarification of the applicable settings in which such items can be used, to better align with the Medicare definition of durable medical equipment (DME)
  • State Medicaid programs are not restricted to only those items covered under Medicare DME 
  • Prohibits states from subjecting home health services to a requirement that individuals be homebound, that individuals require nursing or therapy services, or that services be furnished in the home itself
  • Home health services and items may be provided in patients’ homes and places where “normal life activities” take place, except those where Medicaid payment is or can be made for inpatient settings that include room and board (e.g., hospitals, SNFs/NFs, etc.)

Of note for rural, the authorizing legislation allows required face-to-face encounters to be conducted via telehealth and by non-physician practitioners who may be more likely to be employed in rural settings. However, the rule maintains the existing rule that physicians are the sole practitioners authorized to certify home health services and medical equipment, which may prove burdensome for rural communities where longstanding workforce shortages disproportionately threaten access to care.

CMS does not have the necessary data to project financial impacts on state Medicaid programs, but estimates Medicare savings of $2.29 billion between 2010 and 2019. 

The final rule is effective July 1, 2016. To allow states time for budgetary planning and operational changes, CMS will allow states up to one year (i.e., July 1, 2017) to come into compliance if the state legislature has met in that year, otherwise two years (i.e., July 1, 2018).

This project is/was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UB1RH24206, Information Services to Rural Hospital Flexibility Program Grantees, $1,100,000 (0% financed with nongovernmental sources). This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.