February 2017

February 2017

The Federal Office of Rural Health Policy (FORHP’s) Policy Team is ready to answer any questions you may have about these updates at RuralPolicy@hrsa.gov.

Fact Sheet: New Accountable Care Organization (ACO) Model Opportunity: Medicare ACO Track 1+ Model

The Centers for Medicare & Medicaid Services (CMS) released additional details on the Medicare ACO Track 1+ model, which is one in a series of Innovation Center initiatives that will expand opportunities for clinicians to participate in advanced alternative payment models (APMs) under the Medicare Access and CHIP Reauthorization Act (MACRA). This ACO model incorporates more downside risk than is currently present in Track 1 of the Medicare Shared Savings Program (MSSP) and is designed to help small practices move toward performance-based risk and to allow small hospitals, including rural, to participate.   

The Track 1+ ACO model includes some aspects of the Track 2 and 3 models, such as prospective beneficiary assignment; the introduction of downside risk (although lower than Track 3); and the option to request a skilled nursing facility (SNF) 3-Day rule. ACOs would be able to share in savings up to a maximum 50 percent shared savings rate based on quality performance, and there is a fixed 30 percent loss-sharing rate. The maximum level of downside risk would vary based on the composition of ACOs, with lower levels of risk potentially available to qualifying physician-only ACOs and/or ACOs that include small rural hospitals.

Additional information about the application process is forthcoming, but organizations interested in applying should plan to submit the required Notice of Intent to Apply (NOIA) in May 2017. 

Proposed Rule:  2018 Medicare Advantage and Part D Advance Notice and Draft Call Letter

CMS announced proposed updates to the Medicare Advantage (MA) and Part D prescription drug program, opening a 30-day public comment period. Proposed changes include a net increase to MA payment rates by 0.25%; an adjustment to the MA Star Ratings to account for the impact of dual-eligible and disabled status on plans’ Star Ratings; an adjustment for differences in coding trends between fee-for-service and managed care; and several updates to policies intended to address opioid drug utilization concerns within the Part D program.  

Of particular note to rural stakeholders: Similar to prior years, MA organizations are expected to identify disparities and need for increased preventive services and care among vulnerable populations, including racial and ethnic minorities, people with disabilities, sexual and gender minorities and rural populations. CMS seeks comment regarding their experiences related to identifying and engaging enrollees in order to provide appropriate services to vulnerable enrollees. CMS also seeks comment on the appropriateness of including telehealth and/or remote access technology encounters as eligible encounters in various quality measures. Finally, CMS will continue to implement policies for access to preferred cost-sharing pharmacies, including outliers in rural areas, which have been in place since 2016.  

Comments must be submitted by March 3, 2017, as the final rate announcement and call letter will be published on April 3, 2017.

Request for Letters of Intent for two new Beneficiary Engagement and Incentive Models

CMS is seeking provider participation in two new models from the CMS Innovation Center that will increase patient engagement in care decisions by putting more information in the hands of Medicare beneficiaries. The Direct Decision Support (DDS) model under the Beneficiary Engagement Model (BEI) will test whether engaging beneficiaries outside the clinical setting will inform and empower their health care decisions. CMS will partner with up to seven Decision Support Organizations (DSOs) to provide direct decision support to at least 100,000 Medicare beneficiaries in a geographic region (i.e., state and/or region). Engaged beneficiaries will interact with decision support mechanisms such as web-based tools, decision support via telephone, and/or mobile e-health applications throughout the course of the model, which could be useful in rural areas. Also under BEI, the Shared Decision Making (SDM) model will test integrating a structured four-step shared decision-making process into the clinical practice of MSSP and Next Generation ACOs. The shared decision-making process is a collaboration between the beneficiary and the practitioner. CMS plans to operate and provide financial support for the SDM model in 50 ACOs nationwide. Letters of Intent for both models are due March 5, 2017.

Medicare and Medicaid Conditions of Participation for Home Health Agencies

On January 13, CMS published its final rule (82 FR 4504) updating the conditions home health agencies (HHAs) must meet to participate in Medicare and Medicaid. In the first full update since 1989, CMS modernized and streamlined HHA rules to incorporate recent advances and current medical practices that focus on patient-centered, data-driven and outcome-oriented care. These Conditions of Participation (CoPs) protect all patients, regardless of payer, and include specific requirements related to patient rights, comprehensive patient assessment and interdisciplinary patient care planning and coordination. 

Of note for HHAs in rural areas disproportionately affected by physician shortages, CMS revised its policy to allow licensed practical nurses (LPNs) acting within their state licensure requirements and state scope of practice laws to receive verbal orders for home health services, although statute requires that only physicians establish the home health plan of care for Medicare beneficiaries. The final rule takes effect July 13. For more information, see the CMS press release.

In response to 199 comments from home health providers, industry associations, and patient advocates, the rule finalizes several changes to the CoPs first proposed in October 2014 (79 FR 61163):

  • Requires HHAs to provide written notice of patient rights and responsibilities prior to providing care, but extends the timeframe for the oral explanation of the notice by a skilled practitioner to the first two home health visits
  • Removes the requirement that HHAs routinely provide each patient with a copy of the plan of care, although all patients must be provided their plan of care and any other clinical records free of charge upon request
  • Indicates that HHAs are not required to provide a copy of the discharge summary to each patient, although HHAs are required to communicate changes in the discharge plan to the patient and any representative(s) and caregiver(s)
  • Requires HHAs to involve patients in the development and updating of the plan of care to the degree that a patient chooses to be involved in the process
  • Requires HHAs to assess risk for re-hospitalization for all admitted patients, regardless of payer source, but removes the proposed ranking methodology (“low, medium, high”) with no alternative methodology proposed
  • Allows HHAs to accept orders for home health care from multiple physicians who are involved in the patient’s care, regardless of whether those physicians are part of the same group practice or not, and requires those HHAs to coordinate communication between these practitioners and integrate services ordered
  • Requires HHAs to institute an organized, data-driven, and agency-wide program for quality assessment and performance improvement (QAPI), including a program for the surveillance, identification, prevention, control, and investigation of infectious and communicable disease
  • Establishes maximum timeframes for HHAs to send a completed discharge summary (within five business days) or a transfer summary (within two business days of becoming aware of a patient’s unplanned transfer, if the patient is still receiving care in the receiving facility)
  • Removes the requirement that HHAs provide a summary of care every 60 days to the physician(s) responsible for the HHA plan of care

Extension of Data and Meaningful Use (MU) Deadlines

CMS extended the attestation deadline for hospitals and eligible physicians participating in the Medicare Electronic Health Records (EHR) Incentive Program (i.e., “Meaningful Use”) to March 13, 2017. Hospitals participating in the program must attest to meeting 2016 requirements to avoid a 2018 payment adjustment. The new March 13 deadline for MU attestation aligns with the March 13 deadline for hospitals and critical access hospitals (CAHs) participating in the Hospital Inpatient Quality Reporting (IQR) or MU programs to submit electronic Clinical Quality Measure (eCQM) data for calendar year 2016. Hospitals and CAHs must report on at least four eCQMs using 2014- or 2015-certified EHRs to avoid a 2.7% payment reduction in 2018. CMS is considering future rulemaking to modify the number of required eCQMs for 2017 reporting. CMS also plans to address stakeholder concerns and challenges related to EHR systems and eCQM reporting in the FY 2018 Inpatient Prospective Payment System (IPPS) rule.  

Rural providers and other stakeholders interested in commenting on these and other issues should plan to submit comments on the proposed rule, which should be published in late spring 2017. Of note for Medicare-enrolled rural practitioners, elements of the Medicare EHR Incentive Program for eligible practitioners will be consolidated into the new Quality Payment Program (QPP) authorized by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) to streamline quality reporting and avoid redundant requirements. As a reminder for rural providers and hospitals that considered submitting hardship exceptions, the deadline to submit an EHR Incentive Program hardship exception application to avoid the 2017 Medicare EHR payment adjustment has passed. Email ehrhardship@provider-resources.com for questions.

CMS Proposes Changes for the 2018 Marketplace 

On February 15, 2017, CMS released a proposed rule that would revise provisions in the Benefit and Payment Parameters final rule and Letter to Issuers for the 2018 benefit year to promote market stability in the Health Insurance Marketplace. Of note for rural providers, CMS proposes to 1) modify enrollment processes (i.e., shorten the open enrollment period for the 2018 benefit year, increase verification for special enrollment periods, revise the guaranteed availability requirement); 2) increase variation in the actuarial values for plan levels; 3) revise network adequacy review processes (i.e., lower the Essential Community Provider standard from 30% to 20%); and 4) revise the timeline for certification of qualified health plans. Comments are due for this proposed rule by March 7, 2017.  For more information visit: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2017-Press-releases-items/2017-02-15.html

CMS also released three additional documents regarding changes to timelines for rate submission and posting:

CMS Launches Technical Assistance (TA) to Help Small and Rural Practices Succeed in the Quality Payment Program

Late last year, CMS finalized the details of the QPP. This program is a new approach to Medicare clinician payment with two tracks: Advanced APMs and the Merit-based Incentive Payment System (MIPS). On February 17, 2017, CMS announced the award of up to $100 million to help clinicians in individual or small group practices of 15 clinicians or fewer succeed in the QPP.

CMS awarded approximately $20 million to 11 organizations for the first year of a five-year technical assistance program. These organizations will provide customized, on-the-ground training and education to eligible clinicians and practices. CMS intends to invest up to an additional $80 million over the remaining four years. 

What should rural providers know? Rural practices are among those that will receive priority for this technical assistance. The training and education resources will be available immediately, nationwide, and will be provided at no cost to eligible clinicians and practices. This technical assistance can help eligible clinicians or groups prepare to report performance data to potentially earn positive payment adjustments (and avoid negative payment adjustments). 

The 11 organizations funded by CMS to provide technical assistance are:

  • Altarum
  • Georgia Medical Care Foundation (GMCF)
  • HealthCentric
  • Health Services Advisory Group (HSAG)
  • IPRO
  • Network for Regional Healthcare Improvement (NRHI)
  • QSource
  • Qualis
  • Quality Insights (West Virginia Medical Institute)
  • Telligen
  • TMF Health Quality Institute

CMS also launched a new telephone helpline for clinicians seeking assistance with the QPP. Clinicians may contact the QPP by calling 1-866-288-8292 from 8:00 a.m. – 8:00 p.m. Eastern Time or by emailing qpp@cms.hhs.gov. For more information on the QPP, please visit https://qpp.cms.gov/.  

Office of the Inspector General (OIG) Revisions to the Safe Harbors Under the Anti-Kickback Statute – Final Rule

The OIG for the US Department of Health & Human Services (HHS) recently issued a final rule that eases the ability to provide free or discounted transportation services for health care. Under the rule, federal health care programs arranging service from local transportation providers are granted a “safe harbor” exemption from the anti-kickback statute, which prohibits offering, soliciting or accepting of any type remuneration for referral to a federal health care program business. 

Significant policy changes for rural providers include:

  • New safe harbor to protect free or discounted local transportation services provided to federal health care program beneficiaries in order to obtain medically necessary items or services 
    • Allows for transportation to a provider or supplier of services and back to a patient’s home (air, luxury or ambulance transportation excluded)
    • Permits shuttle service 
    • Sets a 25-mile limit for patients in urban areas and 50-mile limit for patients in rural areas
  • Eligible entities (or the provider or supplier to whom the patient is transported) not required to be in a rural area
    • Does not have to require that transportation be planned in advance
    • Can use vouchers rather than having the transportation provided directly by the eligible entity
  • Patients are those who selects and initiates contact with a provider or supplier to schedule an appointment