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Feds Urge States to Do More for Dually Eligible

In a formal guidance letter to state Medicaid directors, the Centers for Medicare & Medicaid Services has outlined ten ways that states can better serve individuals who are enrolled in both Medicare and Medicaid.

Noting that such dually eligible individuals represent 20 percent of Medicare enrollees but 34 percent of Medicare spending while also constituting 15 percent of Medicaid beneficiaries but 33 percent of Medicaid spending, the letter from CMS administrator Seema Verma to state Medicaid directors explains that

This letter describes ten opportunities – none of which require complex demonstrations or Medicare waivers – to better serve individuals dually eligible for Medicare and Medicaid, including through new developments in managed care, using Medicare data to inform care coordination and program integrity initiatives, and reducing administrative burden for dually  eligible individuals and the providers who serve them. A number of these opportunities are newly available to states through Medicare rulemaking or other CMS burden reduction efforts. We are happy to engage with you and your staff on one, many, or all of the items described in this letter. The CMS Medicare-Medicaid Coordination Office (MMCO) works across CMS and with states to better serve dually eligible individuals, including through efforts to better align the Medicare and Medicaid programs and demonstrations to test new approaches to integrated service delivery and financing.

Those ten ways are:

  • state contracting with dual eligible special needs plans (D-SNPs)
  • default enrollment into a D-SNP
  • passive enrollment to preserve continuity of integrated care
  • integrating care through the Program of All-inclusive Care (PACE)
  • reducing the administrative burden in accessing Medicare data for use in care coordination
  • program integrity opportunities
  • Medicare Modernization Act of 2003 file timing
  • state buy-in file data exchange
  • improving Medicare Part A buy-in
  • opportunities to simplify eligible and enrollment

Private safety-net hospitals serve especially large numbers of dually eligible, Medicare-Medicaid patients and will be interested to see whether CMS’s recommendations translate into action at the state level.

To see the entire letter, including additional information about these ten opportunities, go here.

CMS Rejects Bid to Impose Lifetime Limit on Medicaid Services

The Centers for Medicare & Medicaid Services has denied a request from the state of Kansas to impose a lifetime limit on the Medicaid benefits individuals may receive.

In a move that the agency appeared to signal last week and that appears to have national implications, CMS administrator Seema Verma explained that

 We have determined that we will not approve Kansas’ recent request to place a lifetime limit on Medicaid benefits for some beneficiaries…We seek to create a pathway out of poverty, but we also understand that people’s circumstances change, and we must ensure that our programs are sustainable and available to them when they need and qualify for them.

Medicaid advocates feared that benefit limits would follow in the footsteps of the recent efforts of some states to impose work requirements on many Medicaid participants – efforts that, in some cases, have proven successful.

Such a decision, if it becomes policy, would be beneficial for private safety-net hospitals.  These hospitals serve more Medicaid patients than the typical hospital and would therefore be more likely to encounter patients whose eligibility would be jeopardized by a limit on lifetime Medicaid benefits.

Learn more about Medicaid lifetime benefit limits and the CMS decision in this article in the online publication The Hill.

CMS Proposes Changes in Inpatient Rates, Medicare DSH, and Wage Index

Last week the Centers for Medicare & Medicaid Services published a proposal detailing how it envisions paying for Medicare services in FY 2019 under its inpatient prospective payment system.

Yesterday this space features a summary of the proposed regulation, with an emphasis on aspects of the rule of greatest importance to private safety-net hospitals.

Today, we address Medicare inpatient rates, Medicare disproportionate share payments (Medicare DSH) and the Medicare cost report’s S-10 worksheet, and the Medicare area wage index.

Inpatient Rates

CMS proposes increasing Medicare inpatient rates 1.75 percent in FY 2019.  This reflects the projected hospital market basket update of 2.8 percent reduced by a 0.8 percentage point productivity adjustment, increased by a 0.5 percentage point adjustment required by legislation, and reduced 0.75 percentage points as required by the Affordable Care Act.

Medicare DSH Uncompensated Care Payments and the S-10

CMS proposes distributing $8.25 billion in Medicare DSH uncompensated care payments in FY 2019, a $1.5 billion increase from FY 2018, citing as its reason for this increase both an increase in the CMS Office of the Actuary’s estimate of payments that would otherwise be made for Medicare DSH and an updated estimate of the change in the percentage of uninsured individuals since 2014 based on the latest available data.

CMS also proposes continuing its phase-in of the use of S-10 data in the calculation of Medicare DSH uncompensated care payments.  FY 2019 would be year two of this phase-in, and CMS proposes using S-10 data from FY 2014 and FY 2015 cost reports, in combination with insured low-income days data from FY 2013 cost reports, to determine the distribution of Medicare DSH uncompensated care payments.

CMS is engaged in limited review of some of the uncompensated care data hospitals report on their S-10 form.  According to the proposed rule, these efforts have focused on three types of problems:  unreasonably high cost-to-charge ratios, significant increases in charity care from FY 2014 to FY 2015, and hospitals that report uncompensated care that exceeds 50 percent of their operating costs.

 Medicare Area Wage Index

Every three years CMS updates the wage index to reflect more recent data it collects from the occupational mix survey.  FY 2019 is the first year of a new three-year period for using updated data, and this will result in greater changes in wage indexes than might otherwise be expected from year to year.

CMS proposes changing the deadline for when a hospital that reclassifies from urban to rural will have that reclassification considered in the development of the wage index for a fiscal year.  This proposal would change the threshold from being based on the application’s date of submission to the application’s date of approval.

CMS also proposes changes that would address certain situations arising from lags between when wage index data is reported and when that data is evaluated for reclassification purposes.  These changes would address lag issues for new remote locations of hospitals located in counties participating in group reclassifications and for single-hospital MSAs where new hospitals have opened but that have no data in the wage index files for that MSA.

FY 2019 will mark the first year in which the imputed rural floor (which exists in states where there are no rural areas) will be eliminated.  CMS announced this in last year’s rule.  The only states to which the imputed rural floor applied were Delaware, New Jersey, and Rhode Island and this change will actually only affect hospitals in Rhode Island.

Wage Index Invitation to Comment

The proposed rule describes past efforts to revise the wage index, including past proposals from MedPAC and others.  It invites interested parties to submit comments on regulatory and policy improvements related to the wage index.

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Tomorrow we will look at multi-campus hospitals, the Medicare and Medicaid electronic health record (EHR) incentive programs, and the Medicare hospital readmissions reduction program.  On Thursday we will examine the Medicare value-based purchasing program, the hospital inpatient quality reporting program, electronic clinical quality measures, and price transparency.

You also can learn more by reviewing the entire proposed 1883-page rule here or reading the CMS fact sheet here.

 

CMS Shares Vision for Medicaid

Medicaid is about to undergo major changes, CMS administrator Seema Verma outlined in a news release yesterday and in a speech to state Medicaid directors.

According to the news release, those changes include:

  • re-establishing a state-federal partnership that Verma believes has become too much federal and not enough state
  • giving states greater freedom to innovate
  • offering new guidelines for how states can align their individual programs with federal Medicaid objectives
  • new guidance on section 1115 waivers
  • longer section 1115 waivers with simpler review processes
  • CMS willingness to consider proposals to impose work requirements on Medicaid beneficiaries
  • Medicaid and CHIP “scorecards” that track and publish state and federal Medicaid and CHIP outcomes

Urban safety-net hospitals serve more Medicaid patients than the typical hospital and would therefore be affected more by any major changes in how Medicaid operates.

Go here to see CMS administrator Verma’s full new release and to find links to relevant documents, web sites, and Ms. Verma’s speech about the changes.  Go here to read a Washington Post report on Ms. Verma’s speech and here to see a Kaiser Health News report.

CMS Announces Drive to Reduce Paperwork

The Centers for Medicare & Medicaid Services is launching a new “Meaningful Measures” initiative that will seek to reduce the regulatory burden on health care providers.

According to a CMS news release, Meaningful Measures

…will involve only assessing those core issues that are most vital to providing high-quality care and improving patient outcomes.  The agency aims to focus on outcome-based measures going forward, as opposed to trying to micromanage processes..

In a speech at the Health Care Payment Learning and Action Network, CMS administrator Seema Verma explained that this project will include moving the Center for Medicare and Medicaid Innovation in a new direction that promotes greater flexibility and patient engagement and implementing the Medicare Access and CHIP Reauthorization Act (MACRA) in ways that minimize the burden and cost of complying with the law’s requirements.

To learn more about this new CMS initiative, see this CMS news release or go here to read Ms. Verma’s remarks.

Participation in Alternate Payment Models Rises

In 2017 nearly 360,000 clinicians will participate in Medicare and Medicaid Alternative Payment Model programs sponsored by the Centers for Medicare & Medicaid Services.

CMS also reports that this year 570 accountable care organizations, including 131 that bear risk, will serve more than 12.3 million Medicare and Medicaid beneficiaries.

In addition, nearly 3000 primary care practices will participate in advanced primary care medical home models.

Find more about the growth of participation in CMS’s alternative payment models, including descriptions of the different models and breakdowns in the numbers of participants, in this CMS news release.

CMS Unveils New Medicaid Managed Care Regulation

For the first time in more than 20 years, the federal government is introducing major changes in how it regulates Medicaid managed care.

cmsThe Centers for Medicare & Medicaid Services describes the 1425-page rule as aligning Medicaid managed care with other health insurance programs, updating how states purchase managed care services, and improving beneficiaries’ experience with Medicaid managed care.

To learn more about what CMS has proposed, go here to see the rule itself.

Go here to see CMS’s news release accompanying the new regulation.

Go here to (under the link “final rule”) to find nine fact sheets summarizing key aspects of the new regulation.

And go here for a commentary on the new rule and the context in which it was released by CMS acting administrator Andy Slavitt.

NAUH has prepared a detailed memo describing the new rule and some of its implications for private safety-net hospitals. Representatives of such hospitals may request a copy of this memo by using the “contact us” link in the upper right-hand portion of this screen.

MedPAC Recommends Socio-Economic Risk Adjustment of Medicare Advantage Star Ratings

The agency that advises Congress on Medicare payment issues has suggested to the Centers for Medicare & Medicaid Services (CMS) that it revise its star ratings systems for Medicare Advantage plans.

In a letter to CMS in response to its request for comment on star ratings, the Medicare Payment Advisory Commission (MedPAC) agreed with CMS that there is evidence of a difference in Medicare Advantage plan performance based on the low-income status or disability of plan members that reflect social determinants of health. While CMS continues to consider how to adjust for such a challenge, MedPAC recommended an interim approach called a “Categorical Adjustment Index” that would

… group MA contracts together, by deciles (for example), based on their share of the relevant populations (low-income, disabled). For each of these initial contract groupings, there would be a comparison between the overall or summary star rating determined under the current methodology, and an overall or summary star rating determined if there are adjustments made to measure results. The adjustment to the measure results would be based on a beneficiary-level regression model that determines the average within-contract difference in measure results for the relevant populations. The initial grouping of contracts would then be combined (if appropriate) into final groups for adjustment purposes so as to group together contracts that had similar mean differences between adjusted and unadjusted summary or overall results. Once that final grouping is determined, each contract within the group would receive the same adjustment to its summary or overall star rating, and the adjusted star rating determines the contract’s status for purposes of determining bonus payments.

For a closer look at the issue and the MedPAC recommendation, see this article in McKnight’s Long-Term Care News. See the MedPAC letter to CMS here, on MedPAC’s web site.

CMS Requires States to Monitor Medicaid Access

A new federal regulation requires states to monitor access to Medicaid services.

According to a new regulation issued by the Centers for Medicare & Medicaid Services (CMS), states must submit to CMS plans for monitoring Medicaid beneficiary access to care in five service areas: primary care, physician specialists, behavioral care; pre- and post-natal care; and home health services.

federal registerState monitoring plans must address the extent to which Medicaid is meeting beneficiaries’ needs; the availability of care; changes in service utilization; and comparisons between Medicaid rates and rates paid by other public and private payers.

Interested parties have 60 days to submit comments to CMS about the new regulation.

For a closer look at the regulation, see this CMS fact sheet and the regulation itself here, in the Federal Register.

CMS Proposal Would Mandate Hospital Discharge Planning

Hospitals that participate in Medicare and Medicaid would be required to develop discharge plans for all inpatients and many outpatients under a new regulation proposed by the Centers for Medicare & Medicaid Services (CMS).

According to a CMS news release,

…hospitals, including inpatient rehabilitation facilities and long-term care hospitals, critical access hospitals, and home health agencies would be required to develop a discharge plan based on the goals, preferences, and needs of each applicable patient . Under the proposed rule, hospitals and critical access hospitals would be required to develop a discharge plan within 24 hours of admission or registration and complete a discharge plan before the patient is discharged home or transferred to another facility. This would apply to all inpatients and certain types of outpatients, including patients receiving observation services, patients who are undergoing surgery or other same-day procedures where anesthesia or moderate sedation is used, and emergency department patients who have been identified by a practitioner as needing a discharge plan. In addition, hospitals, critical access hospitals, and home health agencies would have to —

  • Provide discharge instructions to patients who are discharged home (proposed for hospitals and critical access hospitals only);
  • Have a medication reconciliation process with the goal of improving patient safety by enhancing medication management (proposed for hospitals and critical access hospitals only);
  • For patients who are transferred to another facility, send specific medical information to the receiving facility; and
  • Establish a post-discharge follow-up process (proposed for hospitals and critical access hospitals only).

cmsThe proposed regulation stresses the preferences and goals of patients in the development of their discharge plans, including the selection of post-acute-care providers to which they may be discharged or the home health providers that may serve them when they return home.

Significantly, from the perspective of private safety-net hospitals, the proposed regulation calls for hospitals to consider the socio-economic status of the patients for whom they are planning – although no requirements are associated with that status and the social determinants of patients’ health.

Interested parties have until January 3 to submit comments to CMS on the proposed regulation.

To learn more about what CMS is proposing and what it hopes to accomplish, see this CMS news release. Find the proposed regulation itself here.