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Centers for Medicare & Medicaid Services

CMS releases 2015 Medicare payment rules

Posted on July 4, 2014

The Centers for Medicare and Medicaid Services (CMS) issued several rules concerning Medicare payments for 2015.  First, CMS released the 2015 physician fee schedule.  Pursuant to the “doc fix” legislation recently passed, this proposal holds physician payments for the first quarter of next year.  The rule also bolsters the Physician Payment Sunshine Act by requiring providers to report payments received from speaking at continuous education events.  Additionally, the proposal revises the quality scoring methodology so that accountable care organizations (ACOs) are better able to exemplify the improvements they make in quality measures.  The number of metrics will increase from 33 to 37.

Yesterday, CMS also updated the payment scheme for outpatient services by 2.1% for 2015.  Biologics and non-pass-through drugs are still expected to be paid at average sales price plus 6%.  Payments are anticipated to increase by $5.2 billion compared to 2014.

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CMS releases proposed rule on annual eligibility determinations

Posted on June 26, 2014

A new proposed rule issued today by the Center for Consumer Information and Insurance Oversight (CCIIO) discussed annual eligibility redetermination under the Affordable Care Act (ACA) and several other enrollment standards for ACA Marketplace. CCIIO stated that nearly all of those currently enrolled in an ACA Marketplace plan will be re-enrolled unless they choose a new plan in the next open enrollment period or the plan in which they are currently enrolled is terminated. The rule proposes three methods for ACA Marketplaces to conduct annual redeterminations for enrollment. The rule also proposes standards to redetermine eligibility within a plan year and when an individual’s plan in the ACA Marketplace is not available for re-enrollment for the next plan year.

Additional guidance includes:

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CMS rule sets payment adjustments for low-volume hospitals

Posted on June 13, 2014

The Centers for Medicare and Medicaid Services (CMS) issued a rule to change the payment adjustment for low-volume hospitals and Medicare-dependent hospitals. The changes would be issued under the hospital inpatient prospective payment systems (IPPS) for the second half of fiscal-year 2014. According to the rule, a hospital is considered low-volume if it is more than 15 miles from another hospital and has less than 1600 discharges of individuals entitled to or enrolled in Medicare Part A.

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HHS releases final Marketplace rule

Posted on May 16, 2014

The US Department of Health and Human Services (HHS) issued a final rule entitled Patient Protection and Affordable Care Act; Exchange and Insurance Market Standards for 2015 and Beyond. Some specific provisions in the rule include:

  • Raising the administrative costs and profits ceiling under the risk corridor formula by 2%.
  • Providing information on how to include ICD-10 costs under the medical loss ratio (MLR).
  • Requiring qualified health plans (QHP) on the ACA Marketplace to have a more efficient and effective method for enrollees to acquire medications not covered on the plan. This specifically applies to enrollees on a course of treatment in which absence of the medication would substantially impact the individual’s life and health.
  • Requiring insurers to annually report plan changes to beneficiaries.
  • Beginning in 2016, Marketplaces will have to display quality data on all plans for public viewing. The data will be based on a five-star system and enrollee satisfaction surveys.
  • Enumerating state requirements that may prohibit Navigators or other assistors from performing their roles. For example, Navigators may go door-to-door for enrollment assistance and outreach. They may not, however, provide gifts to entice enrollment.
  • Delaying the “employee choice” option in the small business health options program (SHOP) to 2016.

The final rule is largely unchanged from the proposed version. An FAQ addressing market reforms and Marketplace standards can also be accessed here.

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New CMS rule reduces burden and promotes efficiency

Posted on May 8, 2014

A final rule released by the Centers for Medicare and Medicaid Services (CMS) is designed to loosen policies that could save hospitals up to $3.2 billion over the next five years. One policy addressed removes the requirement that a physician must be present at a rural health center every two weeks, which was implemented to help combat the shortage of rural health providers. The rule also relaxes supervision requirements for some providers, such as dieticians. Easing regulations under this rule follows suit with the administration’s “regulatory lookback” that began in 2012.

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CMS releases payment rules

Posted on May 1, 2014

A final rule released on Tuesday indicates that federally qualified health centers (FQHCs) may receive a 32% payment boost under Medicare’s new payment system. Effective October 1st of this year, Medicare will pay FQHCs a per member per day fee of $158.85, which will be adjusted for geographic differences in healthcare costs. The Centers for Medicare and Medicaid Services (CMS) currently does not adjust payments for FQHC patients.

Another rule released by CMS discusses inpatient payment regulations for 2015. Per the Hospital Readmission Reduction Program, Medicare payments to physicians with poor readmission rates could be reduced by as much as 3%. Hospitals with poor performance regarding hospital acquired conditions may face an additional penalty.

Other payment rules released by CMS include skilled nursing facilities, rehabilitation facilities, and psychiatric facilities, which all call for payment increases of 2%, 2.2%, and 2.1% respectively.

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CMS FAQ discusses risk corridor

Posted on April 12, 2014

A new set of Frequently Asked Questions (FAQs) issued by the Centers for Medicare and Medicaid Services (CMS) answers several questions concerning the risk corridor provision of the Affordable Care Act (ACA). Pursuant to the Notice of Benefit and Payment Parameters for 2015 final rule, CMS stated that the risk corridor provisions would be implemented in a budget neutral manner. The new FAQ stated how the administration will address various issues that may arise in providing risk corridor payments, including sufficiency and medical loss ratio (MLR) determinations.

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Update: Final 2015 Letter to Issuers in the Federally-Facilitated Marketplace: Access and Non-Discrimination Considerations

Posted on April 9, 2014

On March 14, 2014 the Centers for Medicare and Medicaid Services (CMS) published its 2015 letter to issuers selling qualified health plans in the federally facilitated Exchange Marketplace (FFM). The issuers letter is designed to provide federal guidance on the qualified health plan certification process to health insurance issuers and states that use the FFM while also maintaining plan management partnerships with the federal government (AL, AK, AZ, AR, DE, FL, GA, IL, IN, IA, KS, LA, ME, MI, MS, MO, MT, NE, NJ, NY, NC, ND, OH, OK, PA, SC, SD, TN, TX, UT, VA, WV, WI, WY). This Update reviews highlights of the final 2015 letter (we reviewed the draft letter in a prior Update.

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Administration releases a deluge of ACA rules

Posted on March 17, 2014

The administration recently issued several rules and guidance concerning the implementation of the Affordable Care Act (ACA). Below are key points from some of these new releases:

  • A new Frequently Asked Question (FAQ) document from the Centers for Medicare and Medicaid Services (CMS) states that most insurance plans will be required provide the same benefits to married gay couples as they do to heterosexual married couples. Insurance companies will extend these nondiscrimination policies to same sex couples for plans offered on the ACA marketplaces.
  • An interim final rule released by CMS requires plans offered through the ACA marketplaces to accept premium and cost-sharing payments from certain federal government programs. Such programs include the Ryan White HIV/AIDS program and various Indian organizations.
  • CMS also released the proposed rule concerning market standards for 2015. The rule covers a multitude of topics, ranging from new standards for self-funded non-federal plans opting out of certain Public Health Service Act (PHSA) requirements to amending guaranteed renewability stipulations.
    • One particular provision of this rule was designed to preempt state laws created to increase the certification requirements and restrict the roles of navigators and other assistors under the ACA. Additionally, the rule prohibits assistors from performing certain activities that received substantial criticism, such as cold calling potential consumers or offering cash incentives to promote enrollment. The rule also provides some leeway for insurers under the medical loss ratio (MLR) requirements as a result of the stymied roll out of the federal health insurance marketplace.
    • Another interesting provision in the rule will require insurers to provider a more robust network of doctors and hospitals for consumers. Many plans offer “narrow networks” as a mechanism to cut costs for consumers, yet many consumers are losing coverage for their family practitioners. CMS will determine whether or not the plans provide “reasonable access” to certain services, such as mental health, oncology, and primary care.
    • In addition to the rule, CMS also provided guidance regarding discontinuing or renewing policies in the group or individual markets.

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CMS releases 2015 final letter to issuer

Posted on March 14, 2014

Today, the Centers for Medicare and Medicaid Services (CMS) released the finalized version of the 2015 Letter to Issuers in the Federally-facilitated Marketplaces. The letter provides technical and operational guidance to help qualified health plans (QHP) and stand-alone dental plans successfully participate in the Affordable Care Act (ACA) Marketplaces operated by the federal government.

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