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Tag: CMS

CMS announces updated training program for ACA navigators

Posted by Sara Rothenberg on August 15, 2014

The Centers for Medicare and Medicaid Services (CMS) is updating the Navigator, non-Navigator assistance personnel, and certified application counselor training curriculum for the Federally-facilitated and State Partnership Marketplaces in preparation for the next Open Enrollment Period beginning November 15, 2014.  The expanded curriculum will include more information on immigration, household income calculations and help for specific populations, including victims of domestic abuse and college students.  All assisters, whether they are seeking recertification or initial certification, will be required to complete the new training program.

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CMS publishes Medicare pay final rule

Posted by Sara Rothenberg on August 5, 2014

The Centers for Medicare and Medicaid Services (CMS) issued a final rule revising the Medicare hospital inpatient prospective payment systems (IPPS). In adherence to the Affordable Care Act (ACA), part of the rule would effectively reduce payments to disproportionate share hospitals (DSH), which serve the most vulnerable patients. DSH payment reductions are a result of the expansion of Medicaid, however in states that chose not to expand, hospitals still risk losing some payment for uncompensated care.

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CMS issues regulations on premium payment

Posted by Sara Rothenberg on July 24, 2014

The Center for Consumer Information and Insurance Oversight (CCIIO) and the Centers for Medicare & Medicaid Services (CMS) issued Federal guidance which gives individuals a three-month grace period to pay a premium without losing coverage. However, the same guidance states that if individuals choose enroll in a new policy for 2015, insurance companies cannot apply new premiums to outstanding 2014 debt. Some have suggested that this inconsistency could allow consumers to avoid paying their December premiums. However, nothing bars an insurer from making a bona fide effort to collect any unpaid premiums, as the consumer would still owe this amount to the insurer.

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CMS releases 2015 Medicare payment rules

Posted by Nikki Hurt 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 by Nikki Hurt 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 issues Medicare Advantage and Part D final rule for 2015

Posted by Nikki Hurt on May 21, 2014

The Centers for Medicare and Medicaid Services (CMS) issued the final rule for Medicare Advantage (Part C) and the Medicare prescription drug benefit program (Part D) for contract year 2015. The rule aims to clarify program provisions, enact statute requirements, and improve payment accuracy. One specific provision provided in the rule said CMS will not open up preferred networks to permit any willing pharmacy to offer preferred cost-sharing. CMS indicated they would continue to study preferred cost-sharing practices to address stakeholder reactions and concerns to the proposed policy.

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HHS releases final Marketplace rule

Posted by Nikki Hurt 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 by Nikki Hurt 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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Administration releases more ACA guidance

Posted by Nikki Hurt on May 5, 2014

Last Friday, the Centers for Medicare and Medicaid Services (CMS) posted a new bulletin on special enrollment periods and hardship exemptions under the Affordable Care Act (ACA). The bulletin provides information on how federally-facilitated Marketplaces (FFM) should address coverage for individuals that fall into the following four categories: hardship exemptions for individuals that obtained coverage effective May 1st, special enrollment periods for individuals eligible for or enrolled in COBRA, special enrollment periods for individuals whose plans are renewing outside of open enrollment, and special enrollment periods for AmeriCorps/VISTA/National Civilian Community Corps Members. The bulletin suggests that state-based Marketplaces (SBM) use these guidelines to help individuals that fall into these categories.

The administration also released a new FAQ set regarding ACA implementation. This FAQ, prepared jointly by the US Department of Treasury, the US Department of Health and Human Services, and the US Department of Labor, addresses questions concerning a myriad of health reform topics. Several of the issues addressed include updated Department of Labor Model Notices for COBRA, out-of-network and out-of-pocket charges, and Summaries of Benefits and Coverage (SBC).

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CMS releases payment rules

Posted by Nikki Hurt 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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