House of Representatives
Health Information Exchange Strategy Released
CMS and the Office of the National Coordinator for Health Information Technology have released a plan they say will accelerate development of a health data exchange among providers and health care organizations by incorporating health information exchange (HIE) requirements into existing Medicare and Medicaid policies. The document outlines steps HHS has taken to accelerate HIE as part of the larger strategy to transform health care delivery and payment, including the release of guidance to states on planning and implementing super-utilizer programs through Medicaid, and a proposed extension of the expiration date for and otherwise modify the physician self-referral exception (Stark Law) and anti-kickback safe harbor, for certain donations of interoperable EHR software, information technology and training services. The plan also identified Stage 3 of the Medicare EHR incentive program as a mechanism for requiring meaningful use participants to electronically share summary of care records to avoid payment adjustments. CMS and ONC are expected to begin rulemaking for Stage 3 in 2014. Stage 3, the final stage of the meaningful use program, is envisioned as improving health outcomes through health IT.
- State Activities
Arkansas Applies for Medicaid Waiver
Arkansas has formally submitted to CMS a request to expand its covered Medicaid population through an arrangement that would allow federal funds for the purchase of private insurance policies for some 225,000 eligible residents. The proposal arose from the Affordable Care Act (ACA) option to states for expanding their Medicaid programs, and is the result of a compromise among Arkansas legislators, who opposed simply expanding the Medicaid program.
Michigan Advances Medicaid Expansion Proposals
On Wednesday, a state legislative committee voted to make more than 300,000 Michigan adults eligible for Medicaid in 2014. The committee also passed two alternatives measures, although the chamber's Republican majority leader is said to favor the main proposal, which would expand Medicaid but require that those earning from 100 percent to 133 percent of the poverty level pay for a portion of their coverage or join an exchange after four years.
Florida Insurance Rates Released
According to a recent report by the state's insurance department, Floridians will see modest hikes in individual and small-business premiums next year under the Affordable Care Act, but many of them could be offset by federal subsidies. The smallest increase was an HMO plan from Humana, which increased 7 percent, from $293 to $315. The largest increase was 59 percent, in the case of a plan that jumped from $293 to $464.
Utah Explored Medicaid Expansion Options
Utah Gov. Herbert has convened a panel of experts charged with developing scenarios for Medicaid expansion, which the governor is expected to consider this month. Among the options: full expansion, partial expansion with an exchange option for those earning from 100 percent to 138 percent of poverty level, a block grant request and a plan to provide traditional Medicaid coverage or subsidies for individuals earning up to the poverty level or families earning up to 138 percent of the poverty level. The last option wouldn't begin until 2017, to leave time for "program design."
- Regulations Open for Comment
Proposed Rule on Exchange Coverage for Members of Congress, Staff
On Aug. 8, 2013, the Office of Personnel Management (OPM) published a proposed rule to amend the Federal Employees Health Benefits (FEHB) Program regarding health insurance requirements for Members of Congress and their staff under the Affordable Care Act (ACA). The proposed rule would require, consistent with the ACA, that Members of Congress and their staff purchase health coverage on ACA-created exchanges beginning Jan. 1, 2014; however, they would not lose employer contributions to their health plans, as many had previously been concerned would happen. The proposed rule defines a "Member of Congress" as a member of the Senate or of the House of Representatives, a Delegate to the House of Representatives (which includes delegates from the District of Columbia and the territories), and the Resident Commissioner of Puerto Rico. In addition, the proposed rule utilizes the statutory definition for Congressional staff. Because there is no existing statutory or regulatory definition of "official office," the proposed rule delegates to the employing office of the Member of Congress the determination as to whether an employed individual meets the statutory definition. OPM seeks comment on the proposal by Sept. 9, 2013.
Proposed Rule, Medicare Physician Fee Schedule (PFS) and Hospital Outpatient Prospective Payment System (OPPS)
CMS has issued the calendar year (CY) 2014 Medicare Physician Fee Schedule (PFS), Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System proposed rules. The proposed PFS regulation would continue to expand access to primary care services by proposing to provide payment for complex chronic care coordination services, beginning in CY 2015. It proposes to adjust payment rates for over 200 codes where Medicare pays more for services furnished in an office than in a hospital outpatient department or ASC, as part of the misvalued codes initiative. It also would make refinements to the Physician Quality Reporting System (PQRS) program, the Medicare Shared Savings Program and the Medicare EHR Incentive Program.
PFS: CMS projects an across-the-board reduction in payment rates based on the Sustainable Growth Rate (SGR) formula. If the SGR goes into effect, Medicare payment rates are projected to be reduced by 24.4 percent for services in 2014. The final projection, based on more recent data, will be made available in the final rule.
OPPS: CMS proposes to update the OPPS market basket by 1.8 percent for CY 2014. The proposed hospital market basket increase published in the fiscal year (FY) 2014 Inpatient Prospective Payment System (IPPS)/Long-Term Care Hospital Prospective Payment System (LTCH PPS) proposed rule is 2.5 percent. The Medicare statute requires a productivity adjustment reduction of 0.4 percentage points and a 0.3 percentage point reduction to the CY 2014 OPPS market basket, so the proposed CY 2014 OPPS market basket update would be 1.8 percent.
ASC: ASC payments are annually updated for inflation by the percentage increase in the consumer price index for all urban consumers (CPI-U). The Medicare statute specifies a multifactor productivity (MFP) adjustment to the ASC annual update. For CY 2014, the CPI-U update is projected to be 1.4 percent. The MFP adjustment is projected to be 0.5 percent, resulting in an MFP-adjusted CPI-U update of 0.9 percent for CY 2014. In addition, CMS is proposing that certain ancillary or adjunctive services that would be packaged under the OPPS for CY 2014 also would be packaged under the ASC payment system for CY 2014.
In the OPPS/ASC proposed rule, total CY 2014 OPPS payments are projected to increase by $4.37 billion or 9.5 percent, and CY 2014 Medicare payments to ASCs are projected to increase by approximately $133 million or 3.51 percent as compared to CY 2013. The CY 2014 OPPS/ASC proposed rule would also expand the categories of related items and services packaged into a single payment for a primary service under the OPPS; create 29 comprehensive APCs to replace 29 existing device-dependent APCs; streamline the current five levels of outpatient visit codes; and continue paying at ASP+6 percent for non-pass-through drugs and biologicals that are covered separately under the OPPS.
The proposed rule would add five new measures for the Hospital Outpatient Quality Reporting (OQR) program, affecting payment in CY 2016, with data collection beginning in CY 2014. It seeks comment on proposed changes to the Quality Improvement Organization regulations.
CMS will accept comments on these proposed rules until Sept. 6, 2013, and will respond to comments in final rules to be issued by Nov. 1, 2013.
IRS Proposed Rule For Tax Credits Issued on Exchanges
On June 28, the IRS issued a proposed rule on specific information regarding premium tax credits the insurance exchanges must report to IRS and to the person receiving the tax credit. Under the proposed rule, IRS explains what specific information regarding the tax credits the exchanges must report to IRS and to the person receiving the tax credit. Under ACA, tax credits can be made available to eligible recipients each month. The proposed rule would require the exchanges to report the required information to the IRS on a monthly basis and to the recipient on an annual basis. The information the exchanges must report would include, among other things, the name, address, taxpayer identification -- i.e., Social Security -- number (or date of birth if a taxpayer ID number is not available), the monthly premium for the applicable benchmark plan used to compute the tax credit and the monthly premium for the plan or plans in which a taxpayer, responsible adult or family member enrolls, without reduction for advance credit payments. According to the proposed rules, the exchange would report the information to the IRS on or before the 15th day following each month of coverage. The exchange must also send the tax credit recipient an annual statement including the same information on or before Jan. 31 of the year following the calendar year of coverage. Comments are due Aug. 31.
CMS Proposed Dialysis Payment Rule
CMS has issued the proposed End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) rule for renal dialysis services furnished to beneficiaries on or after Jan. 1, 2014. CMS projects the updated calendar year (CY) 2014 ESRD bundled market basket increase will be 2.9 percent, which is reduced by an estimated multi-factor productivity (MFP) adjustment for CY 2014 of 0.4 percent, for a projected update of 2.5 percent to the ESRD PPS base rate in CY 2014. Section 632(a) of the American Taxpayer Relief Act of 2012 requires the Secretary to make reductions to the ESRD PPS base rate to reflect the Secretary's estimate of the change in the utilization of ESRD-related drugs and biologicals by comparing per patient utilization data from 2007 with such data from 2012. This adjustment results in an overall 12 percent reduction in Medicare payments for CY 2014. The rule seeks comment on whether this change should be phased in over more than one year.
As a result of the application of the ESRD bundled market basket update reduced by the MFP adjustment, the wage index budget-neutrality adjustment and the drug utilization adjustment, CMS projects the proposed updates for CY 2014 would decrease total payments to all ESRD facilities by 9.4 percent compared with CY 2013.
The rule also proposes changes to the ESRD Quality Incentive Program (QIP) for payment year (PY) 2016.
The proposed rule also addresses issues related to the coverage and payment of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS), including clarification of the definition of routinely purchased DME; clarification of the grandfathering provision related to the three-year minimum lifetime requirement; and implementation of budget-neutral fee schedules for splints, casts and intraocular lenses (IOLs) inserted in a physician's office.
View the proposed rule. CMS will accept comments on the proposed rule until Aug. 30, 2013.
Proposed Rule on Home Health Payments
On June 27, CMS published a proposed rule to update Medicare's Home Health Prospective Payment System (HH PPS) payment rates and wage index for calendar year (CY) 2014. The rule proposes rebasing adjustments, with a four-year phase-in, to the national, standardized 60-day episode payment rates, the national per-visit rates and the NRS conversion factor. Payments to home health agencies (HHAs) are estimated to decrease by approximately 1.5 percent, or $290 million in CY 2014, reflecting the combined effects of the 2.4 percent HH payment update percentage ($460 million increase); the rebasing adjustments to the national, standardized 60-day episode payment rate; the national per-visit payment rates; the NRS conversion factor ($650 million decrease); and the effects of ICD-9 coding adjustments ($100 million decrease). This proposed rule would also establish home health quality reporting requirements for CY 2014 payment and subsequent years and proposes to specify that Medicaid responsibilities for home health surveys be explicitly recognized in the State Medicaid Plan, which is similar to current regulations for surveys of Nursing Facilities (NF) and Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF-IID). Comments must be received by Aug. 26.
Final CMS Rule on Improving Coordination Between Long-Term Care Hospitals and Hospices
CMS issued a rule June 26 that aims to improve care coordination between long-term care (LTC) hospitals and hospice facilities; the new rule, which goes into effect Aug. 26, 2013, clearly defines the role of each provider in delivering and maintaining the continuity of care for each patient. Because LTC facilities and hospitals provide many of the same services, there is a high possibility that residents could receive duplicative and/or conflicting services. In general, LTC facilities are usually responsible for nursing services, dietary services, physician services, dental service, pharmacy services, specialized rehabilitative services and, when necessary, laboratory and social services. The new rule mandates that LTCs that choose to arrange for the provision of hospice care enter into written agreements with Medicare-certified hospice providers of the specific services to be provided by each entity in order to reduce overlap. "We believe that a clear division of responsibilities and increased communication required by this rule will help eliminate duplication of and/or missing services," CMS said in the rule. As the rule stands, the written agreement of care will unanimously be applied to all residents within the LTC facility, not individual patients. Criticisms of the new rule are largely based on the extra burden to providers, as it will take staff time to develop the language for the one written agreement describing the allocated care services. It is estimated that the burden associated with first-year implementation of this rule is 80,695 hours or $5.5 million for the 16,139 LTC facilities affected.
Proposed Rule to Clarify Long-Term Care Ombudsman Program
The Administration on Aging (AoA) of the Administration for Community Living (ACL) within the Department of Health and Human Services (HHS) has issued a Notice of Proposed Rulemaking, with request for comments, to implement provisions of the Older Americans Act, the State Long-Term Care Ombudsman program. This proposed rule replaces AoA's 1994 Notice of Proposed Rulemaking. The proposed rule contains two main parts, both related to the ombudsman program:
An amendment to existing regulations promulgated under the Older Americans Act at 45 C.F.R. Part 1321, and a new Part 1327, which would be added to the existing regulations. The proposed amendment to existing regulations addresses responsibilities of state agencies housing long-term care ombudsman offices not to disclose the identity of any person sending a complaint to the ombudsman or the identity of any resident of a long-term care facility. In addition, the proposed amendment would extend the disclosure protections to include "files, records, and other information" instead of only "files" as the existing rule provides.
The newly proposed Part 1327 would define the following terms included in the Older Americans Act, including "immediate family," "office of the state long-term care ombudsman" and "representative of the office of the state long-term care ombudsman." Comments are due Aug. 19.
Work Remains in Development of Insurance Exchange Data Hub
According a report by the HHS-OIG, entitled "Observations Noted During the OIG Review of CMS's Implementation of the Health Insurance Exchange-Data Services Hub," several critical tasks remain to be completed in a short period of time. During the development process CMS will attempt to develop security controls of the Hub, such as the final independent testing of the Hub's security controls, remediating security vulnerabilities identified during testing, and obtaining the security authorization decision for the Hub before opening the exchanges. The Data Hub would act as a router of information between exchanges and government agencies to assist in determining the eligibility of consumers applying for enrollment in the exchanges, as well as the related advanced-tax credits that will help consumers purchase health insurance in the exchanges. CMS's current schedule is to complete all its tasks by Oct.1, 2013, in time for the expected initial open enrollment period.