2015 National Training Program. Lessons. Lesson 1 Legislative Updates. Module 4. Current Topics. July 2015

Transcription

1 2015 National Training Program Module 4 Lessons 1. Legislative Updates 2. CMS Goals and Initiatives 3. Medicare Updates 4. Medicaid/Children s Health Insurance Program Updates 2 Lesson 1 Legislative Updates Affordable Care Act (ACA) Medicare Access and CHIP Reauthorization Act of 2015 () Strengthening Medicare and Repaying Taxpayers Act of 2012 (SMART Act) 3 1

2 Lesson 2 CMS Goals and Initiatives Paying Providers for Value, not Volume Medicare Shared Savings Program Open Payments Initiatives Independence at Home Demonstration Oncology Initiative Medicare Care Choices Model Million Hearts 5-Star Rating System for Additional CMS Compare Websites 4 Lesson 3 Medicare Updates Program Enrollment Medicare Access and CHIP Reauthorization Act Medicare Provisions Preventive services Medicare Secondary Payer Recovery Medicare Advantage (Part C) Medicare Prescription Drug Coverage (Part D) 5 Medicare Program Enrollment 2015 Average Monthly Projected Enrollment in Millions Medicare Parts A and/or B 55.2 Aged 46.1 Disabled 9.1 Original Medicare Enrollment 39 Prepaid Enrollment 16.2 Medicare Advantage Enrollment 15.7 Part D (Medicare Advantage with Rx Coverage and * May not add up due to rounding. Prescription Drug Plans)

3 Medicare Access and CHIP Reauthorization Act Medicare Provisions Sustainable Growth Rate (SGR) Repeal and Medicare Provider Payment Empowering Beneficiary Choices through Continued Access to Information on Physicians Services Medicare and Other Health Extenders Savings to Medicare and Medicaid programs Protecting the Integrity of Medicare Act of 2015 (PIMA) Prohibition of Inclusion of Social Security Numbers on Medicare Cards Continuing Automatic Extension Of Providers Opt Out Election Income-related Premium Adjustment for Parts B and D Delay of Two Midnight Rule Medigap (Medicare Supplement Insurance) Policy Changes 7 SGR Repeal and Medicare Provider Payment Modernization Provisions to replace the Sustainable Growth Rate (SGR) formula to provide long-term stability to the Medicare physician fee schedule Provides stable updates for 5 years and ensures no changes are made to the current payment system for 4 years Establishes a streamlined and improved incentive payment program that will focus the fee-for-service system on providing value and quality Consolidates the 3 existing incentive programs, continuing the focus on quality, resource use, and meaningful electronic health records (EHRs) Provides financial incentive(s) for professionals to participate in tests of alternative payment models (APMs) 8 Empowering Beneficiary Choices through Continued Access to Information on Physicians Services New publicly available information on doctors and other eligible providers on items and services furnished to Medicare beneficiaries Number of services furnished Submitted charges and payments for such services The information would be searchable by the specialty or type of professional; characteristics of the services furnished; and location Information on Physician Compare by

4 Medicare and Other Health Extenders Extends increased payments for certain low-volume and small rural hospitals, doctors, therapy services, and ambulance providers Through either fiscal year 2017 or calendar year 2017 Depending on Medicare s payment system to that type of provider Extension of therapy cap exceptions process Until January 1, 2018, and reforms the process of medical manual review to help support the integrity of the Medicare program Extension for specialized Medicare Advantage (MA) Plans for special needs individuals (Special Needs Plans) This provision extends authority for SNPs through December 31, 2018 Permanent extension of the Qualifying Individual (QI) program Extends Transitional Medical Assistance under Medicaid 10 Savings to Medicare and Medicaid programs Significant provisions include Higher income thresholds starting in 2018 for determining Part B and Part D premium subsidies Beginning in 2020, more people will pay higher Part B and Part D premiums due to a change in the indexing of income thresholds Payment rate in 2018 for skilled nursing facilities, inpatient rehabilitation facilities, home health agencies, hospices and long-term care hospitals would be limited to 1% Planned 3.2% increase in inpatient hospital payment rate replaced by 0.5% increase each year from Protecting the Integrity of Medicare Strengthening Medicare s ability to fight fraud and build on existing program integrity policies Prohibiting Social Security numbers on Medicare cards (no later than 4 years after enactment) Preventing payments for items and services furnished to incarcerated individuals, individuals not lawfully present, and deceased individuals Modifying Medicare Durable Medical Equipment Face-to-Face Encounter Documentation Requirement Requiring Valid Prescriber National Provider Identifiers on Pharmacy Claims (starting plan year 2016) Option to Receive Medicare Summary Notice Electronically (starting in Fall of 2015) 12 4

5 Prohibition of Inclusion of Social Security Numbers on Medicare Cards Prohibits Social Security account numbers on Medicare cards starting in 2019 The new Medicare Beneficiary Identifier (MBI) will be Recognizably different than the Medicare Health Insurance Claim Number (HICN) The same length as the HICN Displayed on the Medicare cards Will be used by external partners (Beneficiary, Provider, Plans, etc.) participating in claims processing and other related activities when interacting with CMS 13 Continuing Automatic Extension Of Providers Opt Out Election Extend Opt Out election beginning on the date the affidavit is signed to include each subsequent 2-year period Unless the physician or practitioner provides notice not later than 30 days before the end of the previous 2-year period Beginning not later than February 1, 2016, make the list publicly available through website Number and characteristics of opt-out physicians and practitioners 14 Income-related Premium Adjustment for Parts B and D Modified Adjusted Gross Income Threshold for Years Prior to 2018 More than $85,000 but not more than $107,000 More than $107,000 but not more than $160,000 More than $160,000 but not more than $214,000 Modified Adjusted Gross Income Threshold for Years Beginning in 2018 More than $85,000 but not more than $107,000 More than $107,000 but not more than $133,500 More than $133,500 but not more than $160,000 Applicable Percentage 35% 50% 65% More than $214,000 More than $160,000 80% Beginning in 2020, the income thresholds would be adjusted each year by increasing the previous year s income threshold amounts by the consumer price index for urban consumers. 15 5

6 Delay of 2-Midnight Rule Allows CMS to continue use of the Medicare Administrative Contractor (MAC) probe and educate program to assess provider understanding and compliance with the 2-Midnight Rule On a pre-payment basis Through September 30, 2015 Allows CMS to identify providers that have properly understood and implemented the 2-midnight benchmark, and those providers who might benefit from additional education, as evidenced by high claim error rates 16 Medigap (Medicare Supplement Insurance) Policy Changes Limitation on certain Medigap policies for people newly eligible for Medicare On or after January 1, 2020 Medigap policies sold to newly eligible Medicare beneficiaries Will no longer provide coverage for the Part B deductible Newly eligible means an individual who, before January 1, 2020, is neither 65, nor has Part A Plans C and F will become Plans D and G respectively for policies sold to those newly eligible Policies bought before January 1, 2020, won t be affected Section 1882 SS Act 17 New Medicare Preventive Services Multi-target stool DNA test (Cologuard ) Covered for certain people with Medicare every 3 years if they Are between Show no signs or symptoms of colorectal disease Are at average risk for developing colorectal cancer Hepatitis C Screening Single once-in-a-lifetime screening test Covered for adults who don't meet the high-risk determination Born from 1945 through 1965 ACA 18 6

7 Medicare Preventive Services Continued Lung cancer screening Low Dose Computed Tomography once per year for certain people with Medicare Pneumococcal vaccine update An initial pneumococcal vaccine for all Medicare beneficiaries who ve never received the vaccine under Medicare Part B A different second pneumococcal vaccine 1 year after the first vaccine was administered (11 full months have passed following the month in which the last pneumococcal vaccine was administered) All people with Medicare are eligible No copayment or deductible for the vaccines with Original Medicare if the provider accepts assignment ACA 19 Strengthening Medicare and Repaying Taxpayers Act of 2012 SMART Act final rule effective April 28, 2015 Established a formal appeals process for applicable plans where the Secretary seeks Medicare Secondary Payer (MSP) recovery directly from an applicable plan Liability insurance Self Insurance No-fault insurance Workers compensation laws or plans Applicable plan may appeal the amount of the debt and/or the existence of the debt Medicare is required to send a notice to people with Medicare who received the items or services at issue SMART 20 Medicare Advantage Plans (Part C) Expanded rewards and incentive programs Low-performing plans 21 7

8 Medicare Advantage Organizations Expanded Rewards and Incentives Focus on encouraging participation in activities that promote Improved health Prevention of injuries and illness Efficient use of health care resources Can t discriminate based on race, gender, chronic disease, institutionalization, frailty, health status, or other impairments Must be designed so all enrollees are able to earn rewards Can t be offered in the form of cash or other monetary rebates or be used to target potential enrollees Reg 4159-F 22 Low-Performing Health Plan (LPP) Termination Termination of consistently low-performing plans (LPPs) on December 31, 2016 If plan receives Part C or Part D summary score of less than 3 stars for 3 consecutive years Plans will be identified when plan ratings data is released in early October 2015 LPPs currently have icon on Medicare Plan Finder Affected beneficiaries will have an opportunity to join a new plan 23 Medicare Prescription Drug Coverage (Part D) Requirements for Prescribers Low Performing Plan Terminations Improved Coverage in the Coverage Gap Access to Preferred Cost-Sharing Pharmacies 24 8

9 Requirement for Prescribers CY 2015 final rule issued May 23, 2014 requires prescribers of Part D drugs Be enrolled in an approved status, or Have a valid opt-out affidavit on file for their prescriptions to be covered under Part D CMS-4159-F 25 Requirement for Prescribers Continued The June 1, 2015, interim final rule changed enforcement date to June 1, 2016 Requires pharmacy claims and beneficiary requests for reimbursement for Part D prescriptions Written by prescribers other than physicians and eligible professionals permitted by state or other applicable law to prescribe medications Not be rejected at point of sale by the plan if all other requirements are met Requires plans to allow a provisional 3-month supply When prescription is written by a prescriber eligible to enroll but who isn t enrolled in or opted out of Medicare CMS-4159-F 26 Preferred Cost Sharing Pharmacies (PCSPs) Outliers Plans will be required to make disclosures of their outlier status in 2016 plan marketing materials if their network analysis finds that their plans offer access to a PCSP within 2 miles of fewer than 40% of urban beneficiaries residences; 5 miles of fewer than 87% of suburban beneficiaries residences; or 15 miles of fewer than 70% of rural beneficiaries residences. CMS will take compliance actions if plan doesn t provide the required disclosures 27 9

10 Access to Preferred Cost-Sharing Pharmacies (PCSPs) Some plans offer very low access to PCSPs in certain geographic area types compared to other plans Urban, suburban, and rural CMS will publish information on PCSP access for each plan offering preferred cost-sharing by geographic area type CMS will identify outliers and work with plans that are extreme outliers to address access and marketing representation Final CY 2016 Call Letter 28 Low-Performing Prescription Drug Plan (LPP) Termination Termination of consistently low-performing plans (LPPs) on December 31, 2016 If plan receives a summary score of less than 3 stars for 3 consecutive years Plans will be identified when plan ratings data is released in early October 2015 LPPs currently have icon on Medicare Plan Finder Affected beneficiaries will have an opportunity to join a new plan 29 Improved Coverage In The Coverage Gap Year What You Pay for Covered Brand-Name Drugs in the Coverage Gap What You Pay for Covered Generic Drugs in the Coverage Gap % 65% % 58% % 51% % 44% % 37% % 25% 06/01/2015 Understanding Medicare 30 10

11 Lesson 4 Medicaid/Children s Health Insurance Program (CHIP) Updates Medicaid and Children s Health Insurance Program (CHIP) Enrollment Medicare Access and CHIP Reauthorization Act CHIP provisions 31 Medicaid and Children s Health Insurance Program (CHIP) Enrollment 2015 Average Monthly Projected Population in Millions* Medicaid Total 66.7 Aged 5.5 Blind/Disabled 9.8 Children 29.3 Adults 15.1 Expansion Children.7 Expansion Adult 6.4 *Doesn t Children s add up Health due to rounding Insurance Program Implementation of Fingerprint-Based Criminal Background Checks Medicaid agencies are required to screen all provider applications, including initial applications, applications for a new practice location, and applications for re-enrollment or revalidation, based on a categorical risk level of limited, moderate, or high Starting July 31, 2015 State Medicaid agencies must establish categorical risk levels for providers and provider categories who pose an increased financial risk of fraud, waste or abuse to the Medicaid program When the agency determines that a provider s categorical risk level is high, or when the agency is otherwise required to do so under state law, the agency must require providers to consent to criminal background checks, including fingerprinting 42 CFR

12 Medicare Access and CHIP Reauthorization Act CHIP provisions Preserves and extends CHIP funding through fiscal year 2017 Would likely provide enough funds to cover some amount of projected 2018 expenditures CHIP program is authorized through 2019 Extension of Express Lane Eligibility (ELE) Permits states to rely on findings, for things like income, household size, or other factors of eligibility, from another program designated as an Express Lane agency to facilitate enrollment in health coverage. Express Lane agencies may include SNAP, School Lunch, TANF, Head Start, and WIC Extension of Outreach and Enrollment Program 34 This training provided by the CMS National Training Program (NTP) For questions about training products To view all available NTP materials, or to subscribe to our list, visit Cms.gov/outreach-andeducation/training/cmsnationaltrainingprogram/. 12