DECEMBER 8, 2016
What do
medical research, Medicaid provider adequacy, and Star Ratings have in common?
The 21stCentury Cures Act. On January 7, 2016, Congress
overwhelmingly passed this piece of legislation – a package of proposals which
will provide $6.3 billion for medical research over the next decade.
Despite
the broad support from both parties, the legislation is not without criticism.
The new bill provides less money than initially proposed and will about take
about $3.5 billion from Obamacare’s prevention and public health funds.
However, the general consensus is the advancements of the legislation “far
outweigh” the concerns, as put by the White House. Adding Vice President
Biden’s cancer “moonshot” project, as well as funding for opioid treatment and
mental health, into the mix really drives home the fuzzy bipartisan feeling of
the act.
And
that notion brings our focus back to Medicare and Medicaid. A bill with strong
bipartisan support and a plethora of proposals immediately creates the prime
opportunity for Congressmen to fulfill their holiday wish lists. Here are some
notable standouts:
Medicare
Advantage:
·
Delay in Authority to Terminate Contracts for Medicare Advantage
(MA) Plans Failing to Achieve Minimum Quality – This provision delays for three
years the authority to terminate MA contracts based on plans failing to achieve
minimum quality ratings under Star Ratings. This does not prevent the Centers
for Medicare & Medicaid Services (CMS) from terminating plans for the other
10 performance categories considered in the Past Cycle Performance Review at
any time. “One of CMS’ most important strategic goals is improving the quality
of care and health status of beneficiaries, which is measured by the Star Ratings program. It’s hard to
imagine plans consistently performing below 3 stars are achieving that goal,
and it’s unfortunate CMS’ authority to reinforce this goal has been relaxed
through this legislation,” notes Melissa Smith, Vice President of Stars at
Gorman Health Group (GHG).
·
Preservation of Medicare Beneficiary Choice under MA – This
provision brings back the three-month open enrollment provision. Beginning in
2019, an MA-eligible individual, during the first three months of any year, may
now change a previous election to receive benefits through the original
Medicare fee-for-service (FFS) program or an MA plan and to elect coverage
under part D. This is something we initially predicted would come out in 2017
under Ryan’s agenda but was easily wrapped into the Cures package.
·
Allowing End-Stage Renal Disease (ESRD) Beneficiaries to Choose
an MA Plan – This section allows individuals suffering from ESRD to enroll in
any MA plan for plan years beginning in 2021. The legislation will remove the
standard acquisition costs (SACs) for kidneys from the benchmark and bid. SACs
would be compensated for by traditional Medicare. The section also calls for an
adjustment to the CMS-Hierarchical Condition Category (HCC) Risk Adjustment
Model to improve accuracy by directing the Secretary to take into account the
total number of diseases, multiple years of data, and Medicare-Medicaid dual
eligibility status.
Medicaid
·
Oversight of Termination of Medicaid Providers – This will
require providers participating in Medicaid or the Children’s Health Insurance
Program (CHIP) to enroll with the state into an oversight program and will
increase required reporting, sharing of information, and standardization of
documentation of reasons for termination.
·
Publication of Medicaid FFS Provider Directory – Requires State
Medicaid programs to provide beneficiaries served under FFS or primary care
case management (PCCM) programs with an electronic directory of physicians
participating in the program. The directory would include the physician’s name,
specialty, address, and telephone number for each physician serving as a case
manager through PCCM programs. Additionally, for physicians serving as case
managers, the directory would need to include information on whether the
physician is accepting new patients and the physician’s cultural and linguistic
capabilities.
Other:
·
Medicare Access and CHIP Reauthorization Act (MACRA) Payment
Adjustment – Reduces the payment update under MACRA from 0.5% to 0.4588% in
fiscal year 2018.
·
Updating the Welcome to Medicare Package – The Secretary of the
Department of Health and Human Services (HHS) will be required to revise the
pre-Medicare eligibility enrollment notification to include, in a simpler
format, the options available under Medicare, including MA, Medicare FFS, and
Part D. Stakeholders should expect HHS to quickly reach out as it is required
to solicit recommendations on what this notice should include.
·
Enrollment Data Reporting – Requires the Secretary to publish
Medicare enrollment data by Congressional District, ZIP code, and state on an
annual basis
·
Changes to Medicare Shared Savings Program (MSSP) – This section
contains additional requirements to how Medicare FFS beneficiaries are assigned
to Accountable Care Organizations (ACOs). The new law would require the basis
for assignment to reflect beneficiaries’ utilization of not only primary care
services provided by ACO physicians, but also those furnished in federally
qualified health centers or rural health clinics.
These
are just some of the changes the Medicare and Medicaid programs will see, and
the gargantuan bill contains a minutiae of other changes for which
organizations should be on notice. Contact
us for assistance in digesting these or any other legislative
developments.
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