Tag: Medicaid

CMS Proposes to Reduce State Medicaid Requirements for Monitoring Access

CMS proposes to reduce state Medicaid requirements for monitoring access | DAS Health

CMS has issued a proposed rule relaxing certain administrative requirements in states with high Medicaid managed care populations.

Under the proposal, states would not have to analyze and monitor access to care if an overwhelming share of covered lives received care through managed care plans.

The rule would also make it easier for all states to make minor cuts to fee-for-service payment rates.

The proposal is part of the Trump administration’s drive to roll back regulations and reduce administrative red tape.

Currently, states must develop and submit an access monitoring review plan for Medicaid services provided via fee-for-service. The review plan must identify a data-driven means to review access to care, including availability of care through enrolled providers and changes in beneficiary service utilization. If states reduce Medicaid service rates, the affected services must be added to the review plan and the effects monitored for three years.

The proposed rule would change that by exempting states with an overall Medicaid managed care penetration rate of 85% or more from most access monitoring requirements. States meeting the threshold would attest to such at the start of each year. Currently, 17 states meet that criteria.

Further, provider payment cuts of less than 4% in overall service category spending for a given year, or 6% for two consecutive years, would be exempt from access analysis. And states making cuts to Medicaid payment rates would be able to use baseline information on access under current payment rates rather than having to predict how those rate reductions would impact access to care.

CMS said its goal is to do less micromanaging of state programs and focus instead on measurable program outcomes and holding states accountable for results.

The agency is accepting comments on the proposed changes through May 22.

Feds Approve Kentucky Waiver that Requires Medicaid Enrollees to Work

Feds approve Kentucky waiver that requires Medicaid enrollees to work | DAS Health

Kentucky has become the first state to win federal approval for a Medicaid waiver that includes work requirements for beneficiaries.

The state’s demonstration project, which the Trump administration approved on Friday, would require able-bodied, nonelderly enrollees to complete 80 hours per month of “community engagement activities” to remain eligible for Medicaid. Those activities could include employment, education, job skills training and community service, according to a fact sheet.

Certain beneficiaries would be exempt from the community engagement requirements, such as pregnant women, full-time students and those considered medically frail.

The waiver also gives the state the authority to require beneficiaries to pay monthly premiums based on their income. Premiums could be as low as $1 per month or as high as 4% of household income. If people who are above the poverty line fail to pay the required premiums, they could be locked out of the Medicaid program for six months.

In addition, the state will implement a tool called My Rewards Account, which provides incentives for beneficiaries to engage in healthy behaviors and community engagement, plus a tool called the Deductible Account, which aims to inform beneficiaries about the cost of healthcare.

The Trump administration’s approval of Kentucky’s waiver comes in the same week that it issued new guidance for states looking to test programs that include work requirements for beneficiaries.

Indeed, the Centers for Medicare & Medicaid Services said in its approval letter to Kentucky officials that other states should emulate its program.

“Your substantial work will help inform future state demonstrations seeking to draw on Kentucky’s novel approaches to Medicaid reform, and CMS also looks forward to learning from the outcomes of your demonstration project,” the letter said.

CMS Releases 2018 Physician Fee Schedule

Physician Fee Schedule for 2018 | DAS Health

Physicians will receive a small increase in Medicare payments under the 2018 Physician Fee Schedule.

The Centers for Medicare & Medicaid Services issued a final rule (PDF) on Thursday for the 2018 Physician Fee Schedule, which increases payments by 0.41%.

The new rate, CMS said in a fact sheet, reflects the additional 0.50% update established under the Medicare Access and CHIP Reauthorization Act of 2015, reduced by 0.09%, due to the misvalued code target recapture amount, required under the Achieving a Better Life Experience Act of 2014. The final conversion factor is $35.99, an increase from $35.89 in 2017.

RELATED: CMS Expands Threshold for MACRA Exemption

In addition, CMS said in an announcement that beginning in 2018 the agency will update payment for biosimilars, lower-cost alternatives to certain types of drugs known as “biologicals.” This change promotes competition to ensure that millions of patients will have access to new lower cost therapies, the agency said.

Furthermore, the agency said it would transform access to Medicare telehealth services by paying for more services and making it easier for providers to bill for these services. Improving access to telehealth services reflects CMS’ work to modernize Medicare payments to promote patient-centered innovations.

Perhaps the most controversial change in the Fee Schedule is the agency’s decision to cut 20% from payments for certain services to off-campus provider-based hospital departments. These services are no longer paid under the Outpatient Prospective Payment System, and CMS has changed the payment rates for these services from 50% of the OPPS payment rate to 40%. The agency said it believes that this adjustment will provide a more level playing field for competition between hospitals and physician practices by promoting greater payment alignment.

But Blair Childs, senior vice president of public affairs at Premier, an alliance of approximately 3,900 U.S. hospitals and health systems and approximately 150,000 other providers and organizations, said the alliance was disappointed by the action because it fails to reflect the higher costs that these sites incur relative to free-standing physician offices.

“This decision will reverse momentum toward providing care across the continuum. At this transitional moment where the industry is moving from fee-for-service to value-based payment, this decision undermines the movement to provide care outside the walls of the hospital, potentially leading to increased Medicare spending,” Childs said.

Study: Value-Based Programs May Harm Practices That ‘Disproportionately Serve High-Risk Patients’

Value-based payment programs may financially harm practices that disproportionately serve high-risk patients.

  • A new JAMA report that reviewed the first year of the Medicare Physician Value-Based Payment Modifier (PVBM) Program found providers who served “more socially high-risk patients had lower quality and lower costs, and practices that served more medically high-risk patients had lower quality and higher costs.”
  • The finding led to fewer bonuses and more penalties for high-risk practices.
  • The study authors said value-based payment programs may financially harm practices that “disproportionately serve high-risk patients.”



CMS created the PVBM to measure the quality and cost of care provided to Medicare beneficiaries. The program bases payments on providers’ performance on quality and cost measures and rewards quality performance and lower costs.

The agency began to phase in practices to the program in 2015 based on 2013 performance and then planned to expand it to solo practices and later to physician assistants, nurse practitioners, clinical nurse specialists and certified registered nurse anesthetists.

The study reviewed 899 physician practices with nearly 5.2 million beneficiaries that participated in the PVBM, a mandatory pay-for-performance program. Authors studied program payments in 2015 and compared them to 2013 fee-for-service (FFS) Medicare numbers.

The JAMA study’s finding that more medically high-risk patients had lower quality and higher costs is eye-opening. Those patients are usually the most costly and payment models will need to figure out ways to reduce those costs while not penalizing physicians if value-based programs are successful. A payment model that only lowers costs and improves care to healthy people won’t move the needle.

Even worse, if physicians are penalized, what incentive do doctors have to care for the sickest Medicare patients?

The JAMA report will likely not quell physician fears about how value-based programs may lead to lower Medicare payments. It also won’t satisfy individuals concerned that changes to the healthcare system may harm the most vulnerable, which is always a worry when there are major healthcare changes.

The JAMA study isn’t the first to show value-based programs as a mixed bag. Recent studies have shown that it hasn’t consistently improved outcomes and costs.

One key finding about value-based care so far has been that experience in the model plays an important role in whether a provider has success. Organizations with the most success under value-based programs have often spent years creating clinically integrated networks, James Landman, director of healthcare finance policy at the Healthcare Financial Management Association, recently told Healthcare Dive.

“If you look at the data for the Medicare Shared Savings Program, which is the biggest of the ACO programs under CMS, there is a correlation between time spent in the program and the ability to generate savings,” Landman said.

CMS is watching the results of value-based payment models like PVBM closely. The federal agency hopes to transfer 50% of traditional FFS Medicare payments to alternative payments models by next year.

CMS has slowed down the move to value-based payments, but that’s more due to the change in administration and slowly grinding gears of government than a move away from value-based programs.The federal agency has delayed the start of some programs to next year as well as paused expanding others.

Quality Payment Program Hardship Exception Application for 2017 Now Open

Quality Payment Program Hardship Exception Application for the 2017 transition year is now available
Photo from CMS.gov

Clinicians Can Now Submit Quality Payment Program Hardship Exception Applications

The Quality Payment Program Hardship Exception Application for the 2017 transition year is now available on the Quality Payment Program website.

MIPS eligible clinicians and groups may qualify for a reweighting of their Advancing Care Information performance category score to 0% of the final score, and can submit a hardship exception application, for one of the following specified reasons:

  • Insufficient internet connectivity
  • Extreme and uncontrollable circumstances
  • Lack of control over the availability of Certified EHR Technology (CEHRT)

There are some MIPS eligible clinicians who are considered Special Status, who will be automatically reweighted (or, exempted in the case of MIPS eligible clinicians participating in a MIPS APM) and do not need to submit a Quality Payment Program Hardship Exception Application.


About the Hardship Exception Application Process

In addition to submitting an application via the Quality Payment Program website, clinicians may also contact the Quality Payment Program Service Center and work with a representative to verbally submit an application.

To submit an application, you’ll need:

  • Your Taxpayer Identification Number (TIN) for group applications or National Provider Identifier (NPI) for individual applications;
  • Contact information for the person working on behalf of the individual clinician or group, including first and last name, e-mail address, and telephone number; and
  • Selection of hardship exception category (listed above) and supplemental information.

If you’re applying for a hardship exception based on the Extreme and Uncontrollable Circumstance category, you must select one of the following and provide a start and end date of when the circumstance occurred:

  • Disaster (e.g., a natural disaster in which the CEHRT was damaged or destroyed)
  • Practice or hospital closure
  • Severe financial distress (bankruptcy or debt restructuring)
  • EHR certification/vendor issues (CEHRT issues)

Please note: Once an application is submitted, you will receive a confirmation email that your application was submitted and is pending, approved, or dismissed. Applications will be processed on a rolling basis.


Explanation of Special Status Calculation

The Centers for Medicare and Medicaid Services (CMS) has introduced new information on the Quality Payment Program website that indicates whether clinicians have “special status” and can therefore be considered exempt from the Quality Payment Program.

To determine if a clinicians’ participation should be considered as special status under the Quality Payment Program, CMS retrieves and analyzes Medicare Part B claims data. A series of calculations are run to indicate a circumstance of the clinician’s practice for which special rules under the Quality Payment Program will affect the number of total measures, activities or entire categories that an individual clinician or group must report. These circumstances are applicable for clinicians in: Health Professional Shortage Area (HPSA), Rural, Non-patient facing, Hospital Based, and Small Practices.

For more information, please visit the Quality Payment Program website.


For Physicians, Rates Nearly the Same for Medicare and Medicare Advantage

Medicare and Medicare Advantage Plans Cost | DAS Health

When it comes to payment rates, physicians aren’t seeing much of a difference between traditional Medicare and Medicare Advantage plans, according to a new study.

Advantage plans managed by private insurers pay doctors prices similar to Medicare rates, according to the study led by University of Southern California researchers, which was published in JAMA Internal Medicine. However, on some services or equipment, commercial insurers have an advantage, the study found.

“With 1 in 3 beneficiaries enrolled in Medicare Advantage, it is important to look under the hood and get a better understanding of how these plans operate,” Erin Trish, the study’s lead author and an assistant research professor at the USC Schaeffer Center for Health Policy and Economics, said in a university announcement.

“We found that physician reimbursement rates in Medicare Advantage are very similar to traditional Medicare. This is very different than what we see in the commercial insurance market, where insurers tend to pay physicians more than Medicare—sometimes much more,” she said.

In the study, researchers analyzed a sample of 144 million claims from 2007 to 2012 in metropolitan areas and compared reimbursement rates for 11 common procedures. They found mean Medicare Advantage reimbursement rates nearly matched the traditional Medicare rate in many cases, such as the rate for an office visit, which was 97% of the Medicare rate.

Those findings raise the question of how reforms under discussion, which would transition the program toward a premium support model, could affect how physicians and other clinicians are paid, the study said.

The study also looked at prices paid for commercial insurance patients. In general, commercial insurers paid higher prices for procedures. However, for a few services, commercial prices were lower than traditional Medicare.