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✶ Today’s Top Medicare New Stories You’ll Want to Read

New CMS rules for Medicaid plans will improve services

April 26, 2016 – The Obama administration tightened rules Monday for private insurance plans that administer most Medicaid benefits for the poor, limiting profits, easing enrollment and requiring minimum levels of participating doctors.

For consumers the most visible change may eventually be quality ratings intended to reflect Medicaid plans’ health results and customer experiences. The administration agreed to move slowly on such a sensitive industry issue, saying it would develop the scores over several years.

But the sweeping regulation, the biggest for Medicaid managed care in a decade, changes many aspects of how UnitedHealthcare, Aetna and other large contractors who administer care for some of the most vulnerable patients do business. It will:

· Require states to set rules ensuring Medicaid plans have enough physicians in the right places. The standards will include “time and distance” maximums to ensure doctors aren’t too far away from members.

· Limit insurer profits by requiring rate setting that assumes 85 percent of revenue will be spent on medical care. Unlike a similar rule for other plans, such as insurance sold through Obamacare marketplaces, the requirement would not compel Medicaid insurers to rebate the difference if they don’t hit 85 percent. Future rates would be adjusted instead.

· Make plans regularly update directories of doctors and hospitals. A 2014 investigation by the Department of Health and Human Services’ inspector general found that half the doctors listed in official insurer directories weren’t taking new Medicaid patients.

· Push plans to better detect and prevent fraud by providers, including mandatory reporting of suspected abuse to the states.

· Tighten rules for Medicaid plans and states to collect patient data and submit it to HHS.

· Make it easier for states to offer managed-care plans incentives to improve clinical outcomes, reduce costs and share patient information among hospitals and doctors.

“We’re taking a major step forward in our efforts to strengthen Medicaid and the Children’s Health Insurance Program,” said Vikki Wachino, deputy administrator for the Centers for Medicare & Medicaid Services. CMS is a division of HHS. CHIP offers low-cost coverage to children in some families that don’t qualify for Medicaid.

For years consumer advocates have pushed HHS to set stricter rules for managed-care plans, which they said too often favored profits over patients. The industry and some state Medicaid directors resisted, saying plans needed flexibility to serve different members in different states.

States operate Medicaid with big financial assistance from Washington. The 2010 Affordable Care Act substantially expanded Medicaid to include most low-income adults, but some states haven’t opted in.

Thirty-nine states and the District of Columbia outsource their Medicaid administration to managed care companies, which gives a degree of fiscal certainty and administrative relief. Of Medicaid’s 72 million members, nearly two-thirds are enrolled in managed-care plans, according to HHS.

The rules will be implemented in phases over the next three years, starting July 1, 2017.

✶ Read the Rules

Medicaid moving forward say Administration officials

April 26, 2016 – If you haven’t been paying close attention over the last several years, you may have missed some of the major changes that have taken place in the Medicaid program.

You may know that some 72 million Americans rely on Medicaid as their source of health insurance coverage this year – 14 million more than in October 2013 thanks largely to the Affordable Care Act’s coverage expansion. For millions of children who need checkups or follow up care, pregnant women who want their babies to get a healthy start in life, adults who need health coverage when they unexpectedly lose a job, or people with disabilities who want to live independently in their communities, Medicaid has been there over the last 50 years to provide comprehensive health coverage to millions low-income American families.

But a lot has happened to health insurance coverage through Medicaid over the past several years as millions more people have gained coverage because of the Affordable Care Act: The federal government and the states have sought to strengthen the program’s focus on the consumer, the delivery of high quality care, and providing greater access points, and on developing a modern set of rules.

Today, we’re taking a next step in that work today by finalizing a long-anticipated rule that updates how Medicaid works for the nearly two-thirds of beneficiaries who get coverage through private managed care plans.

These improvements modernize the way these managed care health plans operate so that Medicaid and CHIP continue to provide cost-effective, high quality care to consumers. The rule strengthens states’ efforts to support delivery system reform and authorizes the first-ever Medicaid and CHIP quality rating system so that states can publicly report plan quality information, and people can use that information to select plans.

It also deploys 21st century tools to improve beneficiary communications, like electronic notices to beneficiaries and creating online provider directories. It better aligns key rules and practices with those of Marketplace and Medicare Advantage, including the addition of reporting medical loss ratio to Medicaid to ensure managed care plans focus on delivering care, not profits. And the rule also helps strengthen and improve the delivery of health care to low-income children served by the Children’s Health Insurance Program (CHIP).

But before you look at a summary of these rules, it’s worth catching you up on other major developments in Medicaid that affect every aspect of the consumer’s experience–from enrolling, to accessing high quality care, to the availability of home and community-based services.

1. A modern enrollment experience. Applying and enrolling in Medicaid coverage is now easier than it once was and similar to the processes for applying for other health insurance programs.
Enrolling into Medicaid was once very complicated, involving lots of paperwork, long waits and in-person interviews. Now, most people apply on line, by phone, or at a location convenient for them. More convenient, one-stop enrollment is possible in part thanks to sophisticated technology pursuant to the Affordable Care Act that allows enrollee information to be verified electronically – and without paper documentation. In some states, as many as 50 percent of individuals now enroll through these automated processes.

2. Access to high quality physicians and other care providers. Access to quality health servicesis always a central focus of CMS, which was strengthened through new policies recently that seek to ensure access to care.
Today’s rules take additional steps that will more tightly align payment with better, more cost-effective care. And new rules create real accountability to ensure access to care is sufficient in key specialties.
Thanks in part to the work that CMS and states have done to make sure people have access to health services, adults with Medicaid coverage are just as likely to obtain primary care services as those with private insurance, while experiencing less difficulty paying their medical bills than others. And, people with Medicaid coverage report very high satisfaction, even higher than those who get health insurance through their place of employment.

3. Quality care to strengthen health outcomes. Medicaid is also transforming the delivery of care. States are making gains in using population based payments, episodes of care, and quality-based payments.
In addition, states operate 30 health home programs that focus on coordinating care for people with chronic conditions like obesity, diabetes and mental health conditions. Over the last several years, sates have undertaken significant efforts through State Innovation Models, integrated care models, and delivery system reform incentive programs to create alignment with physicians and hospitals to provide the highest quality of care. And we have proven that when we and states dedicate ourselves to changing the delivery of care, we get results.
Consider the role Medicaid has played in supporting seniors and people with disabilities to receive care in their communities. Twenty years ago, more than 80 percent of Medicaid spending on long-term services was on institutional care. Now, thanks to CMS’ and states’ work to make more options available, community-based care has significantly increased.
Medicaid has also partnered with several national organizations at the provider, consumer and state levels to help us think through ways to improve both the delivery and quality of care Medicaid and CHIP provides, such as the March of Dimes, the Medicaid State Dental Association and seven academic Centers of Excellence.

4. A platform for innovation. Medicaid innovates more quickly when states have the tools to respond to the needs of their residents. To help support these delivery system reforms through improvements to the coordination of patient care, states, with the support of CMS, are working to update legacy IT systems to ones that leverage proven IT methods.
This is key in helping to deploy tools, such as electronic health records, that improve the coordination of patient care, further supporting innovative efforts that lead to smarter spending and healthier people.

Most importantly, Medicaid is there when you need it, for working class families, working Americans, people falling on temporary hard times, or living with a disability.

Take Todd, a full time student with two part time jobs in Utah who was recently profiled by the Kaiser Family Foundation. He and his wife, Erin, were uninsured but had a new baby. They learned that Erin and their baby Jane were eligible for Medicaid.

“When we found out that my wife and Jane would be covered, it definitely felt like a burden lifted a weight off our shoulders,” Todd said. “We don’t make enough to really take care of ourselves the way we would like to.”

It’s because of people like Todd and Erin and people like you that we have invested so heavily and thoughtfully in Medicaid and put forward the rules we have today, which will also support physicians and hospitals and states in improving service, quality and health for millions of Americans.

Congress wins delay in new Medicare star rating of hospitals

April 21, 2016 – Bowing to pressure from the hospital industry and Congress, the Obama administration on Wednesday delayed releasing its new hospital quality rating measure just a day before its planned launch.

The new “overall hospital quality” star rating aimed to combine the government’s disparate efforts to measure hospital care into one easy-to-grasp metric. The Centers for Medicare & Medicaid Services now publishes more than 100 measures of aspects of hospital care, but many of these measures are technical and confusing since hospitals often do well on some and poorly on others.

The new star rating boils 62 of the measures down into a unified rating of one to five stars, with five being the best.

But this month, 60 senators and 225 members of the House of Representatives signed letters urging CMS to delay releasing the star ratings.

“We have heard from hospitals in our districts that they do not have the necessary data to replicate or evaluate CMS’s work to ensure that the methodology is accurate or fair,” the letter from the House members said.

In a notice sent Wednesday morning, CMS told Congress it would delay release of the star ratings on its Hospital Compare website until July.

“CMS is committed to working with hospitals and associations to provide further guidance about star ratings,” the notice said. “After the star ratings go live in their first iteration, we will refine and improve the site as we work together and gain experience.”

But in a conference call with hospital representatives, CMS officials said they might delay release of the ratings past July if they are still analyzing or revising the methodology, according to people who participated in the call.

Mortality, readmissions, patient experience and safety of care metrics each accounted for 22 percent of the star rating, while measures of effectiveness of care, timeliness of care and efficient use of medical imaging made up 12 percent in total.

The hospital industry for months has been urging this delay, arguing that many of the measures will not be relevant to patients seeking a specific service. For instance, a hospital’s death rate for Medicare patients might be irrelevant for a woman trying to decide where to give birth.

The industry’s major trade groups said in a letter to CMS that some hospitals perform poorly because their patients tend to be lower income and don’t have the support at home. Many of the nation’s most prestigious hospitals have been bracing for middling or poor ratings.

Rick Pollack, president of the American Hospital Association, said in a statement that “the delay is a necessary step as hospitals and health systems work with CMS to improve the ratings for patients, and the AHA commends CMS for their decision.“

Last year, CMS created a star rating to represent the views of patients in surveys. Two sets of researchers recently determined that hospitals with more stars in patient experience tended to have lower death and readmission rates.

Hospital Compare received 3.7 million unique page views last year, according to a paper published this month in the journal Health Affairs. The author, analyst Steven D. Findlay called the traffic “not at a level commensurate with [the] stature and potential” of the federal government’s health care facility comparison sites.

Dr. Ashish Jha, a Harvard School of Public Health researcher, said consumers will be more likely to use the unified star ratings, but this specific mix of measures raises concerns. “The idea that dying and being readmitted to the hospital are equally important to patients seems funny to me,” he said.

It's easy on Medicare to get Extra Help with prescription costs

April 21, 2016 – In times like these, every dollar counts. Some people qualify for big savings on their Medicare prescription drug costs and don’t even realize it! In fact, if you receive Medicare, you may be eligible for the Extra Help, which could save you about $4,000 per year on your monthly premiums, annual deductibles, and prescription co-payments.

To qualify for Extra Help, you must be receiving Medicare, have limited resources and income, and reside in one of the 50 states or the District of Columbia. To find out if you qualify, Social Security will need to know the value of your savings, investments, real estate (other than your home), and your income. We will also need information about you and your spouse, if you are married and living together.

To apply for Extra Help, you need to complete Social Security’s Application for Extra Help with Medicare Prescription Drug Plan Costs. Our secure online application has self-help screens that guide you through a series of questions. You can apply from the comfort of your home, or from any other computer that is convenient to you. You can start and stop the application at any time, and go back later to finish it.

If you choose, you can apply for Extra Help over the phone by calling 1-800-772-1213 (TTY 1-800-325-0778) or visit your local Social Security office.

After you apply, Social Security will review your application and send you a letter letting you know if you qualify for Extra Help. Once you qualify, you can choose a Medicare prescription drug plan.

When you file your application for Extra Help, you can also start an application for a Medicare Savings Program — state programs that provide help to people with limited resources and income with Medicare expenses

Make sure you aren’t missing out on these easy savings. The sooner you apply , the sooner your savings begin.

New CMS initiative may change the way senior citizens receive health care

April 12, 2016 – In a move that may drastically change the way senior citizens receive medical care from physicians, the Centers for Medicare & Medicaid Services (CMS) yesterday announced the the Comprehensive Primary Care Plus (CPC+) model. It is “designed to provide doctors the freedom to care for their patients the way they think will deliver the best outcomes and to pay them for achieving results and improving care,” says the CMS news release.

“Its largest-ever initiative to transform and improve how primary care is delivered and paid for in America,” according to CMS..

The effort, CPC+, will be implemented in up to 20 regions and can accommodate up to 5,000 practices, which would encompass more than 20,000 doctors and clinicians and the 25 million people they serve.

“Strengthening primary care is critical to an effective health care system,” said Dr. Patrick Conway, CMS deputy administrator and chief medical officer.

“By supporting primary care doctors and clinicians to spend time with patients, serve patients’ needs outside of the office visit, and better coordinate care with specialists we can continue to build a health care system that results in healthier people and smarter spending of our health care dollars. The Comprehensive Primary Care Plus model represents the future of health care that we’re striving towards.”

Building on the Comprehensive Primary Care initiative launched in late 2012, the five-year CPC+ model will benefit patients by helping primary care practices:

Ø Support patients with serious or chronic diseases to achieve their health goals

Ø Give patients 24-hour access to care and health information

Ø Deliver preventive care

Ø Engage patients and their families in their own care

Ø Work together with hospitals and other clinicians, including specialists, to provide better coordinated care

Primary care practices will participate in one of two tracks. Both tracks will require practices to perform the functions and meet the criteria listed above, but practices in Track 2 will also provide more comprehensive services for patients with complex medical and behavioral health needs. This may include, as appropriate, a systematic assessment of their psychosocial needs and an inventory of resources and supports to meet those needs.

CPC+ will help practices move away from one-size-fits-all, fee-for-service health care to a new system that will give doctors the freedom to deliver the care that best meets the needs of their patients.

In Track 1, CMS will pay practices a monthly care management fee in addition to the fee-for-service payments under the Medicare Physician Fee Schedule for activities.

In Track 2, practices will also receive a monthly care management fee and, instead of full Medicare fee-for-service payments for Evaluation and Management services, will receive a hybrid of reduced Medicare fee-for-service payments and up-front comprehensive primary care payments for those services.

This hybrid payment design will allow greater flexibility in how practices deliver care outside of the traditional face-to-face encounter.

To promote high-quality and high-value care, practices in both tracks will receive up-front incentive payments that they will either keep or repay based on their performance on quality and utilization metrics. The payments under this model encourage doctors to focus on health outcomes rather than the volume of visits or tests.

Practices in both tracks also will receive data on cost and utilization. Optimal use of Health IT and a robust learning system will support them in making the necessary care delivery changes and using the data to improve their care of patients.

Track 2 practices’ vendors will sign a Memorandum of Understanding (MOU) with CMS that outlines their commitment to supporting practices’ enhancement of health IT capabilities. These partnerships will be vital to practices’ success in the care delivery work and align with the Office of the National Coordinator for Health IT priority to ensure electronic health information is available when and where it matters to consumers and clinicians.

Under the CPC+ model, Medicare will partner with commercial and state health insurance plans to support primary care practices in delivering advanced primary care.

Advanced primary care is a model of care with five key components:

Ø Services are accessible, responsive to an individual’s preference, and patients can take advantage of enhanced in-person hours and 24/7 telephone or electronic access.

Ø Patients at highest risk receive proactive, relationship-based care management services to improve outcomes.

Ø Care is comprehensive and practices can meet the majority of each individual’s physical and mental health care needs, including prevention. Care is also coordinated across the health care system, including specialty care and community services, and patients receive timely follow-up after emergency room or hospital visits.

Ø It is patient-centered, recognizing that patients and family members are core members of the care team, and actively engages patients to design care that best meets their needs.

Ø Quality and utilization of services are measured, and data is analyzed to identify opportunities for improvements in care and to develop new capabilities.

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CMS will select regions for CPC+ where there is sufficient interest from multiple payers to support practices’ participation in the initiative. CMS will enter into a Memorandum of Understanding (MOU) with selected payer partners to document a shared commitment to align on payment, data sharing, and quality metrics in CPC+.

CMS will accept payer proposals to partner in CPC+ from April 15 through June 1, 2016. CMS will accept practice applications in the determined regions from July 15 through September 1, 2016.

The Affordable Care Act, through the creation of the Center for Medicare and Medicaid Innovation, allows for the testing of innovative payment and service delivery models, such as the CPC+ model, to move our health care system toward one that rewards clinicians based on the quality, not quantity, of care they give patients.

Today’s announcement is part of the Administration’s broader strategy to improve the health care system by paying providers for what works, unlocking health care data, and finding new ways to coordinate and integrate care to improve quality.

In March 2016, the Administration estimated that it met the ambitious goal – eleven months ahead of schedule – of tying 30 percent of Medicare payments to quality and value through alternative payment models by 2016.

The Administration’s next goal is tying 50 percent of Medicare payments to alternative payment models by 2018. The Health Care Payment Learning and Action Network established in 2015 continues to align efforts between government, private sector payers, employers, providers, and consumers to broadly scale these gains in better care, smarter spending, and healthier people.

For more information about the CPC+ model, including a fact sheet, click here

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