Comprehensive Healthcare Reform Update



Health Care Reform Update (8/11)CATEGORYPPACASTAFF TEAM (Lead underlined)EFFECTIVEDATE[S]ITEMS POSTED ON THE AHCA/NCAL WEB:(final rules highlighted yellow)UPDATE:Coverage and Health Insurance ReformsCoverage and Health Insurance Reforms§§ 1001, 1101-1304, 1321-1334, 1501-1502, 1511-1515Individual mandate: all individuals must have health insurance or pay a fine;Employer mandates: Most employers (50+ FTEs) must offer coverage that meets specified eligibility, affordability and value requirements or potentially pay a fine; andInsurance market changes/coverage subsidies/Medicaid expansion.Karl Polzer; Dianne DLM2010-20192014=Critical date for LTC providers: Employers with 50+ FTEs will face penalties if one or more of their full time employees obtains a premium credit through an insurance exchange. Policy paper at: CC articles:Waivers for mini-med plans (available until 2014) at given 1-year reprieve (until 2012) to report health plan costs at ; States receive monies (awarded 10/11) for exchanges at funding for early retiree health subsidies (until 2014) at “insurance finder” web tool at Pre-Existing Condition Insurance Plan (until 2014) at ; HHS/DOL/IRS interim final rule re: reform and consumer protection (effective 9/23/10) at interim final rule re: “grandfathering” or exempting plans already in place (as of 3/23/10) at ; HHS interim final rule re: establishment of Internet Website (by 7/1/10) at ; HHS final rule re: early retiree reinsurance program (effective 6/1/10) at guidance re: health coverage provided to an employee’s children under 27 tax-free at . On-going regulatory discussions with DOL, IRS and Treasury regarding employer mandate hardships.Submitted informal comments to IRS’ request on upcoming proposed rule re: shared responsibility for employers regarding health coverage (due 6/17/11).TAX CHANGESPremium Tax Credits and Cost-Sharing Reductions§§ 1401-15, 1001Allows individuals to receive premium tax credits and cost-sharing reductions to assist in the purchase of health insurance.? Bill Hartung2014=Critical date for LTC providers: Employees that qualify for the premium tax credit or cost-sharing reductions either due to lack of minimum essential coverage or unaffordable coverage could force the employer to pay a penalty.?Policy paper at . Small Business Tax Credit§§ 1421Provides a tax credit for qualified small businesses to help them afford insurance coverage of their workers.Bill Hartung2010Policy paper at . Revenue Provisions§§ 9001-9017Provides revenue offset provisions.Bill Hartung,Teresa Cagnolatti2018-20201/1/2012=Critical date for LTC providers: Must file 1099 information return with IRS if the total amount of payments made in exchange for goods orservices are $600 or more in one year. Policy paper at Follow-up CC articles:Baucus introduces bill to repeal 1099 at passes bill to repeal 1099 at ; Senate introduces bill to repeal 1099 at . AHCA was successful in getting 1099 repealed (4/11) CLASS ACT§ 8002Creates a new voluntary insurance program for purchasing community living assistance services and supports or “CLASS,” to provide assistance for individuals who have difficulty with activities of daily living and need LTC services.Janice Zalen, Karl Polzer2011=Critical date for LTC providers: CLASS insurance program established.10/12=Critical date for LTC providers: CLASS benefit plan established.1/12=Critical date for LTC providers: CLASS eligibility assessment system established.Policy paper at (CLASS)Act.aspx.Follow-up CC articles:House holds hearing on CLASS at MEDICAREProductivity Adjustment§ 3401Describes how Medicare providers can expect a reduction in annual market basket updates.Bill Hartung, Peter Gruhn, Elise Smith 10/1/11=Critical date for LTC providers:Revision of market basket updates; incorporating productivity adjustments.?Policy paper at RUG IV§ 10325Forego any delay on the implementation of the changes to the concurrent therapy rules or the look-back period, or launch of the MDS 3.0.Bill Hartung, Peter Gruhn, Elise Smith10/1/11=Critical date for LTC providers:RUGs IV cannot be implemented prior to this date.? 10/1/10=Critical date for LTC providers:Implement concurrent therapy and lookback changes included in RUGs IV.10/1/10=Critical date for LTC providers:Implement MDS 3.0.Policy paper at. Therapy Caps§ 3103Extends the outpatient therapy cap exception process through 2010.Peter Gruhn, Bill Hartung12/31/10=Critical date for LTC providers:Provides an extension of the exceptions process for Medicare therapy caps until this date. MMEA extends it further until 12/31/11.Policy paper at. MEDICARE PAYMENT REFORMSValue-based Purchasing (SNF P4P)§ 3006Requires CMS to develop a plan to implement a "value based purchasing" program for SNFs.Elise Smith, Sandra Fitzler, Bill Hartung10/1/11=Critical date for LTC providers:P4P plan due to Congress.Policy paper at. Response to RTI International Interview February 27, 2011 Response to CMS Open Door Session - AHCA Technical Comments – CMS Value-Based Purchasing Implementation Plan, march 18, 2011Shared Savings Program –Accountable Care Organizations (ACOs)§ 3022Rewards ACOs that take responsibility for the costs and quality of care received by their patient panel over time. ACOs can include groups of health care providers (including physician groups, hospitals, nurse practitioners and physician assistants, and others). ACOs that meet quality-of-care targets and reduce the costs of their patients relative to a spending benchmark are rewarded with a share of the savings they achieve for the Medicare program. Elise SmithCMS must establish program by January 1, 2012March 31, 2001 CMS Issues Proposed ACO Proposed RuleCMS/OIG issues Waiver Proposed Rule IRS issues Tax-Exempt Proposed RuleJoint FTC and DOJ Proposed Statement of Enforcement Policy -- Antitrust Policy Statement).April, 2011 -- Added ACO responsibility to AHCA Bundling Work GroupMay 31, and June 6, 2011 – AHCA submits comments on all proposed rules March 17, 2011 IO Conference -- Session on ACOsMay 10,2011- State Executive Conference Call on ACOs, Mark Reagan, Nancy RehkampMay 18, 2011 – Webinar on ACOs, Briefings to CPAC and the BoardGovernor Mark Parkinson key address at Brookings ACO Summit -- Role of SNFs in the ACO Medicare Bundling – National Pilot Program§ 3023Establishes a Payment Bundling pilot to make all healthcare providers responsible during an episode of care by rewarding value over volume with incentives to coordinate patient care across the continuum of an entire episode of care.Elise Smith, Bill Hartung, Peter Gruhn,Sandra Fitzler1/1/13=Critical date for LTC providers:HHS must establish a national, voluntary pilot program on payment bundling.Policy paper at . On-going CMS discussions.Bundling member/staff Work Group - bundling research and bundling policy development.Independent Medicare Advisory Board§ 3403Establishes a 15-member IPAB to extend Medicare solvency and reduce spending growth through the use of a spending target system and fast-track legislative approval process. Bill Hartung, Elise Smith1/15/14=Critical date for LTC providers:IPAB must develop and submit detailed proposals to Congress.Policy paper at . Medicare and MedicaidCMS Medicare and Medicaid Innovation Center§§ 3021Expands HHS Secretary authority to resolve health care financing issues and to develop innovative methods for the administration of the Medicare and Medicaid programs.Janice Zalen,Steven Gregory1/1/11=Critical date for LTC providers:CMS must establish CMI.Policy paper at. AHCA web site on Innovation Center at Federal Coverage and Payment Coordination for Duals§ 2602Establishes a coordinated health care office, called Medicare – Medicaid Coordination Office (MMCO) reporting to the CMS Administrator, with the purpose of ensuring that Medicare and Medicaid dual eligibles obtain full access to terms/services.Steven Gregory, Janice Zalen3/1/10=Critical date for LTC providers:New Federal Coordinated Health Care Office to provide coverage and payment coordination for dual eligibles.Policy paper at. Submitted response to MMCO’s Request for Information on aligning Medicare and Medicaid.Contacted Melanie Bella and Jennifer Coleman re integrated care for duals. Met with Jennifer Coleman and Tim Englehardt and regular telephone and email communication continues. (July 18)OTHER MEDICARE ISSUESRACs – Extension to Medicaid and Medicare Parts C & D§ 6411Expands the RAC program to Medicaid and Medicare Parts C and D.Elise Smith4/1/11=Critical date for LTC providers:CMS expects states to fully implement their RAC programs.Medicaid Program; Recovery Audit Contactors, Proposed Rule, 75 Federal Register 69037 (November 10, 2010). January 10, 2011, Comments on Medicaid Program; Recovery Audit Contactors, Proposed Rule,75 Federal Register 69037 (November 10, 2010) Maximum Period of Submission for Medicare Claims§ 6404(a)Reduces the maximum period for submission of Medicare claims to not more than 12 months from the date of service.Elise Smith12/31/10=Critical date for LTC providers:Reduced statutory timely filing deadline for Medicare fee-for-services claims under Medicare Parts A and B to one year.Policy paper at. Follow-up CC articles: CMS details new timely filing for Medicare claims at . On-going discussions with CMS.Physician Assistants to Certify Need for Post Acute Care§ 3108Allows a physician assistant who does not have a direct or indirectemployment relationship with a SNF, but who is working in collaboration with a physician, tocertify the need for post-hospital extended care services for Medicare payment purposes.Elise Smith, Sandra Fitzler1/1/11=Critical date for LTC providers:Physician assistants may order post-acute extended care services.Policy paper at . 42CFR424.20(e)(2)Issued in final rule November 29, 2010Physician Fee Schedules and other revisions to Part B for CY 2011Payment Adjustment for Conditions Acquired in Hospitals – Report on Extending to Other Providers (e.g., NFs)§ 3008HHS Secretary must make recommendations to expand Medicare’s health acquired condition payment policy to otherfacilities, including IRFs, LTCHs, hospital outpatient departments, inpatient psychiatric facilities,cancer hospitals, skilled nursing facilities, ambulatory surgery centers and health clinics. Elise Smith, Sandra Fitzler1/1/12=Critical date for LTC providers: Report to Congress due.2015=Critical date for LTC providers:Implementation deadline.Policy paper at. No report as yet. Community-Based Care Transitions§ 3026Establishes a five-yearCommunity Care Transitions Program under Medicare Janice ZalenKarl Polzer1/1/11=Critical date for LTC providers: Implementation begins and lasts for a period of 5 years.Policy paper at. Independence at Home Demo§ 3024HHs Secretary mustconduct a Medicare demonstration program to test apayment incentive and service delivery model that uses physician- and nurse practitioner-directedhome-based primary care teams designed to reduce expenditures and improve health outcomes inthe provision of items and services to certain chronically ill Medicare beneficiaries.Janice Zalen, Karl Polzer1/1/12=Critical date for LTC providers:Medicare demonstration program for chronically ill Medicare beneficiaries that test a payment incentive and service delivery model.Policy paper at. PHARMACYPharmacy Waste§ 3310Requires Medicare Part D Plans to employ utilization management techniques to reduce the quantity dispensed per fill for beneficiaries who reside in LTC facilities. Sandra Fitzler,1/1/12=Critical date for LTC providers:Uniform dispensing techniques begin.Policy paper at CC articles:1.CMS short cycle dispensing proposed rule at and Congress ask for delay in short cycle dispensing rule implementation at AHCA submits comments on Procedures for the Surrender of Unwanted Controlled Substances by Ultimate Users at delays implementation short cycle dispensing for 1 year to Jan 1, 2013. Short cycle changes from 7 to 14 day, only branded oral solids. ?CMS states that it expects dispensing fees to double. No requirement to return unused meds to pharmacy but reporting requirement remains. CMS was persuaded by comments not to extend requirement to LTC and to work with industry stakeholders on more cost-effective approaches. Short cycle discussion is at pages 96-132, in Coverage Gap – Part D§§3301, 3315§3301 provides $250 rebate check for part D enrollees who hit the gap in prescription drug coverage known as the “donut hole.”Elise Smith1/1/10=Critical date for LTC providers:Reduce amount Medicare Part D enrollees are required to pay for their prescriptions when they reach the coverage gap.Policy paper at. Final Rule76 Federal Register 21478, 21479, 42 CFR 423 104Elimination of Exclusion of Coverage for Certain Drugs§ 2502Medicaid programs can no longer exclude smoking cessation agents, barbiturates, and benzodiazepines from coverage under Medicaid. This provision results in a small expansion of Part D coverage of barbiturates. Elise Smith, Sandra Fitzler1/1/14=Critical date for LTC providers:Medicaid programs can no longer exclude certain drugs from coverage.Policy paper at. MEDICAIDMACPAC § 2801MACPAC reviews state and federal Medicaid access and payment policies and makes recommendationsto states, Congress and HHS secretary.Section 2801 amends statutes related toMACPAC, and requires a review of provider reimbursementrates. Steven Gregory, Janice ZalenFunding approved for FY 2010.Policy paper at. Met with MACPAC staff and attend MACPAC public meetings. Communicate by email on a regular basis.MedPAC Modifications§ 2801(b) – conforming amendmentsSteven Gregory, Janice ZalenPolicy paper at. Attend MedPAC meetings when Medicaid issues are discussedMedicaid Presumptive Eligibility Determination by Hospital§ 2202Allows hospitals to elect to be entities qualified to make presumptive Medicaid eligibility determinations.? Such determinations would permit those hospitals to provide Medicaid services during the period of presumptive eligibility.Steven Gregory, Janice Zalen1/1/14=Critical date for LTC providers:Medicaid presumptive eligibility determinations apply to services.Policy paper at. Home and Community-Based Services§§ 2401-3, 2406,10202Provides states more flexibility to provide HCBS and to extend full Medicaid benefits to individuals receiving these services.Janice Zalen, Karl Polzer10/1/10=Critical date for LTC providers:States can allowaccess to HCBS under certain circumstances before Medicaid recipients need institutional level care.Policy paper at . Follow-up CC articles:1. Proposed rule establishing new state option and enhanced FMAP to provide HCBS attendant service at . Money follows the person (MFP) demonstration grants at . Providing care to the frail and disabled outside of NFs at ; 4. MFP rebalancing demonstration program at . $60 million in grants authorized to states to help individuals navigate their LTC options at . Met with Barbara Edwards, Director, Disabled and Elderly Health Programs GroupCommented on NPRM on Community First Choice OptionsMedicaid Reimbursement for Health Care Acquired Conditions§ 2702Prohibits payments to states for services related to health care acquired conditions (HCAC). No loss of access to services would result from enforcement of this section.Elise Smith, Sandra Fitzler7/1/11=Critical date for LTC providers:Prohibits payments to states for services related to HCAC.Policy paper at CC articles:1.CMS releases proposed rule on HCAC in 2/11. Re: Medicaid Program; Payment Adjustment for Provider-Preventable Conditions Including Health Care-Acquired Conditions, Proposed Rule, 76 Federal Register 9283, February 17, 2011Re: Medicaid Program; Payment Adjustment for Provider-Preventable Conditions Including Health Care-Acquired Conditions, Proposed Rule, 76 Federal Register 9283, February 17, 2011 Medicaid Program; Payment Adjustment for Provider-Preventable Conditions Including Health Care-Acquired Conditions, Proposed Rule, 76 Federal Register 9283, February 17, 2011Comments Submitted by AHCA, March 18, 2011Final Rule issued June 6, 2011. While the statutory effective date is July 1, 2011, CMS is delaying compliance action o n the provisions until July 1, 2012. Medicaid Overpayments§ 6506Extends the period for states to repay overpayments to 1 year when a final determination of the amount of the overpayment has not been determined because of an on-going judicial or administrative process.Steven Gregory, Janice Zalen3/23/10=Critical date for LTC providers:States have a year to repay Medicaid overpayments when a final determination is delayed due to an ongoing judicial or administrative process.Policy paper at. Follow-up CC articles:1. CMS guidance on Medicaid overpayments at . On-going discussions with CMS, Ron Perkins.FMAP for New Eligibles§§ 2001Starts the Medicaid state option to cover adults at or below 133% of the FPL, and includes a number of clarifications and policy adjustments related to the Medicaid expansion to 133% of FPL.Steven Gregory, Janice Zalen4/1/10=Critical date for LTC providers:Starts the Medicaid state option at or below 133% of the FPL.2014=Critical date for LTC providers:Feds will cover cost thru FMAP.Policy paper at. No agency contact to date b/c AHCA/NCAL was waiting for the final policy paper just posted in August (and written by Joel Hamme) to understand the impact of this provision on LTC organizations - looks like impact is minimal. No follow-up.IMPROVING THE QUALITY AND EFFICIENCY OF HEALTH CAREMedicaid Adult Health Quality Measures§§ 2701, 2703Mandates HHS Secretary to publish a recommended core set of adult health quality measures for Medicaid-eligible adults.Sandra Fitzler, Chris Condeelis1/2012=Critical date for LTC providers:Adult Health Quality Measures completed.Policy papers at contact with HHS Public Affairs, but to date unable to determine the status.National Strategy to Improve Health Care Quality§§ 3011-12, 3501Calls for a set of National Health Care Priorities across health care settings.Creates the Interagency Working Group on Health Care Quality to ensure collaboration between Federal agencies; avoid inefficient duplication of quality improvement; and assess alignment of quality efforts in the public sector.Creates the Interagency Working Group on Health Care Quality to ensure collaboration between Federal agencies; avoid inefficient duplication of quality improvement; and assess alignment of quality efforts in the public sector.Chris Condeelis,Sandra Fitzler1/1/11=Critical date for LTC providers:National Health Care Priorities released.12/31/10=Critical date for LTC providers:Created Interagency Working Group on Healthcare Quality.Policy paper at . Quality Measure Development§§ 3013-15, 2701HHS to identify gaps and improvements needed in current quality measures. Call s for the development of endorsed measures.Provides for data collection for quality measures and public reporting.2/1/12=Critical date for LTC providers:HHS will identify gaps and improvements in current quality measures.Policy paper at. HEALTH CARE WORKFORCEInnovations in the Health Care Workforce§§ 5101-04Establishes an independent National Workforce Commission to provide comprehensive and objective information and rec’s to Congress and the Administration for aligning federal health car workforce resources with national needs.Dianne DLM, Jeffrey LiuShelly Sabo2010=Critical date for LTC providers:National Commission established.Policy paper at. Follow-up CC articles:1. GAO announces National Commission members at HYPERLINK "" . AHCA has strong connections with National Commission members: Harold M. Maurer, MD, Chancellor, University of NE Medical Center through Jan Thayer; and Fitzhugh Mullan, MD, Professor of Public Health and Pediatrics, George Washington University through Brian Biles. Increasing the Supply of the Health Care Workforce§§ 5201-02, 5204-07, 5209, 10501Expands and improves low-interest student loan programs, scholarships and loan repayments for health students and professionals.Dianne DLM, Jeffrey LiuShelley Sabo3/23/10=Critical date for LTC providers:Provides incentives to primary care physicians, increases loans to nurses, establishes allied healthcare loan program.Policy paper at. Follow-up CC articles:1. $320 million to expand primary workforce at . $250 million to strengthen physicians and nurses at . Enhancing Health Care Workforce Education and Training§§ 5301-15 Provides for expanded training opportunities for direct care workers in long term care settings.? Allows for grants and/or contracts to geriatric education centers to offer short-term courses.Grants and/or contracts awarded to eligible entities for the purpose of retaining nurses.? Allows for eligible individuals to enter into agreements for the purpose of repayment of nurse student loans.?? Dianne DLM, Jeffrey LiuShelley Sabo2010-15Policy paper at the Existing Health Care Workforce§§ 5401-05Enhances loan repayment and scholarship assistance for disadvantaged and minority students. Reauthorizes the Area Health Education Centers (AHEA) to assist schools of medicine to provide community-based training and education to increase the number of primary care physicians that provide services in underserved areas. Provides stipends for diploma and associate degree nurses to enter a? bridge or degree completion program, student scholarships or stipends for accelerated nursing degree programs and advanced education preparation.Dianne DLM, Jeffrey LiuShelley Sabo2010-15Policy paper at. NF TRANSPARENCY AND IMPROVEMENTImproving Transparency of Information §§ 6101-03, 6105-07§6101 expands the information a NF must disclose to include the organizational structure, as well as additional information on officers, directors, trustees and managing employees of the NF, including names, titles and dates of service.Lyn Bentley3/23/10=Critical date for LTC providers:Organizational structure must be disclosed.Policy papers at . Follow-up CC articles:Regulations issued in NPRM for PPS – comments submitted 6/27/11.Targeting Enforcement§§ 6111-14Lyn Bentley, 1/1/12=Critical date for LTC providers:CMP/IIDR final rule in effect.3/23/12=Critical date for LTC providers:Notification of facility closure final rule in effect.Policy papers at§6111.aspx; CC article:1.CMS releases final CMP/IIDR rule at ; 2. AHCA submits comments to CMP/IIDR proposed rule at . CMS releases interim final rule on facility closure at Staff Training§ 6121Lyn Bentley, Dianne DLM2011Policy paper at in a stakeholder meeting to preview/comment on CMS training materials re: abuse and dementia training.Background Checks§ 6201Dianne DLM, David Kyllo, Lyn BentleyPolicy paper at CC articles:1.States awarded monies to improve state criminal background check programs at Working with CMS to develop a Sep. 12, 2011 summit with providers, law enforcement, state AG’s, CMS staff, and SSAs. Purpose is to discuss importance of initiative; barriers to implementation; and states’ experience with implementation. Dr. Gifford is having ongoing discussions with Martin Kennedy, responsible for implementation of this initiative.OIG is currently drafting a report.Medicare, Medicaid, and CHIP Program Integrity Provisions§§ 6401(a), 6402(a)§6402(a) requires all overpayments be reported and returned within 60 days from the date of identification or by the date that the corresponding cost report is due (as applicable).§ 6409 Self-Disclosure Protocol2010-11Policy papers at CC article:1.Provider screening final rule at ; 2.Self-disclosure protocol at comments to proposed provider screening rule at Fraud prevention fact sheets at On-going discussions with CMS reimbursement staff.Elder Justice Act§§ 6701-03§6703 mandates reporting of “reasonable suspicion” of any crime against a resident to HHS Secretary and local law enforcement up to $300K with possible exclusion from the Medicare and Medicaid programs for failure to report.Lyn Bentley; Dr. Gifford2010-11§6703(b)(3) effective date is 3/23/10Policy papers at CC articles:1.EJA reporting requirement update at . 2.S&C memo on EJA and links to tools and templates at: with CMS on development of Q&A document as follow up to S&C memo.Developed and disseminated tools for members to use to implement this requirement .HEALTH CARE FRAUD ENFORCEMENTAdditional Medicaid program Integrity provisions§§ 6501-02, 6504Requires States to terminate individuals or entities from their Medicaid programs if the individuals or entities were terminated from Medicare or another State’s Medicaid program. Requires Medicaid agencies to exclude individuals or entities from participating in Medicaid for a specified period of time if the entity or individual owns, controls, or manages an entity under certain conditions (e.g., failed to repay overpayments; is suspended, excluded, or terminated from participation in any Medicaid program; etc.)HIT§ 1104 and 2041Policy papers at conversations with HHS, ONC, ASPE and HRSA.TORT REFORM (STATE DEMOS)§§ 6801, 106072010-14Policy paper at. ASSISTED LIVING PART D COPAY ELIMINATION§ 3309Karl PolzerNo earlier than 1/1/12Policy paper at. ................
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