Washington Report – August, 2013 - HBMA



Washington Report – August, 2013

Bill Finerfrock, Zhaneta Mansaku, Greg Price, Kirk Shields

Cost and Participation in Healthcare Marketplaces

The Role of the States in the ACA

Mostashari Announces Departure from ONC

Employer Mandate under the ACA

Medicare to Accept Revised 1500 Claim Form Starting January 2014

Legislation Introduced to Strengthen Medicare Anti-Fraud Efforts

Congress and Congressional Staff MUST get healthcare insurance the Marketplaces

CMS Transmittals

Return to Top

Cost and Participation in Healthcare Marketplaces

Who will actually sign up for health insurance through the Marketplaces under the Patient Protection and Affordable Care Act (ACA) and how much that insurance will cost remains an open question in late August. But with each passing day until the opening of the Marketplaces on October 1, new information is coming forward that tries to answer these questions.

The Henry J. Kaiser Foundation has been a leader in researching and analyzing the Affordable Care Act. Recently, the Foundation published a new report entitled, An Early Look at Premiums and Insurer Participation in Health Insurance Marketplaces, 2014

Background

Beginning October 1, 2013, many previously uninsured individuals and families will be able to purchase private health insurance coverage through “Marketplaces” (nee Exchanges). Coverage under these policies will begin January 1, 2014.

As has previously been reported, these Marketplaces will either be run by the state or the federal government and a small number will be jointly run by a partnership between the state and federal governments. In states that decide against operating their own exchanges, the federal government will either run the exchange or work in partnership with the state to create an exchange.

Regardless of who operates the Marketplace, enrollees with family incomes from 100% to 400% of the Federal Poverty Level (FPL) may qualify for tax credits to help lower the out-of-pocket cost of the insurance premiums. For 2012, the FPL for a family of 4 is approximately $24,000. Based upon this, federal tax credits would be available for a family of four with household income as high as $96,000 per year.

The Kaiser Foundation report tries to take an “early look at insurer participation and exchange premiums – both before and after tax credits – for enrollees in 17 states plus the District of Columbia.” In putting the report together, Kaiser researchers used publicly released data on rates or the rate filings submitted by insurers.

Ten of the States (and Washington DC) reviewed by Kaiser researchers will be operating their own state-run Marketplaces. Seven of the states in the analysis will have federally-facilitated Exchanges (either totally or partially run by the federal government).

All plans sold through the Exchanges must offer a standard set of benefits, referred to as “Essential Health Benefits”. While plans can offer additional benefits, it is expected that Exchange Plans (aka Qualified Health Plans) will offer the basic benefits mandated by the Affordable Care Act.

There will be Four levels of coverage available to all individuals:

Bronze

Silver

Gold

Platinum

The more precious the metal, the higher the premiums will be, but the lower the consumer’s deductible or co-pay expense. Conversely, the less precious the metal, the lower the premium but the higher the deductible and/or co-pay.

Roughly speaking, a Bronze plan will be expected to cover 60% of beneficiary costs, a Silver Plan 70%, a Gold Plan 80% and a Platinum Plan 90%. Marketplaces will also be authorized to offer a catastrophic policy (i.e. very high deductible). However, in order to purchase a high deductible insurance policy through the Marketplace, the purchaser must be under the age of 30. If a family wishes to purchase a catastrophic policy ALL covered lives must be under the age of 30.

During the first year, plan premiums will be based upon the insurance company’s estimated cost of offering benefits to the people who are expected to enroll. After the first year, plans will have a better sense of costs but their ability to raise premiums will be regulated.

In most states, the state will be divided into “Rating Areas”. In Virginia, for example, the state has been divided into 12 separate rating areas. In California, the state has been divided into 19 rating areas.

Insurers will be permitted to offer products in some or all rating areas. Because insurers can limit sales to some or all rating areas of a state, the numbers in the chart Kaiser produced can be somewhat misleading.

|State |Number of Insurers |

|CA |12 |

|CO |10 |

|CT |3 |

|DC |4 |

|IN |4 |

|MD |6 |

|ME |2 |

|MT |3 |

|NE |4 |

|NM |5 |

|NY |16 |

|OH |12 |

|OR |11 |

|RI |2 |

|SD |3 |

|VA |9 |

|VT |2 |

In California for example, the State operated Exchange (CoveredCA) has identified the plans that

will be offered and the specific rating areas in which those plans will be offered. Of the 12 plans that will be sold through CoveredCA, only two will be available state-wide. Most of the plans will be limited to specific geographic regions of the state (Los Angeles only, San Francisco only, San Diego only, etc.). A closer look at the California market shows that the average number of plans per rating area will be 3 or 4 with many rural areas of the state only having the two state-wide plans.

Plans can vary individual and family premiums between rating areas within a state for a variety of reasons but within a rating area, individual and family plan pricing can only vary due to the age of the individual(s), size of the family or smoking status of the individual(s) seeking insurance.

There is a 3:1 rating ratio between the highest rated (i.e. oldest) person in the rating area and the youngest. What this means is that the highest age-based premium charged within a rating area can only be 3 times the lowest age-based premium charged within that rating area.

As the Kaiser Report notes, it is sometimes difficult to compare the cost and coverage of plans currently available in a market with the cost and coverage of the plans that will be sold in the Marketplaces because there are so many fundamental differences between the products you are trying to compare that you end up trying to compare an apple to an orange.

What Kaiser Found

As previously noted, using rate filings, Kaiser tracked insurer participation and plan offerings in the Marketplaces. Kaiser then calculated the unsubsidized premiums for enrollees of bronze and silver plans at various ages (25, 40, and 60 years old) in the rating area of the largest city in each of the 17 states and Washington, DC.

For each of the rating areas, they then calculated the expected tax credit that individuals and families at various income levels would qualify for in an attempt to ascertain the actual out-of—pocket premium cost in those rating areas.

Kaiser found that insurers generally were planning to offer plans at the various tiers of coverage (catastrophic, bronze, silver, gold, or platinum), and that they also planned to offer more than one plan option within a given coverage tier. As a result, the number of plans available to consumers will be significantly greater than the number of insurers participating.

However, it appears that at least in the states reporting thus far, all of the products that the plans intend to sell will be network products (e.g., HMOs or PPOs).

Not surprisingly, Kaiser found that premiums will vary from state to state and from rating area to rating area within a state. Kaiser concludes that this variation is due to a variety of factors, including: differences in the underlying cost of health care; market competition; and, the effectiveness of state rate review programs at lowering premiums.

Price variability is also going to be affected by the ability of the Marketplaces to negotiate premiums with insurers or exclude plans from the market.

It was interesting to note that the highest cost premiums were found in the two states that had previously outlawed insurance pricing based upon health status and moved to community rating many years ago – New York and Vermont.

According to the Kaiser report, the lowest cost Bronze plan for a 40 -year-old ranges from a low of $146 per month in Baltimore, Maryland to $308 in New York City and $336 in Burlington, Vermont.

Moving up the insurance hierarchy, Kaiser found the lowest cost Silver plan in Portland, Oregon - $194 per month for a 40 year old and the highest cost Silver plan again in Burlington, Vermont: $395 per month.

As previously noted, premiums within a rating area can only vary due to age. But the actual out-of-pocket cost of the insurance will also be affected by the individual or family income. The “prepaid tax credits” available to individual/families with incomes up to 400% of poverty level will significantly reduce the out-of-pocket premium expense for many of these individuals or families.

|What is a Prepaid Tax Credit? |

| |

|Normally, tax credits are calculated at the end of a tax year and are credited against the individual taxpayers tax |

|liability. In general, in order to benefit from a “tax credit”, the taxpayer must have a tax liability against which|

|the credit can be applied. Not only is the PPACA premium tax credit “prepaid” but it is also “refundable” which |

|means the individual receives the full cash value of the credit regardless of whether they have an actual tax |

|liability. |

| |

|In the case of a “prepaid” tax credit, the individual gets the cash value of the tax credit throughout the tax year |

|rather than having to wait until the tax year to claim/collect their tax credit. |

| |

|In the case of the PPACA prepaid tax credits, the federal government will calculate the amount of the tax credit the |

|individual /family would be entitled to under the PPACA but instead of waiting until the tax return is filed to claim|

|the tax credit, the total amount available will be divided by 12 and that amount will be deducted from the premiums |

|that person/family would have had to pay for the insurance they are purchasing through the Marketplace. The money |

|will go directly from the federal treasury to the Health Plan on a monthly basis. |

| |

|The prepaid tax credit is ONLY available to individuals who are purchasing health insurance through the Marketplace. |

Kaiser assumes that most of the people enrolling in individual plans sold on the Marketplace will qualify for a tax credit that will lower the amount they must pay for coverage, which means that most enrollees will pay a lower monthly premium than the unsubsidized rates presented above.

The amount of the tax credit an individual will qualify for is based upon his or her income relative to the second lowest cost Silver Health Plan sold on the Exchange. Under the ACA, an individual with an income of 250 percent of the federal poverty level ($30,000 per year income) would pay no more that approximately 8 percent of his or her income to enroll in the second-lowest-cost Silver plan, regardless of the rating area.

This calculation sets the value of the pre-paid tax credit. Should the individual choose to enroll in a higher premium plan (Gold or Platinum or higher cost Silver Plan) the amount of the pre-paid tax credit does not rise.

So in this example, if the individual lived in Burlington, Vermont where the premium for the second lowest cost Silver Plan was $395 per month, the individual would pay an out-of-pocket premium of approximately $200 ($30,000 X .08/12) and he/she would get a pre-paid federal tax credit valued at approximately $195 per month making up the difference.

The Kaiser report makes for interesting reading and there is enough information in the report to fuel the debate over the affordability and value of the Patient Protection and Affordable Care Act for months to come.

HBMA has scheduled a Webinar on the operation of the Marketplaces and other ACA related issues for early October.

Return To Top

The Role of the States in the ACA

Much of the talk about the state’s role in the implementation of the ACA has centered around either the Medicaid expansion provisions or the operation of the Marketplaces. But in reality, that is only a small part of the role the states will play in the implementation and operation of the ACA.

Historically, health insurance has been regulated at the state level. The states approve what health plans can be sold in a state, determine what benefits must be offered and, depending upon the state, will directly or indirectly determine the premiums that health plans can charge for those plans. If the plan is a network plan, state law will typically establish requirements for network adequacy and what types of providers must be included in the network.

Although the Marketplaces in many states will be federally operated, the ACA does not rescind or override the long-standing state authority to regulate insurance products sold in that state. Because of that, State Insurance Commissioners continue to have a significant role in how or how well the ACA will work. State Insurance Commissioners may often be an excellent resource for ACA related questions.

Below is a state-by-state list with contact information for the Health Insurance Commissioners in all 50 states. The chart also indicates whether the Marketplace will be state operated, federally operated (aka federally facilitated) or a state/federal partnership. If you have ACA-related questions, do not overlook this office as a possible resource for answers in that particular state.

Please contact them for further information on what insurance plans and networks will be available to consumers through the Health Insurance Marketplace in your state beginning on October 1.

|State |Marketplace Model |Contact Information for State Commissioner |

|Alabama |Federally Facilitated |P:  (334) 269-3550 |

| |Marketplace | |

|Alaska |Federally Facilitated |P:  (907) 465-2515 |

| |Marketplace | |

|Arizona |Federally Facilitated |P:  (602) 364-2499 |

| |Marketplace | |

|Arkansas |State Partnership |P:  (501) 371-2600 |

| |Marketplace | |

|California |State Based Marketplace |P:  (800) 927-4357 |

| | | |

|Colorado |State Based Marketplace |P:  (303) 894-7499 |

| | |

| | |71&pagename=CBONWrapper |

|Connecticut |State Based Marketplace |P:  (860) 297-3900 |

| | |   |

|Delaware |State Partnership |P:  (302) 674-7300 |

| |Marketplace | |

|District of Columbia |State Based Marketplace |P:  (202) 727-8000 |

| | | |

|Florida |Federally Facilitated |P:  (850) 413-3140 |

| |Marketplace | |

|Georgia |Federally Facilitated |P:  (404) 656-2070 |

| |Marketplace | |

|Hawaii |State Based Marketplace |P:  (808) 586-2790 |

| | | |

|Idaho |State Based Marketplace |P:  (208) 334-4250 |

| | | |

|Illinois |State Partnership |P:  (877) 527-9431 |

| |Marketplace | |

|Indiana |Federally Facilitated |P:  (317) 232-2385 |

| |Marketplace | |

|Iowa |State Partnership |P:  (515) 281-5705 |

| |Marketplace | |

|Kansas |Federally Facilitated |P:  (785) 296-3071 |

| |Marketplace | |

|Kentucky |State Based Marketplace |P:  (502) 564-3630 |

| | | |

|Louisiana |Federally Facilitated |P:  (225) 342-5900 |

| |Marketplace | |

|Maine |Federally Facilitated |P:  (207) 624-8475 |

| |Marketplace | |

|Maryland |State Based Marketplace |P:  (410) 468-2090 |

| | | |

|Massachusetts |State Based Marketplace |P:  (617) 521-7794 |

| | |

| | |rance.htm |

|Michigan |State Partnership |P:  (517) 373-0220 |

| |Marketplace | |

|Minnesota |State Based Marketplace |P:  (651) 296-4026 |

| | | |

|Mississippi |Federally Facilitated |P: (601) 359-3569 |

| |Marketplace | |

|Missouri |Federally Facilitated |P:  (573) 751-4126 |

| |Marketplace | |

|Montana |Federally Facilitated |P:  (406) 444-2040 |

| |Marketplace | |

|Nebraska |Federally Facilitated |P:  (402) 471-2201 |

| |Marketplace | |

|Nevada |State Based Marketplace |P:  (775) 687-0700 |

| | | |

|New Hampshire |State Partnership |P:  (603) 271-2261 |

| |Marketplace | |

|New Jersey |Federally Facilitated |P:  (609) 292-7272 |

| |Marketplace | |

|New Mexico |State Based Marketplace |P:  (888) 427-5772 |

| | | |

|New York |State Based Marketplace |P:  (800) 342-3736 |

| | | |

|North Carolina |Federally Facilitated |P:  (919) 807-6750 |

| |Marketplace | |

|North Dakota |Federally Facilitated |P:  (701) 328-2440 |

| |Marketplace | |

|Ohio |Federally Facilitated |P:  (614) 644-2658 |

| |Marketplace | |

|Oklahoma |Federally Facilitated |P:  (405) 521.2828 |

| |Marketplace | |

|Oregon |State Based Marketplace |P:  (503) 947-7980 |

| | | |

|Pennsylvania |Federally facilitated |P:  (877) 881-6388 |

| |Marketplace | |

|Rhode Island |State Based Marketplace |P:  (401) 462-9501 |

| | | |

|South Carolina |Federally Facilitated |P:  (803) 737-6160 |

| |Marketplace | |

|South Dakota |Federally Facilitated |P:  (605) 773-3563 |

| |Marketplace | |

|Tennessee |Federally Facilitated |P:  (615) 741-2825 |

| |Marketplace | |

|Texas |Federally Facilitated |P:  (512) 463-6169   |

| |Marketplace | |

|Utah |Federally Facilitated |P:  (801) 583-3800 |

| |Marketplace |   |

|Vermont |State Based Marketplace |P:  (800) 964-1784 |

| | | |

|Virginia |Federally Facilitated |P:  (804) 371-9741 |

| |Marketplace | |

|Washington |State Based Marketplace |P:  (800) 562-6900 |

| | | |

|West Virginia |State Partnership |P:  (304) 558-3864 |

| |Marketplace | |

|Wisconsin |Federally Facilitated |P:  (608) 266-3585 |

| |Marketplace | |

|Wyoming |Federally Facilitated |P:  (307) 777-7401 |

| |Marketplace | |

Return to Top

Mostashari Announces Departure from ONC

Dr. Farzad Mostashari has been the National Coordinator for Health Information Technology (ONC) since 2011. Over the past 2+ years, he has proven to be a dynamic and passionate leader of our nation’s efforts to transition from a paper dependent healthcare delivery system to one that fully embraces electronic technology.

In an email message to ONC staff, HHS Secretary Kathleen Sebelius noted,

“During his tenure, ONC has been at the forefront of designing and implementing a number of initiatives to promote the adoption of health IT among health care providers.  Farzad has seen through the successful design and implementation of ONC’s HITECH programs, which provide health IT training and guidance to communities and providers; linked the meaningful use of electronic health records to population health goals; and laid a strong foundation for increasing the interoperability of health records—all while ensuring the ultimate focus remains on patients and their families.”

Although there has been much speculation behind the reasons for his sudden announcement, neither Dr. Mostashari nor Secretary Sebelius have spoken on the record about this development.

Over the past two years, HBMA leaders and staff have developed a solid working relationship with Dr. Mostashari and his senior staff. His leadership at ONC will be missed.

In addition to the Sebelius email, Dr. Mostashari sent a message to his senior staff announcing his departure. A member of the ONC staff sent HBMA a copy of that email.

After outlining what he considered some of the successes of the Department under his leadership, he ended with the following:

“It is difficult for me to announce that I am leaving. I don't know what I will be doing after I leave public service, but be assured that I will be by your side as we continue to battle for healthcare transformation, cheering you on.”

Upon learning of his announcement, Bill Finerfrock, HBMA Director of Government Affairs sent an email to Dr. Mostashari which read, in part, “First, let me add my voice to the many others who have, I am sure, contacted you to say how saddened they were to hear about your decision to leave ONC.  You have been a knowledgeable, dynamic and passionate leader…”

Subsequent to this announcement, Dr. Mostashari did communicate directly with HBMA but as with his initial email, his communication did not indicate the reasons for his announced departure. He did, however, express a desire to continue to work with HBMA and others interested in moving forward on health information technology issues. Stay tuned…

Return To Top

Employer Mandate under the ACA

As has previously been reported, the Obama Administration announced that for a variety of reasons, it was postponing enforcement of the Employer Mandate to provide health insurance to employees authorized under the Patient Protection and Affordable Care Act, until January 2015.

Just as there is an individual mandate included in the ACA, there is also a requirement that employers with 50 or more full-time employees or equivalents must provide Qualified Health Insurance to the company’s employees. Both the individual mandate and the employer mandate were supposed to take effect on January 1, 2014. As it currently stands, only the individual mandate will take effect on January 1, 2014.

Beginning January 1, 2015, employers that do not offer health insurance coverage to their full-time (30 or more hours worked per week) employees face a penalty of $2,000 per employee if at least one full-time employee receives a premium tax credit/subsidy to purchase coverage through a state-based health insurance exchange established under the PPACA.

If employers with 50 or more full-time employees or equivalents do offer health insurance coverage to their full-time employees, but the coverage is deemed “unaffordable” to certain employees or does not provide minimum value, the employer faces a penalty of $3,000 per full-time employee receiving a premium tax credit/subsidy for exchange coverage (not to exceed $2,000 times the total number of full-time employees).

Determining “Affordability” and “Minimum Value”

If an employee’s share of the premium for employer-provided coverage would cost the employee more than 9.5 percent of that employee’s annual household income, the coverage is not considered affordable for that employee. If an employer offers multiple health care coverage options, the affordability test applies to the lowest-cost option available to the employee that also meets the minimum value requirement.

Because employers generally will not know their employees’ household incomes, employers can take advantage of one of the affordability safe harbors set forth in the proposed regulations. Under the safe harbors, an employer can avoid a payment if the cost of the coverage to the employee would not exceed 9.5 percent of the wages the employer pays the employee that year, or if the coverage satisfies either of two other design-based affordability safe harbors.

According to the new Q&As, a minimum value calculator will be made available by the IRS and the U.S. Department of Health and Human Services (HHS) so employers can determine their potential exposure to penalties. The minimum value calculator will work in a similar fashion to the actuarial value calculator that HHS has made available through its Center for Consumer Information & Insurance Oversight (CCIIO).

Once it is up and running, employers will be able to enter certain information into the on-line calculator (employee out of pocket for premiums, deductibles, co-pays, etc.) and get a determination as to whether the plan provides minimum value by covering at least 60 percent of the total allowed cost of benefits that are expected to be incurred under the plan.

HHS and the IRS hope to have the calculator up and running in either late 2013 or early 2014.

Return to Top

Medicare to Accept Revised 1500 Claim Form Starting January 2014

The CMS 1500 Claim Form has been revised to accommodate the use of the ICD-10 diagnosis codes. The revised CMS-1500 form (version 02/12) will replace version 08/05.

According to information from CMS, “The revised form will give providers the ability to indicate whether they are using ICD-9 or ICD-10 diagnosis codes.” This flexibility will be important as the October 1, 2014 start date for ICD-10 approaches. The revised form also allows for additional diagnosis codes, expanding from 4 possible codes to 12. 

Providers who qualify for exemptions from electronic submission may submit the paper CMS-1500 Claim Form to Medicare. For those providers who use service vendors, CMS encourages them to check with their service vendors to determine when they will switch to the new form.

Use of the new form (hard copy or electronic) by Medicare will be done in two stages. Medicare will begin accepting the revised form on January 6, 2014. Providers can use the new form or the old form between January and April. Beginning April 1, 2014, Medicare will accept only the revised version of the 1500 form (version 02/12).

Return To Top

Legislation Introduced to Strengthen Medicare Anti-Fraud Efforts

Representative Kevin Brady (R-TX) Chairman of the House Ways and Means Subcommittee on Health and Jim McDermott (D-WA) Ranking Minority member of the Subcommittee, introduced bi-partisan legislation that would grant the Department of Health and Human Services Office of the Inspector General (HHS-OIG) new authority to exclude from the Medicare program individuals and entities that are found to be affiliated with another entity that has been sanctioned for fraud.

 

In a joint statement issued upon introduction of the legislation, they said, “…this legislation takes a common-sense approach by giving the Inspector General another tool to root out fraudsters. Individuals and companies who are involved with Medicare fraud on any level must be held accountable. We reintroduce this legislation to stem fraud by closing a senseless loophole for criminals who choose to steal from America’s entitlement programs.”

If enacted, the HHS Inspector General would have the authority to prevent individuals involved with fraudulent entities from receiving Medicare payments.  This would have the effect of banning executives whose companies have been involved with subsidiary organizations convicted of Medicare fraud from further participation in the Medicare program. According to both the OIG and the bill’s sponsors, there have been several instances where executives of large companies with subsidiary organizations that have been convicted of committing Medicare fraud have left those companies and started new companies

Under the Brady-McDermott bill, the OIG would also have the authority to prevent individuals entities involved with fraudulent entities from receiving Medicare payments.  This would ban the use of shell companies by corporations engaging in fraudulent activities.  

 

Similar legislation passed the House of Representatives in 2010 but died in the Senate. It is not clear whether the prospects for this legislation are any better in 2013, but the sponsors appear intent on pursuing this initiative.

Return To Top

Congress and Congressional Staff MUST get health insurance through the Marketplaces

When the Patient Protection and Affordable Care Act was enacted, a majority in Congress voted to mandate that Members of Congress and their staff would be required to purchase health insurance through the Marketplaces. The rationale behind this effort was that if Members of Congress were going to establish these Exchanges and they were so wonderful, then Members of Congress and their staff should use these Marketplaces.

Currently, Members of Congress and Congressional staff receive health insurance through the Federal Employees Health Benefits Program, and the government covers about 75 percent of premium costs. Because of the language included in the ACA, it was determined that rather than continuing to use the FEHB program to purchase insurance, Members of Congress and Congressional Staff would have to make their purchases through the District of Columbia’s Health Insurance Exchange or if the staff worked in a state or Congressional District office, through the Exchange in that jurisdiction.

This raised a significant issue that was not fully debated or considered at the time Congress approved this change: Would the Federal government continue to subsidize the insurance purchases of these individuals?

In early August, the Office of Personnel Management (OPM) issued a rule ensuring that the federal government will contribute to the cost of premiums for Members of Congress and Congressional staff purchasing health insurance through the exchanges created by the ACA.

One major change, however will be that the number of plan options available to these individuals will be severely limited. Currently through the FEHB program, DC based employees can choose from among dozens and dozens of health plans with a variety of premium and copay options.

According to the most recent information available from the DC Exchange, they expect that 3 – 4 insurance companies will offer health plans in the Exchange and each will have 4 pricing options (Bronze, Silver, Gold and Platinum). Unlike the FEHB program which offers several fee-for-service options, the DC Exchange plans all appear to be network (HMO or PPO) plans. It is also not clear how the pricing of the Exchange plans will compare to what has been available through the FEHB program both in terms of the overall premiums or the amount of the subsidy the federal government will give to the individual to lower the actual cost of the premiums.

According to the OPM, staff members and lawmakers will not be eligible for federal tax credits or other subsidies to help them purchase insurance through the Exchange, regardless of their income.

The language in the ACA that created this situation was proposed by Sen. Charles E. Grassley, (R-Iowa). Essentially his proposal requires lawmakers and their personal staffs to buy insurance through the Exchanges. However, the Grassley language did not specify how the OPM, which manages government employees’ benefits, would implement the provision, and whether the government would contribute to staff members’ premiums. The new OPM guidance answers those questions.

Return To Top

CMS Transmittals

The following Transmittals have been recently issued by CMS.

|Transmittal Number |Subject |Effective Date |

|R2782CP |Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131 |2013-12-09 |

|R2781CP |Home Health Change of Care Notice (HHCCN), Form CMS-10280, Manual Instructions - This CR |2013-12-09 |

| |rescinds and fully replaces CR 7323. | |

|R1293OTN |Display of ICD-10 Local Coverage Determinations (LCDs) on the Medicare Coverage Database (MCD)|2014-04-10 |

|R226FM |Recovery Audit Program Tracking Appeals and Reopenings |2013-10-07 |

|R486PI |Complex Medical Review |2013-10-07 |

|R2779CP |New Waived Tests |2014-01-06 |

|R2780CP |January 2014 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and |2013-09-06 |

| |Revisions to Prior Quarterly Pricing Files | |

|R225FM |Removal of POR and PSOR Instructions and the Glossary of Acronyms from the Internet Only |2013-10-04 |

| |Manual, Publication 100.06, Chapter 3 | |

|R2778CP |Fiscal Year (FY) 2014 Inpatient Prospective Payment System (IPPS) and Long Term Care Hospital |2013-10-07 |

| |(LTCH) PPS Changes | |

|R4PACE |PACE Marketing Guidelines |2013-10-29 |

|R90SOMA |State Operations Manual Chapter 2, Section 2256A, CAH Distance Criteria |2013-08-30 |

|R89SOMA |Revised State Operations Manual (SOM) Appendix A, I, L and W |2013-08-30 |

|R2776CP |Remittance Advice Remark and Claims Adjustment Reason Code and Medicare Remit Easy Print and |2013-10-07 |

| |PC Print Update | |

|R1291OTN |Standardizing the standard - Operating Rules for code usage in Remittance Advice |  N/A |

|R96MSP |ECRS Batch File Layout Changes for ICD-10 Codes |2014-01-06 |

|R1290OTN |MCS Prepayment Review Report |2013-10-07 |

|R88SOMA |Revisions to State Operations Manual (SOM) Chapter 5 |2013-07-19 |

|R95MSP |Update the Common Working File (CWF) to not Allow Certain Diagnosis Codes on No-Fault Medicare|2014-01-06 |

| |Secondary Payer (MSP) Records | |

|R2775CP |October 2013 Update of the Hospital Outpatient Prospective Payment System (OPPS) |2013-10-07 |

|R1288OTN |Health Insurance Portability and Accountability Act (HIPAA) EDI Front End Updates for January |2014-01-06 |

| |2014 | |

|R115MCM |Chapter 4, Benefits and Beneficiary Protections |2013-08-23 |

|SE1330 |OPEN PAYMENTS: An Overview for Physicians and Teaching Hospitals | |

|R484PI |OMB Collection Number |2012-05-21 |

|R485PI |Program Safeguard Contractor (PSC) and Zone Program Integrity Contractor (ZPIC) Provider |2013-01-29 |

| |Notification | |

|R2770CP |October 2013 Update of the Ambulatory Sugery Center (ASC) Payment System |2013-10-07 |

|R2771CP |Medicare Claims Processing Pub. 100-04 Chapter 24 Update |2013-09-17 |

|R1280OTN |Ambulatory Surgical Center Quality Reporting (ASCQR) Program Payment Reduction (MIEA-TRCAH, |  N/A |

| |2006) - Implementation | |

|R2768CP |Update-Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Fiscal Year (FY) |2013-10-07 |

| |2014 | |

|R2769CP |Inpatient Rehabilitation Facility (IRF) Annual Update: Prospective Payment System (PPS) Pricer|2013-10-07 |

| |Changes for FY 2014 | |

|R1286OTN |Handling Bankrupt Suppliers within VMS |2014-01-06 |

|R1285OTN |Further Instruction to Use Non-Alert Remittance Advice Remark Codes (RARCs) |  N/A |

|R483PI |Reassignment to Part A Critical Access Hospitals (CAHs), Federally Qualified Health Centers |2014-01-06 |

| |(FQHCs), and Rural Health Clinics (RHCs) | |

|R3PACE |PACE Marketing Guidelines |2013-10-29 |

|R2767CP |Handling of Incomplete or Invalid Claims once the Phase 2 Ordering and Referring Edits are |2014-01-06 |

| |Implemented | |

|R2765CP |Diagnosis Code Reporting on Religious Nonmedical Health Care Institution Claims |2014-01-06 |

|R2766CP |Update to Hospice Payment Rates, Hospice Cap, Hospice Wage Index, Quality Reporting Program |2013-10-07 |

| |and the Hospice Pricer for FY 2014 | |

|R1281OTN |Implement Operating Rules - Phase III ERA EFT: CORE 360 Uniform Use of Claim Adjustment Reason|2014-01-06 |

| |Codes (CARC) and Remittance Advice Remark Codes (RARC) Rule - Update from CAQH CORE | |

|R1283OTN |Multi Carrier System (MCS) Modifications to Liability Assignment Regarding Therapy Cap Claim |2013-08-16 |

| |Denials | |

|R2759CP |Update to the Claims Processing Internet-Only Manual (IOM) to Add the National Uniform Billing|2013-11-12 |

| |Committee (NUBC) Payer Only Codes | |

|R2760CP |Annual Clotting Factor Furnishing Fee Update 2014 |2014-01-06 |

|R2762CP |Healthcare Provider Taxonomy Codes (HPTC) Update, October 2013 |  N/A |

|R2758CP |Mandatory Reporting of an 8-Digit Clinical Trial Number on Claims |2014-01-06 |

|R2763CP |October 2013 Integrated Outpatient Code Editor (I/OCE) Specifiations Version 14.3 |2013-10-07 |

|R1276OTN |Revision to the CWF Edit for Technical Component (TC) of Pathology Services Occurring on the |2014-01-06 |

| |Same Day as an Outpatient Hospital Visit | |

|R1277OTN |Medicare Physician Fee Schedule Database (MPFSDB) Field Revisions for the New Purchased |2014-01-06 |

| |Diagnostic Test (PDT) Indicator and New Effective Date Field | |

|R2756CP |Revision to the ViPS Medicare System Diagnosis Code Editing on the CMS-1500 |2014-01-06 |

|R2754CP |October Update to the CY 2013 Medicare Physician Fee Schedule Database (MPFSDB) |2013-10-07 |

|R2753CP |Instructions for Downloading the Medicare ZIP Code File for January 2014 |2014-01-06 |

|R2755CP |Additional States Requiring Payment Edits for DMEPOS Suppliers of Prosthetics and Certain |2013-10-05 |

| |Custom-Fabricated Orthotics. Update to CR 3959 | |

|R1274OTN |The Supplemental Security Income (SSI)/Medicare Beneficiary Data for Fiscal Year 2011 for |2013-09-03 |

| |Inpatient Prospective Payment System (IPPS) Hospitals, Inpatient Rehabilitation Facilities | |

| |(IRFs), and Long Term Care Hospitals (LTCH) | |

|R1272OTN |CEDI Removal of 4010A1 Jobs and Processes |2013-10-07 |

|R224FM |Revisions and Deletions to the Internet Only Manual, Publication 100-06, Chapter 3, |2013-09-03 |

| |Overpayment (Section 50.3); Chapter 4, Debt Collection (Section 50 - 50.6 and 100.6.4) Related| |

| |to Extended Repayment Schedules (ERS) | |

|R156NCD |Positron Emission Tomography |2013-09-03 |

|R2750CP |Positron Emission Tomography |2013-09-03 |

|R477PI |Tracking Medicare Contractors' Postpayment Reviews |2013-10-03 |

|R1271OTN |Health Insurance Portability and Acoountability Act (HIPAA) EDI Front End Updates for January |2014-01-06 |

| |2014 | |

|R479PI |Enrollment Denials When an Existing or Deliquent Overpayment Exists |2013-10-07 |

|R1264OTN |Addition of the End Stage Renal Disease (ESRD) Facilities Located in the Pacific Rim to the |2014-01-06 |

| |ESRD Prospective Payment System (PPS) | |

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download