Final Medicaid managed care rules issued


Nearly a year after releasing its proposed overhaul of the regulations governing Medicaid and Children’s Health Insurance Program (CHIP) managed care, the Centers for Medicaid and Medicare Services (CMS) issued the final version of the regulations last week. In addition to their sweeping impact, these rules are particularly meaningful as the first major changes to the Medicaid and CHIP managed care rules since 2002. [More]


CMS outlines transition to new Medicare payment system for clinical practitioners


On April 27, 2016, the Centers for Medicare and Medicaid Services (CMS) issued proposed rules to implement the Merit-Based Incentive Payment System (MIPS) authorized by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). MACRA repeals Medicare’s sustainable growth rate (SGR) formula, replaces three prior Medicare incentive programs, and outlines steps toward new performance incentives and penalties in 2019 and beyond for physicians and other clinical practitioners. [More]

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CMS outlines steps toward VBP for nursing facilities


On April 25, 2016, the Centers for Medicare and Medicaid Services (CMS) published proposed rules in the Federal Register on Medicare reimbursement for skilled nursing facilities. The proposed rules address inflation and productivity adjustments for these facilities under the current Medicare prospective payment system (PPS), quality of care reporting requirements, and a step-by-step transition to a new, value-based purchasing (VBP) system offering incentives to improve quality of care. For the fiscal year beginning October 1, 2016, aggregate Medicare payments to these facilities will increase $800 million as compared to the prior year, about 2.1 percent overall, based mainly on 2.6 percent inflation adjustments partially offset by -0.5 percent productivity adjustments. Nursing facilities that don’t meet CMS quality of care reporting requirements will subsequently face -2.0 percent offsets in annual PPS updates per the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT). [More]


CMS announces extension of SHOP direct enrollment transition


On April 18, 2016, CMS released guidance entitled “Extension of state-based SHOP Direct Enrollment Transition,” which extends the option of direct enrollment until the end of 2018 giving state based SHOPs more time to make online enrollment available. In order to allow facilitation of enrollment without SHOP portal functionality, CMS has allowed states to direct enroll employers and their employees, while also extending the small business tax credits to those eligible small employers offering coverage on a state-based SHOP utilizing direct enrollment. This most recent guidance includes three options for states regarding enrolling SHOP eligible employers in 2019. States should begin planning now, because significant time is needed to not only give CMS notice but also to implement the option of choice. [More]


Final Medicaid Managed Care Rules


CMS released a proposed overhaul of the regulations governing Medicaid and CHIP Managed Care last May and accepted comments through July. In addition to their sweeping impact, these rules are particularly meaningful as they are the first major changes to the rules governing Medicaid Managed Care since 2002. As states agencies and others review the final regulations, we are sharing a summary of the proposed regulations that we first released last summer. The proposed regulations seek to modernize the rules in light of the expanded use and scope of managed care in Medicaid programs across the country. [More]


U.S. Supreme Court hears oral argument on conduct giving rise to liability under the FCA


On April 19, 2016, the U.S. Supreme Court heard oral argument in an action that will test whether a theory that is described as “implied certification” is a valid one for determining liability under the False Claims Act (FCA). The “implied certification” theory refers to the extent to which violation of a regulation or contract provision is “material” for purposes of triggering liability under the FCA. [More]

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HHS issues report on ACA premium increases


On April 12, 2016, the U.S. Department of Health and Human Services (HHS), Assistant Secretary for Planning and Evaluation (ASPE), issued a report entitled, “Marketplace Premiums after Shopping, Switching, and Premium Tax Credits, 2015-2016.” Data in the report show how price competition among health plans on Exchanges controls premiums for consumers who shop for coverage there, and how tax credits for low income consumers keep premiums affordable for them. [More]


CMS announces CPC+ primary care model


On April 11, 2016, the Centers for Medicare and Medicaid Services (CMS) announced the Comprehensive Primary Care Plus (CPC+) model. The CPC+ model, which builds on the CPC model launched in October 2012, is designed to align Medicare, state Medicaid agencies, and commercial insurance payers to achieve comprehensive, coordinated primary care, especially for patients with complex medical and behavioral health needs. [More]


NEJM examines Medicare physician reimbursement system


On April 7, 2016, the New England Journal of Medicine (NEJM) published an article entitled, “Finding Value in Unexpected Places – Fixing the Medicare Physician Fee Schedule.” The NEJM article notes that the Medicare physician fee schedule (MPFS) may: affect how physicians spend time with patients, drive unneeded tests and procedures, influence physicians’ specialty choices, and worsen shortages of much-needed primary care physicians and geriatricians. [More]

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NAS issues report on improving health outcomes for at-risk populations


On April 7, 2016, the National Academies of Sciences, Engineering, and Medicine (NAS) issued a report entitled, “Systems Practices for the Care of Socially At-Risk Populations.” The report cites research and case studies showing that collaboration between health care delivery systems and community-based social service organizations can achieve improvements in health care outcomes for at-risk, low income populations afflicted by social isolation and limited health literacy. [More]

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