CMS proposes policy changes to Medicare Advantage, Medicare prescription drug benefit

The Centers for Medicare and Medicaid Services (CMS) on Thursday, November 17, 2017, released a proposed rule outlining policy changes to Medicare Advantage (MA) and the Medicare Part D prescription drug benefit (Part D). The proposed rule is intended to provide an opportunity for stakeholders to provide feedback to CMS ahead of the annual call letter process, with the draft call letter historically released in February.

The proposed rule includes policies intended to further CMS’ recently announced Patients Over Paperwork initiative, which aims to reduce regulatory and administrative requirements for health care stakeholders. In addition, the proposed rule continues the Administration’s efforts to exercise regulatory authority to help reduce out-of-pocket spending on prescription drugs.

The policies outlined in the proposed rule would apply to contract year 2019.

The proposed rule is scheduled for publication in the Federal Register on November 28, 2017, and CMS will accept comments through January 16, 2018.

Key provisions of the proposed rule are highlighted below.

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CMS releases final Medicare audit protocol updates

The Centers for Medicare and Medicaid Services (CMS) has released the final protocols for 2017 audits of Medicare Parts C and D plans. This is the latest step in a process RegPulse has reported on during the initial release and as draft protocols underwent updates during the last year.

The audit protocol revisions affect the ways in which plan sponsors—such as Medicare Advantage Organizations (MAOs), Prescription Drug Plans (PDPs), and Medicare-Medicaid Plans (MMPs)—prepare and present information about their data universes to CMS. Sponsors that take part in these programs should review the changes and continue or update their programs assessments to identify the changes that affect them and plan appropriate responses.

Here is a summary of the relevant changes to the audit protocols in the final release, listed by program type:

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CY 2018 changes and policy updates for Medicare health and drug plans

Summary of provisions and impacts

The Centers for Medicare and Medicaid Services (CMS) released its Advance Notice of Methodological Changes for Calendar Year (CY) 2018 for Medicare Advantage (MA) Capitation Rates, Part C and Part D Payment Policies and 2018 Draft Call Letter on February 1, 2017.

The purpose of the Advance Notice and draft Call Letter was to notify Medicare Advantage Organizations (MAO) and Part D sponsors of proposed changes to the Part C and Part D programs for the following plan year, including but not limited to:

  • Planned changes in the MA capitation rate methodology and risk adjustment methodology applied under Part C for CY 2018
  • Proposed changes in the Part D payment methodology for CY 2018
  • Proposed changes to the quality rating system and information the MAOs and Part D sponsors should consider while preparing their 2018 bids

CMS received many submissions in response to the request for comments on the Advance Notice and released final updates to MA and Part D Prescription Drug Programs for 2018 on April 3, 2017.
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CMS adds new changes to Medicare audit rules already under review

The Medicare Parts C and D Oversight and Enforcement Group (MOEG) of the Centers for Medicare and Medicaid Services (CMS) have released updates to the proposed 2017 Program Audit Protocols and Data Requests (CMS-10191) for Medicare Parts C and D that RegPulse first commented on in August 2016.

These changes have arisen, in part, because of public comments the agency received during the first 60-day comment period on the revised rules. Health plans that participate in these programs should familiarize themselves with the changes, especially the particular elements that have substantive effect, and may wish to participate in the new public comment period that ends December 5, 2016.

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CMS releases rules to implement site-neutral Medicare payments for certain provider-based departments starting January 1, 2017

The Centers for Medicare and Medicaid Services (CMS) on Tuesday, November 1, 2016, moved forward with the adoption of a site-neutral Medicare payment policy for non-excepted (non-grandfathered) items and services provided at certain off-campus provider-based departments (PBDs). CMS provided the guidance as part of the final rule on the Medicare Hospital Outpatient Prospective Payment System (OPPS).

The final rule is scheduled to be published in the Federal Register on November 14, 2016.

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Congress seeks feedback on changes to Medicare payment policy for certain off-campus hospital outpatient departments, site-neutral payments; American Hospital Association weighs in with CMS

US Supreme Court building

Posted by Anne Phelps, Principal, US Health Care Regulatory Leader on February 12, 2016.

A letter seeking comments on site-neutral payments under Medicare went out to the health care community from Congressional leaders on Friday, February 5 and highlighted a recent change in law that will affect Medicare payments for certain provider-based off-campus hospital outpatient departments (PBD HOPDs).

On November 2, 2015, President Obama signed the Bipartisan Budget Act of 2015, which included a provision on site-neutral payments for PBD HOPDs. Beginning January 1, 2017, the provision will bar PBD HOPDs that execute CMS provider agreements after November 2, 2015 (the date the law was enacted), from being reimbursed under the CMS Outpatient Prospective Payment System (OPPS). PBD HOPDs barred from OPPS will only be eligible for reimbursement under the Medicare Physician Fee Schedule (PFS) or the Ambulatory Surgical Center Prospective Payment System (ASC PPS), both of which have generally lower reimbursement rates than OPPS.

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“Two-midnight” scrutiny may change, but the need for documentation remains

Low-angle view of hospital sign

Posted by Nancy Perilstein, on October 22, 2015.

Regulators are poised to change the ways they police short-stay requirements, and those changes will make a difference – but they should not give provider organizations a false sense of security.

Under Medicare’s “two-midnight rule,” quality improvement organizations (QIOs) affiliated with the Centers for Medicare and Medicaid Services (CMS) will not take over the job of reviewing short inpatient hospital stay claims until January 1, 2016, more than two months later than earlier planned.

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CMS takes next steps in implementation of new Medicare payment law: critical new details emerging for health care professionals, hospitals and health plans

CMS takes next steps in implementation of new Medicare payment law
Posted by Anne Phelps, on October 21, 2015.

The Centers for Medicare and Medicaid Services (CMS) is beginning the process of seeking comment and developing regulatory guidance on the recently passed Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). MACRA fundamentally changes how Medicare provider payments will be set in the future. It is critically important for health systems and health plans that employ physicians to begin to assess now how the law might affect their revenue and strategic priorities. Health systems and health plans may want to revisit their strategic relationship with health care providers in light of the law’s financial incentives for health care professionals to participate in risk-bearing coordinated care models.

Stakeholders should keep abreast of the critical regulations that the Administration is releasing over the next six to 12 months in order to be prepared to adapt to new requirements and processes that will start to be rolled out as soon as July 2016.

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CMS kicks off regulatory process on new Medicare payment law: hospitals should move quickly to evaluate their strategic options

Long-awaited release of drug discount rule mega-guidance means hospitals need to act quickly—but think long-term

The Centers for Medicare and Medicaid Services (CMS) on September 28, 2015, released a Request for Information (RFI) related to the implementation of provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).  The law fundamentally changes how Medicare provider payments will be set in the future. MACRA repeals the Sustainable Growth Rate formula and establishes a path toward a new payment system that will more closely align reimbursement with quality and outcomes measures while steering health care providers away from the fee-for-service reimbursement system. The RFI was published in the October 1 Federal Register and is open to a 30-day comment period.

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As public light shines on Medicare payment data to medical providers, planning becomes key

Medicare payment data

Posted by Kimberly Zeoli , Partner, Governance, Regulatory & Risk Services Practice, Deloitte & Touche LLP on April 16, 2015.

Recent news articles talk about how Medicare payment data won’t stay pent up in the databases of providers and federal agencies. For example, it was recently reported that Medicare will publish physician-payment data yearly. This information is finding its way into the spotlight as news organizations and other groups aggressively seek to understand more about how Medicare dollars flow to healthcare providers.

The heightened curiosity surrounding Medicare payment data should prompt healthcare organizations to ask important questions about what they are billing and why they are billing it. On one hand, organizations with many physicians on staff should understand that high volumes or potential anomalies in payment data aren’t necessarily a sign of impropriety. On the other hand, these organizations should become serious about understanding the implications of detailed Medicare payment data and other relevant information available in the public realm. While there are many considerations that organizations will need to evaluate, below highlights four key points for organizations to know now.

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